BUILDING WORKER RESILIENCE BYRECOGNIZING AND RESPONDING TOSECONDARY TRAUMATIC STRESSMIRIAM SILMAN MSWSYSTEM OF CARE ACADEMY

JUNE 10, 2020

Objectives learn about secondary traumatic stress and burnout identify individual, organizational and contextual risk for STS recognize signs and symptoms associated with STS understand strategies and approaches to minimize risk and

promote resilience to STS identify constructive response strategies for STS create a personal plan to reduce risk and promote resilience to STS

Self-Awareness Reminder

• Pay attention to your own needs & responses

• Take care of yourself however you need to during our discussion

• Effects can linger, or surface later

• Use coping skills that help you metabolize your responses to trauma

• Find a safe space in which you can process your experiences – this may mean using coping strategies including talking to colleagues, friends, family, or a professional provider

3

Work Stress

What is Burnout?

“the extinction of motivation or incentive, especially when one’s devotion to a cause or relationship fails to produce the desired results”

(Freudenberger, 1980)

Signs & Symptoms of Burnout

Physical

EmotionalCognitiveWork

Performance

Unhealthy Coping

Social

Signs & Symptoms of Burnout Physical exhaustion, lack of energy, illness, loss of appetite, poor sleep Emotional exhaustion, irritability, anxiety, depression, Cognitive negativity, hopelessness, cynicism, sense of reduced effectiveness, poor concentration, poor memory, apathySocial isolation, withdrawal, detachment, anhedoniaPoor work performance, increased absenteeismAdoption of maladaptive coping strategies (food, drugs, sex, deprivation, etc.)

Sources of Burnout Too much to do, heavy workloadsActual or perceived lack of peer support and connectivity in the workplaceActual or perceived lack of supervisory support, poor communication with supervisor/ leadershipLack of role clarity, sense of limited or no controlPerfectionism, taking on too much responsibilityLimited successful outcomes, working in a helping professionOther life stressors, poor work-life balance

Combatting Burnout Unplug regularly (even if it’s for short periods)Adjust work-life balance, set limits, take breaksGet organized & schedule your timeCultivate healthy habits: Sleep more & develop good sleep hygiene; exercise & eat regularlyHave fun when you can, cultivate your non-work lifeBe in tune with yourself, identify what’s internally and what’s externally-drivenAccept good: “the perfect is often the enemy of the good”

Maybe it’s not Burnout…

Trauma Stewardship Institute

(www.traumastewardship.com)

“An introductory video to make you smile”Video is last one on this page:

https://traumastewardship.com/watch/

Workplace Threats to Worker Resilience

Compassion Fatigue

Secondary Traumatic

Stress

Vicarious Traumatization/

Moral Injury

Burnout

Compassion Fatigue• “the cost of caring” (Figley)

• “the emotional duress that results when an individual hears about the firsthand trauma experiences of another” (NCTSN)

• “gradual erosion of…our empathy, our hope, and of course our compassion – not only for others but also for ourselves” (Mathieu)

Secondary Traumatic Stress

• “the natural, consequent behaviors and emotions resulting from knowing about a traumatizing event experienced or suffered by a person” (Figley, 1995)

• Exposure to secondary trauma manifests in signs and symptoms of traumatic stress

Sources of Secondary TraumaHearing the stories of others in interviews, assessments, investigationsReading about traumatic experiences of consumersReviewing case materialSeeing images of traumaLearning about a trauma that seems close to you personally (e.g. same age child as one in your family)Chronic poor outcomes for those you serve

Vicarious Traumatization

• Transformation of the…helper’s inner experience as a result of empathic engagement with survivor clients and their trauma material….our cherished beliefs are challenged and we are changed” (Saakvitne & Pearlman)

Moral Injury/ Moral Distress• Challenges our core values and

ethical frameworks • Disrupts the foundation of how we

live in small and large moments• Elicits feelings of shame, guilt,

betrayal, doubt, mistrust, despair, hopelessness, powerlessness

• Impacts our working and personal functioning

Fractured Soul by Tate Krupa

Risk Factors for STS• Professionals working with populations who have experienced trauma• High rates of exposure to traumatic material: high caseloads, high

percentages of trauma cases • Being female (statistically)• Personal history of trauma and haven’t been able to attend to it• Not feeling trained, prepared or competent to do your job• Being new to the field• High level of emotional intelligence and strong empathy

