Preparing the Adult Mental Health Workforce To Succeed in a Transformed System of Care Life Span Approach to Workforce Development With Stress Management and Self Care: Essential Strategies for Career Success Module XVIII NASMHPD/OTA Curriculum January 2009 Created by Hines-Cunningham & Jorgensen

Self Care and Direct Care Staff One of the things that doesn’t get talked about very much is the trauma of the staff. We talk about the trauma paradigm for our clients or people in recovery But not very often in my 20 years of work in the field of mental health have I heard much about what happens to us, the workers, and I think that’s an area where we need to do some work I’ve seen some pretty traumatic things from when I first started 20 years ago. Some of those things still haunt me that I’ve seen -Said by a Female direct care staff (SAMHSA, 2005)

Learning Objectives Participants will understand the importance of self care and stress management as key factors in working in a mental health care environment Participants will obtain definitions of burnout, compassion fatigue, and secondary traumatic stress Participants will be introduced to stress self- assessment as a way of self monitoring Participants will participate in developing their own self-care and stress management plan

Lifespan Approach to Workforce Development Entry: Preparing the Workforce Planning Education Recruitment Workforce: Enhancing Performance Supervision Compensation Systems Support Lifelong Learning This is a way of looking at how careers for people in the mental health workforce develop over time. Exit: Managing Attrition Migration Career Choice Health and Safety Retirement (Indart, 2006)

Self-Care Best Practices for Mental Health Workers In addition to becoming attuned to the needs of consumers, a transformed mental health system calls us to develop self-care and stress-reduction strategies Maintaining and improving a psychologically, physically, emotionally, cognitively, and spiritually healthy self enhances our sense of vitality and resilience

Key Factors for Helping in a Transformed Mental Health System Offer hope and help the individual to cultivate their own sense of hope Do not offer a prognosis of gloom and doom. Listen, listen, listen Help the individual to solve their own problems Help them to believe in themselves Help the individual to find support and learn to offer support to others (Swarbick, 2009) ALSO: Key components of a transformed system… (from the SAMHSA Consensus Statement on MH Recovery, 2005) Self-direction Individualized and Person Centered Empowerment Holistic Non-Linear Strengths-based Peer Support Respect Responsibility Hope Key Factors for Mental Health Staff in a Transformed Mental Health System-Although these components have been previously reviewed in other modules it is important for participants to understand that these factors are very different from a mental health system that is “maintenance focused”.  There is a change in the system, change in how the staff members see themselves and interact with consumers.   

Potential Vulnerabilities of Health Care Workers Repeated exposure to traumatic events Carrying out difficult and exhausting tasks Exposure to unusual demands to meet others’ needs Feelings of helplessness Frequently facing moral/ethical dilemmas Exposure to anger and/or lack of gratitude Frustration with bureaucratic policies Heightened sense of lack of control (Figley, 1995) Work-related stress conditions and Vulnerabilities of Mental Health Care Workers-These slides provide specific definitions and information regarding stress.  We should emphasize that stress is an inevitable part of life and sometimes good experiences in our lives (i.e. the birth of a baby) can be stressful.  For staff we need to understand specific vulnerabilities, including organizational and personal Again, although previously highlighted the prevalence of trauma among consumers is important. A significant part of transformation is the understanding of traumatic histories of many consumers and to consider ways in which our system of care is more “trauma informed”.  Prevalence of histories of trauma among consumers in psychiatric hospitals range from 43% to 81% and higher.

Potential Stress and Work-related Responses Quitting the job Poor work performance Absenteeism Tardiness Diminished morale Diminished concentration Difficulty completing tasks (Figley, 1995)

Stress: Non-specific response of the body to any demand placed upon it (Hans Selye, 1926) Perceived threat Change Flight or fight Deadlines Temporary Chronic Unrelenting Constant state of anxiety Nerves Physiologic changes in your body High glucose High heart rate Blood pressure Breathing Increased abdominal fat (Taylor, 2007)

The Compassion Continuum Compassion Fatigue The Compassion Continuum Compassion Fatigue Compassion Satisfaction (Depletion) (Vitality) Burnout Secondary traumatic stress (STS) --Vicarious traumatization Compassion fatigue Countertransference (Figley, 1995) Important Concepts in the Prevention of Work Related Stress for Mental Health Workers-These slides provide participants with factual information beginning with the concept of “compassion continuum” so that participants can recognize that work related stress exists on that continuum.  The purpose of the definitions is to sensitize and inform participants of the differences of these symptoms/conditions.  

