Course Articles

This is an edited transcript of the webinar, Understanding Communication Styles on Diverse Teams, presented by Marva Mount, CCC-SLP, FNAP

Learning Outcomes

After taking this course, participants will be able to: 

• Describe characteristics of a practitioner who can easily adapt and/or read communication styles.
• Explain strategies that are useful for communication with all types of communication partners.
• Explain strategies useful when attempting to get someone to say yes.

Introduction

As professionals, there's a crucial topic we must address—one that holds significance for everyone, but particularly for those of us in our chosen fields. We often find ourselves discussing sensitive matters that people may not yet be prepared to hear or that they may struggle with emotionally. These conversations might involve families, clients, or patients, and understanding their communication styles is vital.

Today, our focus is on comprehending communication styles within diverse teams—a topic that directly applies to all of us since we work in such diverse environments. Before we delve into the specifics, let's take a moment to acknowledge the limitations and risks involved.

Throughout this course, we will explore general communication patterns among different groups and delve into generational communication styles. It's important to note that these generalities do not apply to entire groups of people; rather, they are based on research that has categorized certain characteristics for each group. However, these characteristics are not universal to everyone within a category, and no single group is limited to the traits found within it. The intention behind presenting these categories is to encourage conscious consideration of communication styles and their variations in the workforce.

What is ONE Thing that Causes Stress at Work for You?

Let's take a moment to reflect together on what one thing causes stress at work. For me, as someone who regularly gives presentations to diverse audiences, a major source of stress is ensuring successful communication within my team and effectively conveying information, even when it may not be easy to hear. This seems to be a universal concern, regardless of occupation or workplace.

Today, I'd like us to explore the reasons behind this stress and why communication can be challenging. Why is it that some interactions with team members are always pleasant, while others seem to be consistently challenging?

The same applies to our interactions with clients or families. Sometimes, we effortlessly establish rapport with someone, and we can communicate complex or difficult information with ease. Yet, other communication attempts may not yield the same positive results. We need to examine ourselves and consider what factors contribute to these different outcomes.

Research indicates that 18% of employees cite their peers as a cause of stress at work (Scott, 2019). A grandparent used to say to me the only place that you can work and not have disagreements with people is if you work alone and by yourself. And that is a very true statement that I never really understood as a young person, but I've definitely appreciated as I've gotten older.

As professionals, our work environment often exposes us to significant stress, which appears to be more prevalent today than ever before. The current state of the world and the multitude of challenging situations individuals face contribute to this heightened stress level. When we come to work, we bring our lives with us. While we may attempt to compartmentalize and present our best selves, our personal experiences undoubtedly impact how we interact with our coworkers. Moreover, research from the American Institute of Stress reveals that more than 90% of the stress we encounter can be directly attributed to the dynamics within our teams (see www.stress.org).

In our work environment, we encounter so many different individuals. Some we may instantly connect with and form a natural bond, while others may not share the same connection. It's important to acknowledge that we can't be everyone's best friend or colleague, and that's perfectly normal.

However, the real challenge lies in effectively communicating with those individuals with whom we may not naturally click. Learning how to engage with them is even more crucial than communicating with those we naturally connect with. Failure to do so can lead to friction and tension in our workplace.

Why?

Why should we concern ourselves with this matter? What makes it so crucial? Workplaces can be so complex when it comes to communication. This complexity arises from various factors, including the environment in which we find ourselves and the demanding workload we carry. Numerous reasons contribute to the difficulties in communication with our colleagues. It is essential to be fully aware of this reality because encountering communication challenges with someone often leads to negative energy and tense situations, evoking feelings of irritability. I don't know about you, but whenever I have a conversation that doesn't go well, it tends to leave me feeling irritable. Additionally, it might increase my sensitivity towards that person, and subsequently, I may dread any future interactions with them because I can't easily let go of past experiences and their impact.

Disagreements and misunderstandings often stem from miscommunication. Addressing such issues is vital as they can lead to numerous problems in the workplace, affecting not just the individuals involved but also everyone around them. Therefore, it is crucial to make a conscious effort to avoid these situations whenever possible.

In times of stress or discomfort with someone's communication style, it is common for us to withdraw or retreat. However, this retreat can result in a significant decline in productivity, which is undesirable in any workplace where productivity standards must be adhered to. The lack of interaction can hinder progress and hinder collaborative efforts. As professionals, it is essential not to lose confidence in our ability to communicate effectively with others.