How many individual risk factors? zero12345 or more

• Clients have experienced trauma• High rates of exposure to traumatic material• female• Personal history of unresolved trauma • Don’t feel trained, prepared or competent• New to the field• High emotional intelligence & empathy

Signs & Symptoms of STS

Physical

EmotionalCognitiveWork

Performance

Unhealthy Coping

Social

Spiritual

Signs & Symptoms of STS• Hypervigilance, fear, excessive

anxiety

• Avoidance, inability to listen

• Physical ailments, chronic exhaustion, poor sleep

• Hopelessness, depression, sadness, feeling numb

• Intrusive thoughts, nightmares

• Anger, cynicism

• Minimizing

• Guilt

• Inability to embrace complexity & nuance

Organizational Symptoms of STSLow level of staff satisfaction

Poor retention, high turnover

Disruption of continuity of care

Miscommunication/ errors in casework

Increased caseloads -> increased dose exposure -> increased STS risk

Economic losses for agency

Poor care for consumers

Organizational Risk for STS• High case loads• Limited or no access to reflective supervision and support• Lack of training & preparation of workforce• Re-traumatization through sharing of traumatic content • Culture of “sucking it up” or “stiff upper lip”

How many organizational risk factors? zero12345

•High case loads

•Limited supervision/ support

•Lack of training/ preparedness

•Sharing of traumatic material

•Stiff upper lip culture/ stigma

What’s the Relationship?

BurnoutSecondary Traumatic

Stress

Burnout STS

What’s the Relationship?

STS Burnout

OR

Complex Relationships

ProfessionalQualityof Life

Compassion Fatigue

Compassion Satisfaction (ProQOL CS)

Work Environment

Client Environment

Personal Environment

Traumatized by work

Secondary Exposure

(ProQOL STS)

Primary Exposure

Frustration Anger

ExhaustionDepressed by

Work Environment(ProQOL Burnout)

Copyright Beth Hudnall Stamm, 2008; www.proqol.org

Additional Stress during COVID-19• Concern for client well-being; disparities clients may

experience

• Work limitations

• Workload increases

• Exposure & contagion concerns• Personal stressors

The Impact of Racial Trauma • Concern for clients’ physical and psychological well-being;

disparities are clearly evident

• If we are Black: fear, anxiety, persistent threat, anger, grief

• If we are not Black: overwhelm, powerlessness, frustration, anger, sadness, guilt, discomfort, confusion

• Unsure what to do & how to be with one another & with clients

Laura Vandernoot Lipsky

TedXTalk: “Beyond the Cliff”Top one on this page:

https://traumastewardship.com/watch/Clip I used is from 5.35 – 9.25

(but of course the whole talk is great)

Protective Factors

Mentoring

Sense of Satisfaction

Work Boundaries

Self-Care

Social Emotional Support

Ludick, M. & Figley, C.R. (2017). Toward a mechanism for secondary trauma induction and reduction: Reimagining a theory of secondary traumatic stress, Traumatology, 23(1), 112-12

Promoting ResilienceBe aware & acknowledge Take care of your bodyTake care of your mindMaintain a routineStay connected Be prosocialCreate safe spaces for BIPOC staff

• Physical• Psychological• Emotional• Spiritual• Personal• ProfessionalAvailable at: https://www.olgaphoenix.com/key-offerings/self-care-wheel/

Using the Self-Care Wheel• Write one thing in each pie piece

• Rate each thing 1, 2 or 3: 1 = never use it; not helpful 2 = use it some; somewhat helpful3 = use it regularly; helpful

• Forget the 1’s; modify the 2’s

• What else can you do?

Reflection: Set an Intention

What is one thing you can do this week to care for yourself?