What is Burnout? A state of physical, emotional, and mental exhaustion caused by long term involvement in emotionally demanding situations (Pine & Aronson, 1988) Burnout is a process rather than a fixed condition that begins gradually and often becomes progressively worse The process includes increasing job strain, erosion of idealism, and a sense of futility

Secondary Traumatic Stress (STS) sometimes called Vicarious Traumatization Secondary Traumatic Stress describes a professional worker’s subclinical or clinical signs and symptoms of PTSD that are similar to those experienced by trauma clients, friends, or family members (Figley, 1995) People who work in “helping professions” are called to respond to individual, community, national, and even international crises. Health Care Professionals may be negatively affected by their contact with these events. Helpers are exposed to both primary (i.e., direct) and vicarious sources of traumatic stress. Helpers may feel a positive effect associated with their ability to help.They may also feel negative, secondary effects, called vicarious trauma (VT). Vicarious trauma can be caused by repeatedly hearing horrible stories about extremely stressful events. Some workplace models exist that may be used as a basis for developing prevention and interventions programs for helpers at risk for VT. (Reprint from Stamm, B.H., Varra, E.M., Pearlman, L.A., & Giller, E., 2002) You may hear other terms used…. Secondary stress has also been termed Secondary Traumatic Stress Disorder (STSD), vicarious traumatization, compassion fatigue, or empathic strain. http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_working_disaster.html

What is Compassion Fatigue? A state of tension and preoccupation with the individual or cumulative trauma of clients as manifested in one or more ways: Re-experiencing the traumatic event Avoidance/numbing of reminders of the traumatic event Hyper-arousal (Figley, 1995) Referred to as “the high cost of caring” Differs from burnout Can be insidious and the helper can be unaware of the symptoms Can mimic PTSD

Burnout or Compassion Fatigue? Unlike burnout, the professional with compassion fatigue experiences: Faster onset of symptoms Faster recovery from symptoms Sense of helplessness and confusion Symptoms disconnected from “real” causes Symptoms triggered by additional events (Figley, 1995)

Burnout or Compassion Fatigue? Dose-response relationship: In compassion fatigue, a dose-response relationship is often evident, e.g., the more intense the traumatic circumstances of the clients, the greater the risk to the therapist Increased exposure leads to increased symptoms (generally) (Figley, 1995)

What helps me [deal with trauma] is professionals who have the ability to take care of themselves, be centered, and not take on what comes out of me – not [be] hurt by what I say – sit, be calm and centered, and not personally take on my issues --Survivor from Maine A professional who is in a healthy place themselves will be better prepared to listen to and care for individuals who are going through difficult times. (Maine Trauma Advisory Group, 1997)

Compassion Fatigue and Countertransference Compassion fatigue – absorbing the reactions of the client Countertransference – reaction to the client (Figley, 1995)

Compassion Fatigue and PTSD Similarities between compassion fatigue (also known as secondary stress disorder) and post-traumatic stress disorder (PTSD): 1. Re-experiencing of the event 2. Avoidance/numbing 3. Hyper-arousal (Figley, 1995)

Compassion Fatigue and Burnout Warning Signs: Sleep disturbances Anxiety Helplessness Inability to concentrate Pessimism Absenteeism Decreased empathy with clients, coworkers, and self Seeing the world as either “victims or perpetrators” Lack of meaning in life (Figley, 1995) Compassion Fatigue and Burnout Six categories of reactions: (warning signs) physical, Emotional behavioral, work-related, 5) Interpersonal and 6) spiritual

Physical Warning Signs Fatigue Exhaustion Sleep disturbances Susceptibility to illness (diminished immune system functioning) Specific somatic complaints, such as headache, GI distress, etc. (Figley, 1995)

Emotional Warning Signs Irritability Anxiety Depression Guilt Helplessness Apathy Grandiosity Loss of joy/pleasure (Figley, 1995)

Behavioral Warning Signs Aggressiveness Callousness/uncaring attitude Inability to concentrate Pessimism Defensiveness Cynicism Substance abuse (Figley, 1995)

Work-Related Warning Signs Quitting the job Poor work performance Absenteeism Tardiness Diminished morale Diminished concentration Difficulty completing tasks (Figley, 1995)

Interpersonal Warning Signs Withdrawal and isolation Abrupt communication with coworkers Increased conflicts with coworkers and supervisors Increased complaints re: clients Decreased empathy with clients, coworkers, and self Difficulty separating work from personal life (Figley, 1995)