At times, such experiences can erode our confidence, making us hesitant to communicate, particularly with certain individuals. It is natural to become cautious after a negative interaction, which can hinder our willingness to engage with others.

One of the most common pitfalls in communication is having unrealistic expectations of others. We all have our unique preferences and personalities, shaped by our upbringing, values, and experiences. These factors significantly influence how we perceive others and how we anticipate their behavior. Consequently, our expectations often manifest in our communication style and interactions with others.

Awareness is Key

Let's focus on a few essential aspects.  First, we want to heighten our awareness, as awareness plays a pivotal role in improving our communication. To do this effectively, we must have a profound understanding of ourselves. Engaging in self-analysis and self-discovery may not always be pleasant or preferred, but it is essential, particularly after encounters that didn't go as expected. With self-analysis, we can ask critical questions, such as what contributed to the outcome and why things didn't unfold as intended. Uncovering the reasons behind these situations is vital for personal growth and improved communication.

Similarly, it is crucial to analyze the other party involved in the conversation. Although it can be more challenging to understand someone else's perspective, it remains an essential aspect of enhancing communication. Often, our initial reaction might be to label the other person as difficult, rude, or not a team player. However, a deeper analysis of the circumstances leading up to the conversation can offer insights into their viewpoint as well as our own. It's always essential to keep the big picture in mind.

We all have our triggers. And by triggers, I mean those little things that can really get to us. For example, when someone addresses us in a way we don't appreciate. Instead of using our names, they might say, "hey honey," "hey lovely," or "hey dude," and it just sets us off right from the start. That's what I'm talking about - triggers. These are the things that can easily rub us the wrong way and end up affecting how the whole communication goes and how we react to it. So, recognizing our triggers is crucial because it helps us better understand ourselves and how we respond to different situations.

And then comes the challenge of working without letting emotional triggers interfere. Going back to the self-analysis point, it's not enough to simply identify our triggers; we must also learn to control our initial reactions. You see, our first response to a trigger usually carries an emotional component. However, it's important to recognize that emotions can cloud our rational thinking, as that's just how our brains work. So, knowing our triggers is just one part of the equation; we must ensure that we don't let emotions get in the way when these triggers come into play.

I often find myself engaging in self-talk, especially when I recall moments from when my children were in high school and their friends would come over. In my generation, it was customary to address adults as "Mr." and "Mrs.," and respond with "ma'am" and "no ma'am." However, times had changed, and my children's friends didn't always follow those norms. Some of my son's friends would casually call me "Hey Marva," which sometimes caught me off guard. My instinctive emotional response would be to think, "My name is Mrs. Mount, and you don't know me well enough to use my first name." It triggered a sense of disrespect that I had to navigate carefully, especially since they were teenagers.

While I refrained from reprimanding or correcting them, it did stir up an emotional reaction in me. I couldn't help but wonder, "Who do you think you are?" The incident served as a clear example of the emotional triggers I mentioned earlier.

Do any of you recall "Leave It to Beaver"? It was a sitcom on television, quite a long time ago. One of the characters on that show was Eddie Haskell, a young man who had a unique way of interacting with his parents. He always tried to impress them by being articulate and observant, noticing everything around him. He had a talent for buttering them up and making himself look good. Those were certainly some memorable moments from the show! He was very complimentary, and I used to find it quite amusing while watching the show. The reactions of the parents to Eddie Haskell's behavior were always entertaining. It's a great way to put things into perspective as we talk about various communication styles.

Many Factors at Play

There are many factors at play when it comes to communication. Everyone has their unique way of expressing themselves. A significant aspect that influences communication is the presence of multiple generations in today's workforce. Generational factors inevitably come into play, whether we intend them to or not. Reflecting on the classic example I just mentioned, it's apparent how generational differences can manifest in various communication styles. For instance, in my generation, it was uncommon to address a parent by their first name. It was common to address adults with titles like Mr. and Mrs. back in the day, but as generations have evolved, our approach to greetings and formality has changed significantly. Things are quite different now compared to when we were kids or teenagers, and that includes how the younger generation communicates today.

Recognizing and understanding the diverse generational perspectives and preconceived notions is crucial in today's workplace, as well as in our daily interactions. Each generation brings its unique set of beliefs and expectations, which can influence how they perceive and engage with others.

