Molyn Leszcz MD, FRCPC Psychiatrist-in- Chief, Sinai Health System

1. PSYCHOLOGICAL SAFETY and WELLBEING IN THE WORKPLACESOCIETY OF ONTARIO ADJUDICATORS and REGULATORS (SOAR) Toronto, ON Nov 3, 2016 Molyn Leszcz MD, FRCPCPsychiatrist-in- Chief, Sinai Health System Professor and Vice-Chair, Clinical Department of Psychiatry The University of Toronto

2. WORKSHOP OUTLINE • Context and Background- Sinai Experience as Model • Scope of Contemporary Concern • Approaches to Improve and Sustain Workplace Psychological Safety and Wellness – 3 domains: • Employee health resources • Healthy culture • Healthy workplace • Training and Interventions to reduce psychological risk and enhance recovery • Culture and Resilience –organization and individual levels

3. Illness Schizophrenia Major depression Bipolar disorder Adult ADHD Personality disorders Borderline personality disorder Anxiety disorder Panic disorder +/- agoraphobia Social anxiety Obsessive-compulsive disorder Generalized anxiety disorder PTSD Life Prevalence 1 – 1.5% 15-20% 1.1% 4.4% 13 – 15% 1.8% 9 – 19.5% male/female 1.5 – 4% 13% 2% 5 - 6% 8 - 9% F>M 2:1 SCOPE AND IMPACT OF MENTAL ILLNESS AND ADDICTIONS • Recognize limits of DSM IV diagnostic criteria- new DSM V controversies • Diagnosis by consensus – DSM II 1972 homosexuality was a mental illness  Co-morbidity with substance use disorders > 40%

4. SCOPE AND IMPACT OF MENTAL ILLNESS • Lifetime prevalence with  family impact • One in Five are impacted at any moment • Morbidity • Economic costs > $30 Billion annually in Canada • Leading cause of disability claims • Greater economic costs than cardiac disease • Canada spends < 6% of health dollars on mental health (MH) • Below minimum levels set by European Mental Health Economics Network (Jacobs et al, 2008) - – should be at 13% • National Commission on Mental Health is changing the landscape

6. SCOPE AND IMPACT OF MENTAL ILLNESS •  Access due to limited resources and stigma (74% of Canadians polled were uncomfortable talking to their GP about mental health concerns (2008 Gallop poll) • Health care providers are often blind to their own bias both as patients and as providers(Stuart, 2013) • 40% of >2000 physicians surveyed reported a mental illness for which they did not pursue care due to stigma (APA 2016) • Stigma is multiply determined – shame; fear; culture of society/organization • Stigma substitutes blame for care: Stigma is a form of discrimination – faulting>compassion • Labelling; diagnostic overshadowing; prognostic negativism • Our language matters • Dialogue is changing – viz. Sports icons and public figures – Economist feature • Ontario Bar Association is a leader – viz. Opening Remarks series; web resources • Contact education helps – mental illness is real and it is treatable

8. MENTAL ILLNESS/ADDICTIONS AND THE WORK PLACE • Up to 25% workers struggle with mental illness • Chiefly depression and anxiety +/- substance use • 35m workdays lost annually in Canada • Presenteeism increases productivity losses 6x • Impact of environment on MH: Beyond Dilbert cartoons • Organizational Justice: relational justice; decisional justice (Whitehall II Studies) • Bell Canada is becoming a leading champion • Growing recognition of the humane, economic and legislative imperatives • What can be done to improve psychological safety in the workplace? Why is this important?

9. ORGANIZATIONAL CULTUREPrinciples and action that improve resilience Build organizational reserves now>in extremis (Maltz 2003) • Value your human capital – no organization can afford the waste of our human resources • Reserves required of materials and relationships • Grow capacity to support one another • Mutual trust and respect • Identify staff needs (e.g. Starbucks) • Training and environment – upstream and downstream • Leadership’s presence, skills and responsiveness • Evident in engagement and communication • Elements of organizational trust – leaders experienced as competent; benevolent and operating with integrity • Champions of a healthy system – CONGRUENCE • Operationalize the organization’s intent

10. HEALTHY WORKPLACES ENGAGE, ENABLE AND ENERGIZE STAFF, WHICH LEADS TO BETTER BUSINESS RESULTS Source: The Power of Three -Taking Engagement to New Heights. Towers Watson, 2012

11. HEALTHY WORKPLACES IMPROVE PATIENT CARE Source: How Employee Engagement Matters for Hospital Performance. Graham Lowe, Healthcare Quarterly, 2010

12. Self-Reported Annual Sick Days by HWE index 5.4 5 4.1 k 4 c i S 2.9 3 s y a D 2 1 0 Low Medium High Health Work Environment (HWE) Index HEALTHY WORKPLACES AND SICK COSTS (Yardley 2008).