Spiritual Warning Signs Shattered assumptions Seeing the world as either “victims or perpetrators” Crisis of faith Cynicism Lack of meaning in life Loss of framework for understanding Profound changes in how one views oneself, the world, and the future (Figley, 1995)

Current Research Secondary Traumatic Stress (STS) There is some evidence that STS is not simply a function of secondary exposure to trauma, but also related to a lack of access to appropriate supports and resources Rural workers are more at risk than those in urban areas There is some evidence that STS is linked to organizational climate: role ambiguity & role complexity (Rothschild, 2006)

Secondary Trauma Organizational Prevention Organizations’ core values reflect respect for the human dignity of all employees This respect for and value of the employee is conveyed in tangible and intangible ways Leadership leads by example (Indart, 2006) Organizational mission for addressing health-related problems: Goal: to get the right workers with the right skills in the right place doing the right things!

Secondary Trauma Organizational Prevention Organizational Practices: De-stigmatize secondary trauma through organizational recognition and acknowledgement Establish policies Professional consultation, training, and counseling Self-care Practices: Resiliency Emotional competence Regular self-care practices Compassion for self (Daniel, 2007) WHAT CAN WE DO? Experience has shown that a systemic prevention program can maintain helpers’ well-being and decrease individual and organizational losses like turnover and burnout. A top priority is educating the workforce and those who assist with the long-term responses about VT and other trauma issues. It is important to de-stigmatize secondary trauma through organizational recognition and acknowledgement. Organizations can establish policies that are consistent with current knowledge of risk and prevention of secondary/vicarious traumatization. Support resources, including peer consultation and support, are useful for those involved in helping. Professional consultation, training, and counseling for VT and other secondary effects are vital for those helpers in need. Reprint from Stamm, B.H., Varra, E.M., Pearlman, L.A., & Giller, E. (2002) The Helper’s Power to Heal and To Be Hurt - Or Helped – By Trying. Washington, DC: Register Report: A Publication of the National Register of Health Service Providers in Psychology.

Self-Care Prevention and Practices Self care is personal health maintenance. It is any activity of an individual, family, or community with the intention of improving or restoring... Resiliency Emotional competence—know thyself Regular self-care practices Compassion (en.wikipedia.org/wiki/Self_care) Self Care” Best Practice for Mental Health Workers”-These slides introduce the concept of “best practice in self care” which is meant to emphasize the importance of this for staff. Prevention of Stress Disorders… Effective Stress Management Strategies: Must help you FEEL better …..Must help you FUNCTION better

What is 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 (Daniel, 2007) Resilience means being able to adapt to life’s misfortunes and setbacks. Test your resilience level and get tips to build your own resilience. When something goes wrong, do you tend to bounce back or fall apart? People with resilience harness inner strengths and rebound more quickly from a setback or challenge, whether it’s a job loss, an illness or the death of a loved one. Resilience won’t necessarily make your problems go away. But resilience can give you the ability to see past them, find some enjoyment in life, and handle future stressors better. If you aren’t as resilient as you’d like, you can work on skills to become more resilient.

“The Key to Building Resilience” 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)

Strategies for Building Resilience to Stress 1. Maintain flexibility and balance in your life as you deal with stressful circumstances and traumatic events 2. Let yourself experience strong emotions, and also realize when you may need to avoid experiencing them at times in order to continue functioning 3. Step forward to take action, and also step back to rest yourself 4. Rely on others, and also rely on yourself (Daniel, 2007)

Ten Strategies for Building Resilience 1. Make connections-- Family, friends, civic groups, faith-based organizations, other local groups 2. Avoid seeing crises as insurmountable problems. You can change how you interpret and respond to stressful events 3. Accept that change is a part of living. The only thing that is constant in life is change 4. Do something regularly, even if it seems small, which enables you to move toward your goals (Daniel, 2007) Accept and anticipate change. Be flexible. Try not to be so rigid that even minor changes upset you or that you become anxious in the face of uncertainty. Expecting changes to occur makes it easier to adapt to them, tolerate them and even welcome them. Work toward goals. Do something every day that gives you a sense of accomplishment. Even small, everyday goals are important. Having goals helps direct you toward the future.