Regarding expectations, it's essential to be mindful of the ones we set for ourselves and not unfairly project them onto others. Likewise, it's unfair when others impose their unrealistic expectations on us based on their beliefs or experiences. Communication plays a vital role in addressing these issues.

Four Common Communication Styles

Today, we're going to explore four fundamental communication styles. As we discuss these styles, take a moment to consider which one resonates most with you compared to the others. It's essential to keep in mind that these styles are not all-encompassing; rather, they offer generalities, as we discussed earlier. However, in broad terms, everyone tends to fall into one of these four basic communication styles.

While exploring these communication styles, you might find that you have elements of several different styles, and that's completely normal. You might not neatly fit into just one category we talk about, but that's perfectly okay. The key is to reflect on whether any of these styles describe your predominant approach to communication. Understanding your communication style can be incredibly valuable in self-awareness and recognizing how you engage with others, particularly in comparison to their style.

Intuitive Communicators

The first communication style we'll discuss is the intuitive communicator. Intuitive communicators tend to be unemotional and freeform in their approach. They don't invest much emotion in their communication. When interacting with an intuitive communicator, you might not initially perceive them as warm and fuzzy or very friendly. They focus on bottom-line communication, efficiently getting to the point, and avoiding wasting time.

When engaging with an intuitive communicator, picking up on the cues and clues they provide is essential. If you are not an intuitive communicator yourself, be mindful of their preference for directness, and avoid going into great detail unless necessary. They might express themselves by saying something like, "You know what? All that information is great, but just give me the bottom line. What was the end result?" This kind of response would indicate that the person you're conversing with is an intuitive communicator. They prefer receiving the essential information without delving into background details or the events leading up to it. Their communication style revolves around efficiency, seeking concise and quick responses, with no time wasted on unnecessary elaboration.

Consider your own communication style. Are you an intuitive communicator? Do you appreciate freeform, to-the-point exchanges that minimize unnecessary discussion? If so, you likely prefer getting straight to the main points and then moving on swiftly. Keeping this in mind will be helpful as we proceed to discuss the next type of communicator.

Analytic Communicators

The next broad group of communicators is the analytical communicator. Similar to the intuitive communicator, they are also unemotional, but their style is more linear in nature. Analytical communicators value confident communication that demonstrates expertise, particularly in presenting hard facts and numbers.

In contrast to intuitive communicators, analytical individuals place greater emphasis on receiving concise information without unnecessary fluff. However, when approaching analytical communicators with information, they expect it to be well-supported by hard facts and expertise. They don't seek an abundance of details, but they do want the information to be precise and well-founded.

When engaging with analytical communicators, be prepared to answer questions like, "What brought you to this conclusion?" or "How do you know that this is accurate information?" Analytical communicators want to know that you've done your homework. They seek concrete facts and figures, which sets them apart from intuitive communicators. Both groups value brevity, but analytical communicators specifically want you to demonstrate why you believe the information you're sharing is accurate. They expect you to provide evidence or support for your claims in some way.

Functional Communicators

The next type of communicator is the functional communicator. Functional communicators can be very emotional, expressing a strong attachment to the information they are discussing. They bring not only the facts but also an emotional investment in the topic. They prefer having control of the communication process.

When engaging with functional communicators, providing process-oriented and linear communication is essential. Present information in a sequential manner, starting from the beginning and progressing logically to the middle and finally concluding firmly and concisely at the end. They prefer a structured and well-organized flow of information and might not appreciate jumping around from topic to topic.

In conversations, functional communicators may be highly emotive, using gestures and expressions to convey their thoughts and ideas. They might present their ideas dramatically and passionately, emphasizing the significance of the subject matter to them. It's important to recognize that what may not seem like a big deal to you might be highly important to functional communicators due to their emotional attachment or response. Their emotional investment influences their perspective and the way they engage in conversations.

As we've discussed the different communication styles - intuitive, analytical, and functional - it becomes apparent how communication can be affected when interacting with various personalities. Misunderstandings and misalignments in communication styles can lead to communication getting off track and hinder effective interactions.

Personal Communicators

The final type of communicator is the personal communicator. They combine both emotional and freeform characteristics, valuing interpersonal relationships in their communication.

Personal communicators prefer using informal and friendly language to engage others. They are warm, inviting, and emotionally invested in the conversations they have. Factors like who is involved or the impact of what they're being asked to do can greatly affect their feelings about a particular situation.

