A friend recently shared with me her experience of training staff at a behavioral health center in trauma-informed care. She asked for participants to share an example of when their work had triggered their own trauma response and her question was met with a gripping silence as a blanket of tension pressed heavily on the room. It was clear participants did not want to share or didn’t feel safe enough to share. Rather than simply moving on or providing a cookie cutter example, she took a risk. She chose to be vulnerable and share her experience of being triggered during a family session due to trauma she experienced in her marriage. Her intentional choice to be vulnerable and share something personal opened a doorway for others. The feeling in the room shifted and a participant was then able to share their own trauma response experience.
Another friend participated in a national behavioral health leadership program and returned from one of the conferences energized and passionate about the power of vulnerability in leadership. So, I did what any person like me would do when something piques my interest: I googled it. I spent a few hours reviewing articles on trauma-informed systems of care and the power of vulnerability. I also reflected upon my time working at two behavioral health organizations as staff learned to adopt a trauma-informed culture.
These two incidents occurring so closely together made me pause and consider how a leader’s level of vulnerability might be correlated with the degree to which that organization’s culture is trauma informed. The basic characteristics of a Trauma Informed System of Care (TISC) include safety, trustworthiness, choice, collaboration, and empowerment. To become a TISC, an organization must examine multiple aspects of the system, including the physical environment, clinical assessment, and interventions, staff relationships and morale, organizational communication, response to secondary trauma, etc. It is a culture, not a set of services or interventions. Leaders must learn to be vulnerable if there is any hope for their organizations to truly adopt this trauma-informed culture. This culture must include everyone, from clerical staff to the cleaning crew, to clinicians and perhaps most importantly (and often overlooked), leadership.
Regardless of where your organization is on the journey to becoming a TISC, as a leader in your organization, challenge yourself to explore how vulnerable your team is willing to be, and your own reactions to vulnerability. Do you avoid it? Do you see vulnerability as a weakness? Do you become anxious or tense at the thought of sharing personal experiences with your co-workers? Do you feel your co-workers need to “suck it up” and not be so “needy”? Do you view co-workers as overly dramatic and attention seeking? Do you feel disconnected from others at your workplace? Do you rationalize your emotional distance by telling yourself that you shouldn’t have meaningful connections with others at work or that you need to maintain an image of strength? Do you find yourself fighting back when someone criticizes you or your decision?
Or, do you embrace your vulnerability? Brene Brown and Myric Polhemus both discuss the critical importance of connecting deeply with the people with whom you work. A leader must be vulnerable in order to truly connect with her staff. Are you self-aware? Do you reveal your thoughts and feelings to others, even when doing so makes you feel emotionally at risk? Are you open to considering you made a mistake? Do you admit it when you’re wrong? Do you approach your imperfections with humor and grace? Do you ask clarifying questions to better understand your co-workers, especially when you disagree with them? Do you truly listen to their perception of events and allow this to alter your perceptions?
By opening yourself up to be vulnerable, your employees will follow your example, and find motivation from a genuine interest to serve (relationship power), rather than feeling coerced (role power). By fostering deep and meaningful connections with your staff, they will learn to feel safe, a fundamental requirement of a TISC. I have observed that when staff on my team felt secure (in their position, in the organization) they were more likely to provide needed feedback to the organization and to be more innovative. Leaders work tirelessly to ensure that those served by the organization feel safe, supported and that the systems of care do not re-traumatize them. As leaders, we should settle for no less for our staff.
We seem to have a love/hate relationship with them. Even if we try not to, we find ourselves using them in meetings or in discussion with co-workers. In healthcare, the “Triple Aim” is one of these. The concept is great: Improving the patient experience of care AND improving the health of populations AND reducing the per capita cost of health care.
“Triple Aim” has definitely become “a buzz” within the behavioral health community over the past few years. Many behavioral health organizations have included it in their mission, vision or strategic plan. These important tools identify the direction of the organization.
But if the focus on the Triple Aim never escapes the C-Suite (CEO, COO, CFO, etc.), there is risk that it will not become embedded within the workplace culture and actually impact workflow, outcomes, and ultimately, the people whose lives it could benefit most.
It is far easier to discuss buzz words than actually adapt our business to reflect a new reality. To adapt to a new environment or the presence of a new variable is challenging. It’s also necessary. Adaptation can take years but ultimately can determine your organization’s survival.
Biologists are very familiar with this concept. Rosemary and Peter Grant are two researchers who spent almost 30 years researching the finch population on two small islands, Daphne Major and Genovesa, in the Galápagos archipelago, Ecuador. They found that there was a difference in the size of the ground finches’ bills between islands. The size of the bills was conditional upon which other finch species were present. To survive and thrive, these animals had to adapt. I propose that program managers within your organization need to be like those finches.