Ten Strategies for Building Resilience 5. Take decisive actions rather than detaching completely and wishing problems and stresses would go away 6. Look for opportunities for self-discovery. People often grow in some respect as a result of their struggle with loss 7. Nurture a positive view of yourself. Develop confidence in your ability to solve problems; trust your instincts 8. Keep things in perspective. Keep a long-term perspective--avoid blowing things out of proportion (Daniel, 2007)

Ten Strategies for Building Resilience 9. Maintain a hopeful outlook. Expect that good things will happen in your life; visualize what you want rather than worrying about what you fear 10. Take care of yourself. Pay attention to your own needs and feelings. Engage in activities you enjoy and find relaxing (Daniel, 2007) Work toward goals. Do something every day that gives you a sense of accomplishment. Even small, everyday goals are important. Having goals helps direct you toward the future. Calming Practices: Meditation and spiritual practices help some people build connections and restore hope. Journaling: Writing about thoughts and feeling related to trauma or other stressful events are also helpful to some people

Effective Stress Management Strategies Must help you FEEL better Must help you FUNCTION better Take action. Don’t just wish your problems would go away or try to ignore them. Instead, figure out what needs to be done, make a plan to do it, and then take action (Figley, 2002) Over the next several slides we will be focusing on the development of your self care plan…we will support you through a list of questions.

Lowell Youth Treatment Center Staff Office - Lowell, MA This facility created a staff comfort room, knowing that staff have difficult jobs and need to be cared for too! Staff need a little comfort, too 37 37

KNOW THY SELF Emotional Competence: Self-awareness Self-management Social awareness Social skills (Daniel, 2007)

Your Stress Profile SELF ASSESMENT Things That Stress You Out Warning Signs You Are Stressed Out Negative Stress Management Strategies Positive Stress Management Strategies (Daniel, 2007) This is a quick way to evaluate your own stress levels. Another exercise helps participants obtain a stress “score.”  We can introduce this scale with explaining that the authors explored a vehicle to postulate the chances of people developing a stress related illness.  Participants should complete the scale and add up their points.  The trainer should consider posing the following questions/comments, either for the full scale below, or for the self-assessment stress profile above.   For those of you who feel comfortable in sharing their experiences, what did you learn about your stress level? Did anything concern you regarding your stress level? Do you plan to utilize the information you obtain? If yes how? Please be specific  Facilitators might consider printing this into a page they can give as a handout. If time it can be done in class, or it could be given to people to use afterwards. This is clearly not a comprehensive list, but can give participants an idea of what kinds of things might be causing stress in their lives that they are unaware of. Death of a spouse -100 Divorce -73 Marital Separation -65 Jail term -63 Death of a close family member -63 Personal injury or illness -53 Marriage -50 Fired at work -47 Marital reconciliation -45 Retirement -45 Change in health of family member -44 Pregnancy -40 Sex difficulties -39 Gain of a new family member -39 Business readjustments -39 Change in financial state -38 Death of a close friend -37 Change to different line of work -36 Change in no. of arguments with spouse -35 Mortgage over $ 50,000 -31 Foreclosure of mortgage -30 Change in responsibilities at work -29 Son or daughter leaving home -29 Trouble with in-laws -29 Outstanding Personal achievements -28 Wife begins or stops work -26 Begin or end school -26 Change in living conditions -25 Revision of personal habits -24 Trouble with boss -23 Change in work hours or conditions -20 Change in residence -20 Change in school -20 Change in recreation -19 Change in religious activities -19 Change in social activities -18 Loan less than 50,000 -17 Change in sleeping habits -16 Change in no. of family get- together -15 Change in eating habits -15 Vacation -13 Holidays -12 Minor violation of laws -11 SCORING Each event should be considered if it has taken place in the last 12 months. Add values to the right of each item to obtain the total score. Your susceptibility to illness and mental health problems: Low< 149 Mild= 150-200 Moderate= 200-299 Major>300 (Horowitz et. Al, 1977)

Self-Care Practices Practice good sleep “hygiene” Practice good nutrition Practice regular exercise Practice active relaxation Practice your faith Practice letting others take care of you for a change Practice BREATHING! (Daniel, 2007) Final reminder

Exercise: Developing Your Self- Care Plan What do you value most about your current job as a mental health worker? What do you expect to be the most stressful aspect of your job? What do you expect will be the most rewarding? How will you know when you are stressed? How will you monitor your stress level?   What can others do for you when you are stressed?   What can you do for yourself when you are stressed?  What prevention strategies will you utilize?   What will you do if your strategies don’t work?  Following this training will you do anything differently at your job?  

Self Care is Not Selfish Thank You