These warm and fuzzy individuals are genuinely interested in knowing more about the people they interact with. If you work with a personal communicator, you might find them asking about your well-being before delving into the main topic. They take a genuine interest in how you are doing and how you feel about various aspects of your life, including X, Y, and Z. In the office setting, personal communicators are often the ones who express genuine concern for others' feelings and emotions.

Consider the following.  What if you're more of an intuitive communicator, and you have a coworker who's a personal communicator? It could really get on your nerves, right? But here's the thing - you should consider this: you know they prefer a warmer and more informal style of communication, and they appreciate it when you take the time to understand their feelings. "So, how do you feel about this? Are you okay with what we've talked about so far?" It might not be your natural approach if you tend to be more analytical or intuitive and keep emotions out of your conversations. But recognizing this difference can help you get along better with your coworker.

Take a moment to analyze which communication style suits you best. Do you fall into one specific category, or do you find yourself having traits from various communication styles? Maybe you resonate strongly with the intuitive communicator, but you also appreciate the touchy-feely aspects. Take a look at your personality style and try to identify it. Jot down some notes and give yourself permission to reflect on your communication style. Consider which type of interaction you feel most confident with. As for the other communication styles that you might not feel as comfortable with, it's alright! You can tell yourself, "Hey, I need to do some additional reading and take a more comprehensive look at how I can improve my communication with people in the workforce."

These four communication styles are powerful because they provide an opportunity to reflect on past communication events that may not have gone well. By understanding these styles, you can gain insight into why certain interactions fell apart. Perhaps you weren't truly listening to what the other person was saying, even though you thought you were. It's about recognizing and appreciating the different styles in which information is presented.

So, if you take away anything from today, let it be these four communication styles. By understanding them, you'll have a better grasp of the people around you, including your significant other, as opposites often attract. It could be an eye-opener in your relationships, helping you comprehend why certain disagreements and misunderstandings occur. This newfound understanding can prove to be highly valuable, not just in personal relationships but also in the workplace.

Generations in the Workplace

In addition to understanding the different styles of communication, which focus on the "how" of communication, we also need to consider the "who" - that is, the individuals we communicate with. Let's delve into the concept of generations in the workplace. Keep in mind that the following information is based on generalities from research, and it's not meant to categorize or label every individual within a generation negatively. Rather, it's about recognizing patterns that have emerged from various research projects about generations in the workplace (See Sheridan 2017 and Paychex 2019).

One generation that has become relatively scarce in the workforce is the Traditionalists, who were born before 1945. While some industries, such as education, may still have teachers from this generation, and there might be businesses working with seasoned professionals like doctors who fall into the Traditionalist category, their numbers are gradually decreasing. 

Next, we have the Baby Boomers, born between 1945 and 1964, who represent another significant generation in the workforce. Following them is Generation X, born roughly between 1965 and 1980, who bring their own unique perspectives and experiences to the workplace.

Then, we have the Millennials, who make up a large portion of the workforce today. Born between 1981 and 1999, they have been transforming the workplace with their tech-savviness and emphasis on work-life balance.

And finally, we have Generation Z, born around 2000 and onwards. Some of them might already be college-educated and making their debut in the professional world, while others could be taking on assistant roles such as receptionists or administrative assistants. It's essential to take note of this generation as they are the new emerging workforce, bringing fresh ideas and an innate understanding of technology.

"Traditionalist" Views

Looking at the characteristics of Traditionalists born before 1945, it's no surprise that work was seen as an obligation for them, as they worked to make a living rather than living to work. Respecting authority and following rules come naturally to them, and they tend to avoid confrontational situations whenever possible.

Due to their seniority and tenure-focused mindset, Traditionalists place great importance on being addressed with respect. It's common for them to prefer titles like "Mr." or "Mrs." followed by their last name, and if they happen to be a physician, "Doctor" is expected. They may eventually grant permission to be addressed more informally, but initially, they prefer the formal approach.

As they believe in a clear hierarchy within the workforce, face-to-face communication is their preferred method. They are comfortable with in-person conversations and may not be as familiar with or receptive to newer technologies like texting or emails. Therefore, it's essential to be mindful of their communication preferences, ensuring that important messages are conveyed through channels that resonate with them.

