Creating Positive Cultures of Care

2. 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

3. Compassion Fatigue www.workshopsforthehelpingprofessions.com 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.

4. 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.

5. Biological Trauma lives in the body. The body has ways to indicate to us that a threat cue is perceived.

6. 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

7. 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

8. Serum Cortisol almazarconsulting.com 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)

9. Some Stressors: • Fiscal and funding cuts • Downsizing/organizational changes/ mergers • DIfferentpayor systems • Regulatory changes • Role changes • Reimbursement changes • Do more with less • Practice changes • New metrics • Natural organizational events almazarconsulting.com

10. 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

11. 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

12. 2009 GALLUP POLL Employee Engagement Index • 33% - Engaged in their jobs • 49% - Are not Engaged • 18% - Actively Disengaged almazarconsulting.com

13. 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

14. 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….

15. 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

16. 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

17. Parallel Process between Traumatized Individuals and Traumatized Organizations(Adapted from Organizational Trauma as Barrier to Implementing Trauma Informed Care by Sandra Bloom) almazarconsulting.com

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22. 16 Warning Signs of Trauma Exposure Response almazarconsulting.com From “Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others” 2009 Laura van Dernoot Lipsky with Connie Burk

23. 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)

24. 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)

25. 16 Warning Signs… almazarconsulting.com 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

26. 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

27. 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

28. 16 Warning Signs almazarconsulting.com 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

29. 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

30. 16 Warning Signs almazarconsulting.com 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

31. 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

32. Exercise – Choose Your Focus almazarconsulting.com 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?”

33. 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

34. Healing Organization almazarconsulting.com • Adjective An organization whose mission is to help people get well • Verb An organization actively restoring its health, making itself whole

35. 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

36. 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

37. 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 others-in 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

38. 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

39. Protective Factors Connectedness Social Support Shared Values Commitment Self Determination

40. Workforce Development Components Training Staff Appreciation Staff Empowerment almazarconsulting.com

41. 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

42. 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

43. 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 self-preservation almazarconsulting.com

44. 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 self-determination almazarconsulting.com

45. 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

46. 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

47. 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

48. 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

49. 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

50. Staff Support and AppreciationStrategies and Examples almazarconsulting.com 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