5-M

inut

e Br

eak

• Stand up, move around, stretch

• Go to the rest room

• Get a glass of water

• Make sure you have more paper and something to write with

Promoting Workforce Resilience AwarenessAvoid Re-traumatizationABalanceBuild Compassion SatisfactionBConnect & CollaborateCrisis ResponseCompassionC

Awar

enes

s

Organizations• Normalize STS as a potential occupational

hazard• Avoid stigmatization of STS• Recognize risk factors• Check in with people regularly• Include assessing STS as part of supervision;

don’t make quantity the only measure of valuable work

• Support workforce activities that promote self-reflection & self-awareness

Individuals• Stay present• Recognize risk factors• Hear what peers & supervisors are saying• Assume supervision includes STS monitoring• Use self-report measures periodically• Acknowledge when there is exposure, seek

support, and monitor carefully afterwards• Ask for assistance from peers, mentors and

supervisors

Awareness

Checking InFormal Check-in

• Supervision

• Meeting starts

• Check-in at beginning or end of day

• Project check-in

• Case Review/ Treatment Team/ PLC

• STS focused groups

Informal Check-in• “Water Cooler”

• Lunch

• Email outreach

• Phone call

• Sharing a funny

• Social media

Professional Quality of Life (Pro-QOL 5)B. Hudnall-Stamm (2009)◦ 30 items◦ 3 Subscales: Compassion

Satisfaction, Burnout, Secondary Traumatic Stress

◦ Self-Score◦ Publicly available at

https://www.proqol.org/

Secondary Traumatic Stress Scale (STSS)Bride (1999, 2013) Bride, Robinson, Yegidis & Figley (2004)◦ Total STS score◦ 4 subscales correlating to 4 domains

of traumatic stress: Avoidance, Intrusion, Arousal, Negative Alterations of Cognition & Mood

◦ Author permission

STS Screening Measures

Avoi

d Re

-Tr

aum

atiz

atio

n

OrganizationsBuild low-impact approach into all protocols: • minimize sharing of details by only repeating

those that are actually necessary • focus on how the situation is impacting our

work with the student rather than what happened to the student

• adopt a low-impact processing approach • focus on how the situation makes us feel

rather than the details of the traumatic experience

Individuals• Use low-impact processing

• Know when you need to say “no” to a request to debrief from someone else

• Identify your triggers; prepare or avoid them when possible

• Speak up to peers, supervisors, friends and family about what you need and what is helpful

Avoid Re-traumatization

Low-Impact Debriefing/ Processing

1. Self-Awareness

2. Fair Warning

3. Consent

4. Limited Disclosure

Copyright 2019, TEND Academy: www.tendacademy.ca

Low-Impact Debriefing/ Processing

Where can you utilize low-impact processing in your routine practices?

As an individual? As an agency?

Bala

nce

Integrating work with life

Integrating empathy & compassion with healthy boundaries

Integrating assistance & advocacy; help with building independence & self-reliance

Balance: Correct Proportions

Compassion Satisfaction

Compassion Fatigue

Build Compassion Satisfaction

Recognize, share, celebrate, remember these moments

◦ Moments of grace

◦ Moments that give you goosebumps

Recognize & Celebrate

Reflection: Your Inspiration

◦ Why did you enter the field?

◦ What’s a case that reminds you why you do this work?

◦ Share, remember & cherish your inspiration

Conn

ect &

Co

llabo

rate

Organizations• Promote collaborative work for problem-

solving, innovation and creativity• Support connections between workers

for work and celebration & support• Encourage supervisors & leaders to

connect on a human level with staff• Create opportunities for staff to have a

meaningful voice

Individuals• Connect with peers & colleagues• Connect with supervisors &

leadership • Offer input• Collaborate to problem solve• Collaborate to become more STS-

informed• Connect with family and friends

Connect & Collaborate

Cris

is

Resp

onse

Hot Walk & Talk (for non-physical incidents)

1. Go to the person – don’t wait for them to come to you

2. Walk away from the “hot spot”3. Walk beside them briskly enough to

help discharge energy & stress4. Have water available & offer it5. Establish a sense of psychological

safety; normalize the stress response

6. Ask them to recount the incident; help them get to the end

7. Complete incident report as required8. Prompt them to use calming

strategies e.g. deep breathing9. Ask them what they need next:

sandwich? break? back to work? 10.Offer support & BH resources

Crisis Support in the Moment

Patricia Fisher, PhD, 2012, Tend Academy

Com

pass

ion

Extend to yourself what you give to others3 Components:

1.Self-kindness2.Common humanity3.Mindful self-

awareness

What to do:• Positive self-talk• Visualize how you would

respond to a friend or colleague• Notice your own suffering &

Seek support. Ask for help!