When interacting with Traditionalists, it's important to employ strategies that resonate with their values and preferences. Expert endorsements and testimonials from trusted sources work particularly well for them. They tend to trust information coming from individuals they know and respect, rather than random sources on the internet. So, building trust through established relationships and reliable references is key.

Traditionalists appreciate teamwork and collaboration. In group settings, they feel more comfortable and engaged, and they value the input and contributions of their colleagues. When making decisions, they prefer to take their time and carefully consider all aspects before providing an answer. Rushing them or demanding quick responses can be counterproductive.

To communicate effectively with Traditionalists, it's essential to show respect for their process and decision-making style. Avoid pressuring them to make snap judgments, as it may make them feel uneasy or dismissive. Instead, allow them the time they need to arrive at a thoughtful conclusion.

Giving them ample time to think and make decisions is crucial, as they value thorough consideration and dislike being pressured into quick choices. Face-to-face conversations are their preferred mode of communication, so whenever possible, engaging in in-person discussions will foster better understanding and rapport.

Traditionalists are not as familiar with technology, which is perfectly understandable given the time they grew up in. Therefore, it's essential to be patient and accommodating when it comes to technological aspects of communication.

They also appreciate hierarchical work structures, respecting top-down authority and formal titles. Addressing them with the appropriate title, such as Mr. or Mrs., is significant to demonstrate respect. If they feel comfortable enough to be addressed more informally, they will let you know.

"Boomer" Views

Currently, there are still many Boomers in the workforce, along with Millennials and other generational groups we'll discuss. Boomers were born between 1945 and 1964, making them individuals in their 50s to 60s. Due to the retirement age, they continue to contribute significantly to the workforce.

One distinctive trait of Boomers is that they tend to "live to work." As a Boomer myself, I can relate to this mindset because it reflects the values in which I was raised. My parents, who were also Boomers, were highly dedicated to their work and deeply involved in their professional lives. The term "workaholic" was practically coined by this generation. Work is often an integral part of their identity, and they find a sense of fulfillment and success through their career achievements.

Boomers thrive on competition, which can be attributed to the historical context of the time they grew up in. During the period between 1945 and 1964, competition and striving for success were prevalent in society. They are determined individuals who don't like being told that something is beyond their capabilities, as they are motivated to prove others wrong and accomplish their goals. However, this level of dedication to work can sometimes lead to challenges in achieving work-life balance. Boomers are known for putting in long hours and working diligently, which might come at the expense of their personal time and well-being.

Some things that happen within the Boomer generation and strategies that might work for them, require supporting facts. Let's consider the four communication styles. Would a Boomer be intuitive, analytical, or personal? Reflecting on what we know about Boomers so far, we can determine their likely communication style.

Boomers are not typically intuitive communicators; they prefer a more analytical approach. Unlike intuitive communicators who seek concise information, Boomers like to see the big picture and appreciate well-reasoned proposals as new ideas. Instead of presenting fixed solutions, approach them with alternative choices, as Boomers prefer to weigh their options.

Boomers are goal-focused and oriented. If you identify as a Boomer or feel close to this generation either entering or exiting it, setting and achieving goals hold significant importance to you. And that's how people achieved success in the workplace, as it was crucial for earning higher rankings and promotions. Boomers tend to prefer one-on-one communication or discussions in meetings. Since they didn't grow up with technology, they might feel hesitant about communicating via email or text. Therefore, it's essential to consider this aspect when interacting with individuals from this generation. Instead of relying on frequent emails, it's often more effective to request a face-to-face meeting, giving them the opportunity to share their thoughts comfortably. Making this minor adjustment can significantly improve your interactions with them.

"Gen X" Views

Next, we have the Gen X perspective. Gen Xers are known for their strong work ethic and their enjoyment of both hard work and leisure. However, they value a clear distinction between their work and personal lives. Unlike Boomers, they are less likely to be committed to long-term career aspirations. They possess transferable skills and are open to exploring various professions and experiences. Gen X bosses often appreciate employees who can multitask effectively and showcase diverse experiences.

Independence and entrepreneurship are prominent traits among Gen X individuals. In fields like speech-language pathology, you'll find many private practitioners who transitioned from school or hospital jobs to establish their own practices. They believe they can make a difference and create a work-life balance that aligns with their work hard, play hard mentality.

Gen Xers tend to be somewhat skeptical, preferring others to demonstrate their claims. Growing up with technology and the internet, they have instant access to a wealth of information, making them inclined to seek proof and verification.

