This may be an unpopular way to begin a blog entry on vicarious trauma in the human services, but I have developed a very large distaste for the concept of self-care. It is not that I don’t believe in the need for public servants in the human services to bring intention to their daily practices so as to provide space for self-regulation, healing, joy, and to cope with the rigors of a very emotionally and psychologically taxing chosen profession. My distaste for the term self-care is that the phrase itself has become so overused that we often confuse talking about self-care with actually engaging in the practice of self-care. We must also recognize there is a tension in being primarily responsible (ethically responsible) for your own self-care in a neoliberal system, where you are also messaged that your responsibility to bill for services is the brick and mortar of program sustainability, and if you do not meet productivity demands the structures themselves may fall and jobs may be compromised. The message is—you need to take care of yourself. Also, you need to deal with untenable human conditions and document in very specific ways to justify the necessity of your work. Also, if you don’t—we may all lose our jobs.

An excellent example of how self-care has become literalized or a dead metaphor, often talked about and seldom integrated, occurred when I worked in an outpatient mental health clinic serving people with severe mental illness. Clinic work is exhausting, involving many duties including facilitating walk in clinical biopsychosocial assessments (often with people in a psychotic, manic, or depressive episode), intensive Medical documentation compliance standards, individual and group therapy facilitation, and regular 5150 evaluations and psychiatric holds for individuals with suicidal or homicidal thoughts and intentions, as well as grave disabilities (an inability to engage in life sustaining activities of daily living such as eating food or drinking water). Being a clinical staff in a community based Behavioral Health setting is extremely difficult work that has cumulative effects on the good people who provide the services. Burnout, compassion fatigue, secondary and vicarious trauma are very real things.

In an effort to address vicarious trauma in the workplace, the clinic Supervisor emailed a journal article titled “Self-Care as an Ethical Responsibility” to the entire staff. She spoke at length in a unit meeting about the article, and advised she would be putting self-care as a regular agenda item in our recurring staff meetings. This particular Supervisor was very trauma informed and the idea appeared to be a very positive one. Inevitably, the staff meeting agendas would be highly impacted with agenda items about staff productivity, changing forms and QA/QI needs, program initiatives to meet ever changing and expanding insurer and State demands, and numerous ancillary community-based programs which depend on clinic referrals to sustain their programs. As a result, the self-care agenda item was regularly last on the agenda, and often we would run out of time before the agenda item causing staff to scurry with their self-care presentation; a reality symbolic of the professions proposed trauma informed efforts being incongruent with the realities of the system. It is an untenable proposition to task individuals with an ethical responsibility to engage in something they are solely responsible for but not afforded the time or support to actually engage in.

There is a tremendous amount of responsibility and loss weaved in to the very nature of community behavioral health. The population served are very sick and some (too many) do die by suicide or drug overdose. People in a manic or psychotic episode who are actively paranoid and/or delusional do show behaviors and make threats that inevitably cause legitimate concerns for safety and traumatize staff members. Couple those elements with a neoliberal business model environment where staff productivity is less measured qualitatively in empathically developed relationships, client stabilization, and treatment breakthroughs, rather bottom-line spread sheet results in a thoroughfare where programs fail if staff do not generate revenue through billing. Meanwhile, siloed culture becomes the norm, Supervisors struggle to deal with difficult personnel matters, and staff often have to step outside of procedures to fill gaps and serve clients while their own well-being is often compromised. The reality is using flex funds to create quiet rooms with cozy couches the staff have no time to use—or webinars where a facilitator models deep breathing techniques and participants talk briefly about watching baseball, listening to music, or exercising is antiquated and simply does not work.

The questions remain, how do you know you are working in a trauma effected system, and what do you do to create space and community approaches to care for the caretakers? Answering “yes” to any of the following questions may indicate you work in a trauma effected system:

· Do staff often talk about silos?

· Do staff often complain to each other behind closed doors but are silent when given the opportunity to talk in large groups?

· Are there multiple initiatives that cover the same topics?

· Do initiatives or workgroups fizzle out?

· Despite limited to no violent incidents, do meetings often center on “safety”?

· Do staff who professionally challenge the status quo get labeled as “resistant” or “unsafe”?

· Do employees feel the “place will fall apart” if they are not there?

· Are teams positioned against each other? Does it often feel adversarial when collaborating with other units?

· Do staff members often seek measures of control (metal detectors; overusing law enforcement intervention; always talking about conservatorship)?

· Do staff members seek to not serve (ask if the client really lives in the jurisdiction; try to refer out “difficult” client’s)?

· Does it always feel like a crisis?

· Are people cynical in response to adverse outcomes (deaths of clients)? Do staff make judgmental comments about the client’s death?

In answering these questions, I ask we consider the symptoms of post-traumatic stress disorder (PTSD). Whereas when most people think about PTSD, they often think about symptoms such as nightmares, flashbacks, and depressive symptoms such as suicidality, there are many other symptoms of PTSD which can be applied to trauma effected systems/organizations. The following is a list of symptoms of PTSD often overlooked. Please take a moment to read through these then re-read the questions above considering which symptoms could be applied:

· Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the trauma.

· Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the trauma.

· Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

· Persistent, distorted cognitions about the cause or consequences of the trauma that leads the individual to blame himself/herself or others.

· Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

· Feelings of detachment or estrangement from others.

· Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.

· Hypervigilance.

· Exaggerated startle response.

· Problems with concentration.

The types of negative or toxic workplace culture issues that arise in trauma effected systems can be understood in exploring trauma response as applied to systems. Silos can be understood as a distorted cognition or avoidance response (or detachment and estrangement from others). Adversarial relationships between units can be understood as persistent negative beliefs about others as can power oriented cliques amongst middle managers. Pervasive distrust can also explain behind doors conversations that become muted in larger meetings intended to support system change. Consider the types of pervasive fears that exist in trauma effected systems: fear of change; fear of being fired; fear of failure; fear of being held responsible for a client death; fear of being excluded from promotional opportunities for speaking your truth.

The realty is no 2-hour skill-based self-care seminar is going to change what makes systems so traumatic. Most human service professional know what the skills are—what they typically don’t have is the support or opportunity to enact those skills during moments professionally that call for it. Many great employees leave organizations for the sake of the own care and wellness, despite being passionate about client care and wanting to continue the work. For the overall health of an organization and its employees, and to increase the public trust of Behavioral Health systems, this has to change. It is important to maintain hope that this can change. Trainings that provide safe and honest spaces to discuss the realities staff face every day are more meaningful than skill-based trainings. Organizations supporting middle managers to develop community care processes, peer support teams, unit meetings which promote authenticity, vulnerability, and honesty can be developed. CCT would like to help you with this process.

Mark Mautner, CCT