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:
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 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)
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Some Stressors:
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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
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Impact on the Individual
 Loss of meaning and purpose
 Decreased creativity
 Inability to innovate
 Absenteeism
 Retreating into the familiar
 Distracted, unfocused
 Physical health effects
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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
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2009 GALLUP POLL
EMPLOYEE ENGAGEMENT INDEX
• 33% - Engaged in their jobs
• 49% - Are not Engaged
• 18% - Actively Disengaged
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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)
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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
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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
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Individual
Impoverishment of Relationships
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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15. Addictions
Adrenaline rush addiction
16. Grandiosity: An Inflated Sense of Importance Related to
One’s Work
Work is the center of our identity
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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?”
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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
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Healing Organization
Adjective
An organization whose mission is to help
people get well
Verb
An organization actively restoring its
health, making itself whole
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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.
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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)
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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.
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• 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.
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Protective Factors
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Connectedness
Social Support
Shared Values
Commitment
Self Determination
Workforce Development
Components
• Training
• Staff Appreciation
• Staff Empowerment
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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)
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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)
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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
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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
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• 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)
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Physical Safety
Sense of being safe, living in a physically
safe space
Physical/Biological Safety
Good health practices
Occupational security and sound financial
management
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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
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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
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Social Safety
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Sense of feeling secure, cared for, trusted
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Ability to express oneself
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Ability to be safe with other people
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Acceptance of differences and diversity
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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
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Staff Appreciation and Support
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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)
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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
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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
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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
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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”
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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
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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)
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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)
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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)
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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)
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Effective Stress Management Strategies
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Healing is a matter of time,
but it is sometimes also a matter of opportunity.
Hippocrates
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