Gen Xers have had the advantage of growing up with technology and the internet, which has provided them with easy access to vast amounts of information. This access to information has opened up numerous possibilities and opportunities for them that were not as readily available to previous generations like Boomers and Traditionalists.

Because of their familiarity with technology, Gen Xers often turn to online research to validate and expand upon the information they receive from others. If you share an opinion or information with them, they may seek to verify it independently, not out of distrust, but because they are accustomed to fact-checking and ensuring that the data aligns with what they find.

So, it's essential not to take offense if a Gen Xer seeks to corroborate the information you provide. They appreciate the collaborative nature of gathering information and making informed decisions.

Gen Xers highly value work-life balance and like finding ways to work smarter rather than just longer hours. They are known for their innovative thinking and are not afraid to step outside the box to find creative solutions to problems.

One aspect that sets Gen Xers apart is their preference for flexible scheduling. They question the need to adhere to rigid working hours when they can complete their tasks efficiently and effectively in a shorter time frame. If they can accomplish their responsibilities in 20 hours a week, they don't see the need to be tied to the office for 40 hours. They value productivity over just putting in the time.

Given their tech-savviness, Gen Xers are comfortable with various communication methods, but they do tend to favor texting and emailing. They appreciate the convenience and efficiency of electronic communication, and it aligns well with their preference for flexibility.

In the workplace, if you want to communicate effectively with Gen Xers, consider using email or texting as a primary means of contact. They may prefer receiving information through these channels rather than engaging in face-to-face conversations when it's not necessary.

When thinking about Gen Xers and their communication style, ask yourself what kind of communication style they may have and which one of those communication styles overlays the best with a Gen Xer. Are they intuitive, or are they analytical? Do you find them to be more personal? Do you find them to be more factual? Think about what type of communication style might go along with this generation.

Strategies that work well with our Gen Xers involve avoiding hard-sell tactics and allowing them to make their own decisions. They prefer not to be bombarded with excessive information (A, B, C, D, E, F, G) but instead appreciate receiving the basics to conduct their own research. This generation values being on the same page with others based on their own findings.

Providing choices is a valuable approach because Gen Xers are out-of-the-box thinkers who challenge the status quo. It's crucial to avoid saying phrases like, "That's how we've always done it here," as it might discourage them.

Gen Xers hold others accountable for their promises. If you commit to something and fail to deliver, expect them to follow up via email or text to inquire about the situation. Being reliable and keeping your word is essential when working with them.

When offering guidance or suggestions, it is more effective to avoid direct instructions. Since Gen Xers enjoy fact-checking and verifying information on their own, they prefer having some freedom in decision-making.

In communication, being straightforward and getting to the point is appreciated by Gen Xers. Avoiding hidden agendas in conversations is crucial because they will lose trust in those who try to manipulate or conceal their intentions.  With Gen Xers, it's essential to practice a "mean what you say and say what you mean" communication style. They value straightforwardness and honesty in interactions.

In terms of communication methods, email is generally their preferred mode of contact. However, they are also comfortable with text messages and other technology-driven communication tools.

"Millennial" View

Next, we have the Millennials, who view work as a means to achieve a good life. For them, work is essential, but they prioritize finding a balance between their personal and professional lives. Millennials heavily rely on technology because they are considered the native technology generation. They grew up with constant access to technology, which profoundly shapes their communication style and preferences. Millennials are known for speaking their minds and being direct in their communication. Sometimes they can be thought of as "too direct." 

One significant aspect of Millennials' communication style is their desire for instant feedback and recognition. When they complete a task, they expect it to be acknowledged promptly. It's not just about praise; they seek constructive feedback that helps them grow and improve in their roles.

At times, clashes may occur in the workplace between Millennials and Boomers who are dedicated workaholics. While Boomers might be fully focused on the job, Millennials emphasize the importance of recognition and feedback to maintain motivation and job satisfaction.

Informal work environments are preferred by Millennials, reflecting the changing times and a broader shift towards informality in various settings, including the workforce.

As technology-driven communicators, Millennials favor texting and instant messaging over in-person interactions. They find efficient and convenient ways to communicate through various technology platforms, as they don't consider face-to-face meetings or phone calls necessary to perform their duties effectively.

Some effective strategies for working well with our Millennial coworkers involve honoring their preference for electronic communication, as they are avid users of blogs, instant messaging, and direct messaging for convenience.