13. PROFESSIONAL FACTORS THAT MAY INCREASE VULNERABILITY Lawyers no less vulnerable than other professionals: • High demand work; • Long hours- social and work/life balance; • Perfectionism; • Emotional intensity of the work - money and relationships; • Vicarious trauma; exposed to humanity not at its best; • Adversarial, competitive and power based >affiliative • Confidentiality/privacy is silencing • Narrow view of professionalism – deny limits • Pre-existing vulnerability - Type A or internalizers • Justice Joseph Story: The Law is a jealous mistress (1829)

14. WHAT IS BURNOUT? Prominent concern in health care – due to stresses of increasing demands; fiscal pressures; loss of autonomy; sector shrinkage; growing clinical complexity; ethical dilemmas and moral distress (MAID) Burnout carries broad negative impact on health care outcomes Key elements: • Emotional exhaustion • Loss of enthusiasm for one’s work • Loss of sense of effectiveness/accomplishment • Depersonalization – people matter less – loss of human connection (Maslach et al, 1996)

15. FACING STRESS:WHAT HELPS? • Recognize normal responses to extraordinary stress • Cope with healthy evidence supported strategies – organizational provision • Seek help when you need it • Be attuned to your self experience – change in function/interest/activity/pleasure/self concept • Upstream vs. downstream interventions – broad range • Resilience: the ability to maintain /regain mental health in the face of adversity – positive adaptation (Hermann et al, 2011) • Contributes to resilience as an organization

16. NORMAL RESPONSE TO EXTRAORDINARY STRESS • Feeling afraid, tense, jumpy and very alert • Difficulty sleeping, nightmares • Seeing images associated with the stressful event • Feeling numb, dazed, confused • Feeling depressed, anxious, worried • Avoiding reminders of the source of stress • Sudden changes in mood • Over-activity, irritability or lack of energy; appetite; substances • Shorthand: too much; too little; hyperarousal – viz. H1N1

17. RESPONDING TO STRESSFUL EVENTS Appraisal: figuring out what is wrong Coping response – tripartite approach Outcome & Re-appraisal Makeexplicit what is implicit and sensible (Folkman & Greer, 2000)

18. THEORETICAL MODEL OF APPRAISAL AND COPING PROCESS (Folkman & Greer, 2000) Emotion Appraisal Outcome Event Coping Outcome Problem-focused coping Emotion-focused coping Favorable resolution Positive emotion Harm Threat Person Characteristics Unfavorable resolution No resolution Distress Event Meaning-Based coping Challenge Positive emotion Sustains coping process

19. HEALTHY COPING STRATEGIES • Address the situation actively • Mobilize, don’t minimize • Communicate effectively • Assertive, affiliative, non-blaming communication; intent vs. Impact • Be an active learner • Follow up of >4,000 post 9-11 responders concluded that mental wellness in the face of extreme adversity was significantly impacted by prior training/preparedness; active coping; sense of moral purpose (J Psych Res, 2016) • Take care of yourself • Stay engaged in your relationships • We are all vulnerable – don’t pretend to be Teflon • Express emotions when it feels safe and helpful • Recognize your limits • Reflection > Reactivity – Huge mediator of enhanced coping

20. PROBLEM-FOCUSED COPING FIXING OR REDUCING THE PROBLEM Take care of yourself Take time for yourself; give yourself time to bounce back. Exercise moderately, participate in recreation. Get adequate sleep. This may mean more sleep than normal. Simplify your tasks. Do one thing at a time when possible. Use relaxation strategies and stress management Avoid substances in excess Breathing, yoga, meditation – simple, enduring and effective and reduces burnout(Krasner et al, 2009)