Program managers within behavioral health organizations have a great opportunity to use the Triple Aim as a foundation for program evaluation. My experience has been that a program manager’s time is often consumed by meetings, staff supervision, reviewing staff documentation, updating policy and procedures, preparing for audits and accreditation surveys, as well as the ever popular and time-consuming HR problems. With all these demands, it is no surprise that it can be very challenging to actually engage in meaningful program evaluation and identify any areas in which the team may need to adapt.
If you are leading a behavioral health program, such home based therapy or case management, the Triple Aim framework can be used to evaluate and improve the program.
Does your team utilize patient satisfaction measures? Are they meaningful or a survey that staff pass out once a year that most patients throw away? How are your staff collecting patient report of satisfaction on an ongoing basis? Do they simply check “satisfied” in the progress note if the patient didn’t seem upset about their services that day? Or do they have meaningful discussion with persons served about how services are helping them and any changes that need to be made? How do you measure quality of your services? Do you use fidelity measures for best practices? Once patient satisfaction and quality metrics are measured, do you share this information with staff? With persons served?
This one can seem pretty overwhelming. Behavioral health clinicians work very hard to keep those they serve out of jail, inpatient units, etc. Improving their health may feel like an impossible task — but it’s not! Start small, pick one population you want to target, such as children taking atypical antipsychotics or adults with diabetes and depression. Define clear goals and measures. Work closely with your information specialists and analysts to identify a way to collect data and track your outcomes. Implement Plan, Do, Study, Act (PDSA) cycles to improve care. Research shows that persons with severe and persistent mental illness die, on average, 25 years younger than the general population, often due to treatable conditions*. Therefore, it is critical that we adapt the care that we provide to be more integrated, focusing on overall health.
In some behavioral health organizations, program managers may think “How am I supposed to impact cost? Isn’t that the finance department’s job?” If you feel out of the loop regarding the cost of your program:
These activities only focus on the cost of your team’s services. That’s a good start. But to impact per capita cost, you have to look at all health care costs. This is a significant challenge.
Even though we now have growing access to encounter data and various data analytic software packages, many do not include cost data. There are some creative efforts at the local level to engage in dialogue with other health care providers via regional health improvement councils. What’s needed are data sharing agreements or releases of information to gain patient consent so that protected health information data can be shared.
Dialogue with community providers can help you identify ways to reduce the cost for specific populations. You could also try contacting a player, such as a Medicaid HMO, that provides coverage for a large portion of the population you are addressing. They may be willing to work with you on a pilot project and would be able to track the overall cost of your participants (for which they provide coverage).
In the ever-changing landscape of healthcare reform, it is increasingly critical for behavioral health providers to be competitive within the larger health care market. Now more than ever, we need to be able to demonstrate effective outcomes (evidenced by data!), competitive costs, and high patient satisfaction.
We encourage you to use team/individual goal setting and process improvement teams as an opportunity to integrate Triple Aim principles into your workflow and agency culture. This will help you to flourish in the era of integrated, value-based care. Implementing Triple Aim goals at the program level and monitoring progress with data will help ensure your success.
* For additional information please see Morbidity and Mortality in People with Serious Mental Illness,” published in October 2006 by the National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council (http://www.nasmhpd.org/) and an earlier report by the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (SAMHSA), Sixteen State Study on Mental Health Performance Measures. Rockville, MD: DHHS Publication No (SMA) 03-3835; 2003).
In behavioral health treatment, the pendulum of personal and professional experience has slowly swung from side to side for the past century. From Alcoholics Anonymous to the advent of Vet Centers for returning Vietnam veterans, peers have exemplified the power of empathy by supporting one another through shared life events. Their firsthand knowledge helps to bridge the chasm of fear that clients carry that they will not be truly understood.
While peer support has grown and evolved, so, too, have the clinical professions and their effectiveness. Identifying and implementing best practices in therapeutic settings have helped change the face of clinical services, from a nebulous, undefined journey through the subconscious to a meaningful service that delivers results.
As recently as 5 years ago, graduate training programs in fields such as psychology, counseling, and social work did not give substantial attention to peer support or sharing personal experiences as an effective treatment tool, instead advocating an approach that all but extinguished self-disclosure in a therapeutic setting due to fears of transference and crossing professional boundaries.
Empirical studies that validated the tools and methods of clinical professionals are now affirming the effectiveness of peer supports in treatment settings, demonstrating similar outcomes to their more educated constituents. In the last 10 years, many states have formalized the training and certification process for peer support specialists, bringing a level of credibility to their work that has not previously been seen. To make matters more complex, clinical professionals and peer supports are now working side-by-side in recovery-oriented systems of care, forcing both parties to recognize one another’s skills while working together to provide effective treatment.
In a healthy recovery-oriented treatment environment, clinicians and peer supports would complement one another in doing what is most helpful for the client: supporting their recovery. With all of the changes that have occurred in both fields, what will the next 100 years bring?