Providing prompt feedback on their ideas is crucial, as it helps them understand that they are on the right track. Millennials are accustomed to receiving a wealth of information during their upbringing, so timely feedback reinforces their confidence and sense of progress.

Involving them in projects in a way that highlights their value is essential. Millennials seek meaning and purpose in their work and want to feel that their contributions are valuable and meaningful to the overall goals.

When communicating with them, ensure that your messages offer value and assist them with problem-solving. They appreciate collaborative discussions and enjoy talking things out.

Before engaging with Millennials, make sure you have done your homework because they are known for their thorough research and fact-checking capabilities. They have grown up with easy access to information, and they appreciate working with others who have also put in the effort to be well-informed.

Though they may come across as opinionated, it is important to understand that they value well-informed conversations and appreciate others who have taken the time to understand the topic at hand.

When considering strategies that work effectively for Millennials and exploring their communication styles, what type of communication style might they possess? Are they intuitive, analytical, more inclined toward personal communication, or do they tend to present information in a factual manner? Could they potentially have a combination of these communication types?

"Gen Z" Views

Then we have the Gen Zers, the newest individuals who have recently entered the workforce. Diversity is the norm for them, and being digital natives, they have always had easy access to technology. They tend to be pragmatic and financially minded, showing a strong awareness of what they want to achieve in their jobs and the financial outcomes they desire. As very conscious consumers, they are shrewd in their approach to comparing and contrasting services and products. They don't make purchases solely based on brand names or their parents' preferences. Instead, they carefully evaluate prices and the promises that products make before making decisions.

This particular group is highly politically progressive, actively engaging with politics, following its developments closely, and possessing an impressive knowledge of political matters. They are quite open to discussions about politics, even in the workplace, although we should be aware that political conversations can become personal and potentially create tensions.

It's important to note that they might feel offended if they perceive a lack of political progressiveness or if someone is unable to engage in political discussions. Being well-informed about current world events and political issues is valued by them.

Furthermore, this generation is deeply concerned about the environment and the impact humans are having on the planet. They are likely to be proactive in their environmental activism, often participating in protests and advocating for positive change in various situations where they believe improvement is needed.

Gen Z individuals possess big ideas and strong viewpoints, and they are unafraid to express and discuss them openly. Unlike some other generations, they do not shy away from confrontation or difficult conversations.

One effective strategy for working with Gen Z individuals is recognizing and supporting their emphasis on work-life balance. They prioritize and expect a healthy separation between work and personal life. Weekends are sacred to them, and they are not inclined to bring work home or stay late regularly. Of course, they may occasionally work extra hours to accomplish important tasks, but they are generally not the ones you'll find at the office before or after regular work hours.

you'll likely not find Gen Z individuals working at the office on weekends or consistently bringing work home in the evenings. Their strong focus on health and well-being is evident in their conscious effort to maintain a healthy work-life balance. I must admit, I admire this approach, and I find myself wishing I could adopt it for myself as well.

Their understanding of the impact of stress, overwork, and anxiety on their overall well-being and relationships is commendable. They recognize that taking care of themselves is essential for their own benefit and be their best selves for others. It's a quality I deeply appreciate, and I genuinely wish that individuals across all generations could embrace this same mindset. I think we'd all be healthier.

Gen Z individuals seek work that has a clear and meaningful purpose. They want to feel that their efforts are contributing to something significant. Technology is an integral part of their lives, and they rely on it extensively for communication and various tasks. Their proficiency in using communication tools allows them to be efficient and timely, sometimes prioritizing speed over a meticulous approach to completing tasks. Their focus on the end result, rather than striving for perfection, may be a source of frustration for individuals from other generations.

How Can We Adapt?

When thinking about the various communication styles and the different generations we have in the workplace nowadays, it's essential to consider a few things before having a conversation with someone. If you get a chance to observe people, that's a great idea. And when you're listening, try to be an active listener – that means really listening to understand, not just waiting to respond. These things are important when you're dealing with difficult conversations with families, patients, clients, or your coworkers. It helps you understand what they need and how to approach things better.

To handle these conversations well, start paying close attention to people and what matters to them, not just their age. Consider how you can approach each discussion to make it beneficial for everyone involved.