Self-Compassion: Grace & Forgiveness

Self-Care is Nourishing1. Take care of your body: eat well, exercise, sleep enough

2. Quiet or focus your mind: use mindfulness, meditation or mental focusing strategies

3. Metabolize your feelings: consider journaling or talking about what you are feeling

4. Practice self-compassion: give yourself permission to be “good enough” instead of “perfect” or “the best”

5. Maintain healthy boundaries: know when to say “no” or “not now”

6. Ask for help from others: use peer consultation & supervision; know how to seek assistance from professionals

Self-Regulation & Self-Awareness

Mindfulness

“Mindfulness is awareness that arises through paying attention, on purpose, in the present moment, non-judgementally, in the service of self-understanding and wisdom.”

-- Jon Kabat-Zinn

The Science of Self-RegulationSympathetic Nervous SystemActivated by the Alarm response

Sends body into flight, flee or freeze mode by releasing cortisol and adrenaline

Diverts blood flow to muscles needed for fight, flee, freeze & contracts muscles

Releases glucose from liver to provide energy

Increases heart rate, dilates lungs to breathe more quickly, dilates blood vessels to promote flow,

Parasympathetic Nervous SystemMaintains system in a non-alarm state of rest

Restores body to state of normal functioning, ideally one of calm and rest; no stress hormones released

Blood flow goes to all areas of body working, e.g. digestion, thinking

Energy production is paced and relatively even

Decreases heart rate, constricts bronchial tubes, constricts blood vessels,

Mindfulness Strategies• Breathing• Progressive muscle relaxation• Meditation• Grounding• Mindful walking• Mindful eating

• Try Headspace, Calm and Stop, Breathe & Think

The Six Pillars of Self Care from Stephanie Winn, LMFT

Rest Nourishment Cleansing Grounding EnergySafety/Protection

Physical

Mental

Emotional

Spiritual

Available at: https://adai.uw.edu/nwattc/pdfs/6pillarscare.pdf

RestNourish-ment Cleansing Grounding Energy

Safety/Protection

PhysicalGood sleep hygieneGetting enough sleep

Healthy snacksRegular meals & water

Showers/ bathsClean work & living spaces

Daily routinesTime in nature

ExerciseNutritionSunshine

Safe work & home spaces

MentalMeditation AcceptanceLetting go

Lifelong learningBrain-teasers

MeditationDigital detox

Setting intentionsMaking a listBeing present

Inspirations Meaningful work

TherapyDiscernmentPriorities

EmotionalSelf-acceptanceSocial media breaksLetting go

FriendsPetsAffirmations

GrievingCrying“Letting it out”Unburdening

Sensory groundingMemoriesHands in dirt

LaughterMusic, dance, artSports, exercise

Setting boundariesTrusted connections

SpiritualContemplationMeditationPrayer

Spiritual reading, music, community

Spiritual ritualsRites of passageHolidayscelebrations

Finding purposeSpiritual community

Protection prayersTalisman

Culture of Compassion is TIC

Safety Trust Choice

Empowerment CollaborationCultural

Competency & Equity

Based on Fallot & Harris, 2009

What can you do for yourself?Awareness: Learn more about STSAvoid Re-Traumatization: Know what you need, what triggers you, set boundariesABalance: Add some fun to your lifeBuild Satisfaction: Celebrate successes, set goals & enjoy working towards them; be proud!BConnect: Connect with friends & familyCollaborate: Seek & offer input, assistance, and guidanceCompassion & Care for Self: As a routine part of workC

What can you do in your workplace?

Awareness: Talk about & normalize STSAvoid Re-Traumatization: Low-impact processing routinesABalance: Adjust exposure doseBuild Satisfaction: Share moments of grace, remember inspirations, celebrate successesBConnect: Colleagues, mentors & supervisors Collaborate: On tasks, problem-solving, solutions, supportCulture of Compassion: For self & others, in crisis & alwaysC

Reflection: Set an Intention

What is one thing you can change in your workplace to promote resilience?

Reflection: Taking it Back

1. One thing you plan to use

2. One thing you want to learn more about

3. One thing that worries you about being more STS-aware and more STS-responsive

Miriam Silman, MSWProject AWARE/Trauma Informed Care Program Administrator Department for Behavioral Health, Developmental and Intellectual DisabilitiesCabinet for Health and Family Services275 East Main Street 4W-FFrankfort, Kentucky 40621miriam.silman@ky.gov502-782-3662