21. EMOTION-FOCUSED COPINGHELPING YOURSELF TO FEEL BETTER Use your relationships; stay engaged The best remedy for stress is often the company of loved ones Distinguish between what you feel and what you do, who you are Negative feelings are normal; you are still okay

22. EMOTION-FOCUSED COPINGHELPING YOURSELF TO FEEL BETTER Expressing emotions and grieving Talk to others if you feel the need and if it feels safe and helpful Needing to talk is not a sign of weakness Preferring not to talk does not mean denial Beware tentative communication shrinking one’s world and fostering isolation Accept your vulnerability

23. MEANING-BASED COPING Finding meaning in the challenge Personal values & spirituality Vision and moral purpose (Maltz, 2003) Altruism: the greater good of one’s work Personal growth opportunity- Posttraumatic growth

24. EMPLOYEE HEALTH RESOURCES Sinai Health System Employee Emotional Wellness Committee co-chaired by VP of HR and Chief of Psychiatry – interprofessional team. We aim to improve the coping skills and reflective capacity of healthcare providers aimed at reducing burnout, improving satisfaction with work in turn improving the quality of care. (Maunder et al,2010; Aiello et al,2011) • Prevention; early recognition and effective care • The Stress Vaccine building upon the Pandemic Stress Vaccine • Compassion Fatigue Training • Mindfulness-Based Practice Training • EAP promotion

25. at Mount Sinai Hospital EMPLOYEE HEALTH RESOURCES • Health, Arts & Humanities Program • Docs for Docs film series • Lunch and Learns at MSH • www.ars-medica.ca (Humanities and Health journal) • Poet in Residence – language to experience • “Art of …” Annual Community Event • www.health-humanities.com

26. HEALTHY CULTURE Team and Leadership Interventions • Psychiatry staff help teams learn to respond and work through high stress situations together- distinct from critical incident debriefing which can be noxious • Helpful with coping strategies; reflective capacity and measure of our mutual commitment to one another • Harassment and Violence Prevention including a focus on early identification of potentially violent patients. • Safe Patient Safe Staff program • “Supporting a Healthy Work Environment: Managing Stress and Building Resiliency” • ½ day training offered as part of Management and Employee Development Certificate programs

27. HEALTHY WORKPLACE SYSTEMS • Monitoring key metrics • Psychological Safety Risk Scores (employee survey) • Health Risk Appraisal mental health risk scores • Emotional Wellbeing Program Participation Rates • EAP and Drug Utilization Rates • Absenteeism and Long Term Disability Rates • Awards and Recognition – Safe Patient Safe Staff and Stress Vaccine; Magnet Status; Top National Public Sector Organizational Culture x 2.

28. WORKPLACE PSYCHOLOGICAL SAFETY • Reduce stigma and discrimination • Change the conversation • ALLY Campaign success Any member of the Hospital community can be an ALLY in helping to create a healthy and safe Hospital. An ALLY supports the rights of marginalized people and acts when people face discrimination.

29. WHAT IS THE ALLY CAMPAIGN? • People with mental health issues • Gay, lesbian, bisexual people • Trans, intersex and two-spirit people • Racialized people • People with physical disabilities

30. ALLY CAMPAIGN • Address implicit bias and discrimination. • Expand empathic awareness. • Recognize experience of those who are a minority in the midst of the majority • Attune to hierarchy/status • Psychological value of recognition and validation as a person of worth

31. WORKPLACE PSYCHOLOGICAL SAFETY • National Commission on Mental Health focus on Psychological Safety (PS) in the Workplace (2013) • Shain(2010): “..every practical effort is made to avoid reasonably foreseeable injury to the mental health of employees.” • CSA standards available • Mount Sinai is one of 25 national early adopters/test sites • Key organization-individual interface equation in 3 domains • Prevent harm • Promote health • Meaningful response to critical incidents

32. WORKPLACE PSYCHOLOGICAL SAFETY • Psychological First Aid (PFA) – as important and more relevant than HAZMAT training • Key aspects: contact and engagement; opp to talk without judgment/shame; social support; reduce isolation; practical assistance; coping strategies; links to resources; • Workplace peer support • Psychological safety EQUATION • Control + Reward – Demand + Effort • Mediated by relationship with one’s manager/supervisor • Operationalize in each domain of the equation (see handout)