Here are a few things to think about: How do you adapt your personality or communication style? You don't need to change who you are completely, but you can make some tweaks to be a better observer and communicator. Find that sweet spot where you stay true to yourself while connecting with others effectively.

The most crucial thing is to be observant and have good observational skills. In healthcare professions, we're trained to do this with our clients, patients, and their families. We pay close attention to their words, the way they say things, and their body language. It's essential to extend this observant nature to other people in our lives, especially our coworkers, supervisors, and colleagues.

Being intuitive is key too. We should be able to read the room and gauge the atmosphere before jumping into discussions. It's not a good idea to charge in and blurt out our thoughts without considering the context and the people involved.

I can't emphasize enough how crucial it is to be observant, not only with the clients and patients we serve but also with the people around us all the time. It's about being in tune with others and picking up on their cues and needs.

Adapting our communication style to fit our audience is essential. If everyone in my world were exactly like me, it would be a disaster! I know I have my flaws, and that's why being observant helps me keep my emotions in check during conversations. It allows me to navigate tricky situations and connect with people in different ways. Be adept at reaching others in various ways.

The same communication strategies won't work for everyone. It's just like being a parent - you know that each of your children is unique, and you have to approach and discipline them differently to avoid constant fights at home. People are like that too.

If we can learn to reach out to others in various ways and adapt our communication styles, we can build trust and understanding. Sadly, there's not enough of this happening in the world today. We tend to talk at each other rather than engaging in true dialogue. This issue persists in our government, schools, and community resources. As professionals, we need to be aware of this and strive to be better communicators.

We need to be aware that everyone is not like us and that we have to present information in a way that is going to be the most helpful to our patients, our clients, and our families. Building trust in those situations is essential (See Nemko, 2019).

Why Do We Adapt?

The main takeaway from this slide is that impact trumps intent. In most cases, we genuinely have good intentions when entering a situation or communicating with someone. We don't aim to harm or hurt others. 

The main takeaway from this slide is that impact trumps intent. In most cases, we genuinely have good intentions when entering a situation or communicating with someone. We don't aim to harm or hurt others.

However, what's crucial to understand is that our intent isn't the most important factor. It's the impact we have on the person we're communicating with. The outcome matters more than our initial intentions. We need to be mindful of how our words and actions affect others.

To avoid misunderstandings and build better collaborative relationships, we must work with people's unique communication styles and respect their generational backgrounds. When we take the time to understand others and adapt our approach, we gain their trust.

Ultimately, the key is to recognize that what we say and how we say it carries significant weight. The way others interpret our words holds more significance than our intentions going into a conversation.  I cannot stress that enough. Some people say, "This is just how I am, take it or leave it." But as professionals, we cannot afford to have that mindset. We must ensure that our intent aligns with the positive impact we want to have on others. It's not just about being ourselves, but also about being mindful of how others perceive us.

Adaptation is key to effective communication. To recap, we need to recognize different communication styles, understand our own style, and be aware of any biases we might have toward other styles. It's not about being judgmental or prejudiced; it's about understanding what we bring to the table.

Absolutely, examining our biases is essential. We all have them, and they can significantly impact how we communicate with others. It's crucial to be aware of these biases and understand how they might influence our interactions with individuals from different backgrounds or generations.

Recognizing and celebrating the differences between generations is vital. We are all unique, and that diversity brings incredible value to our interactions. Each generation offers a unique perspective and experiences that enrich our conversations and relationships. Applying proper communication techniques and the strategies we've discussed is beneficial for all generations. These approaches are valuable in bridging gaps and fostering understanding across age groups.

Big Five

The Big Five, as we wrap up, is to create an environment for fresh ideas with shared credit. It's okay if somebody else takes the credit. We don't always have to have that. We also need to have an environment where people know they can come to us with ideas, and we're not going to dismiss them.  We want to accept them in the manner that they were presented to us.

We want to have a willingness to accept open and honest feedback, even if it might hurt your feelings. This includes being a good communicator and having great relationships with other people. Sometimes it takes your feelings being hurt for you to truly understand what is important in that relationship.

Have clear goals and expectations for yourself, and don't deviate from those. It's okay to set expectations for yourself. It's not okay for you to set expectations for someone else, especially if you don't tell them what those expectations are.

Everyone has the right to professional encounters without emotional reaction. Psychological safety in the workplace begins with good communication without those emotional knee-jerk responses.

Finally, is a win-win orientation. Conversation should be such that everyone walks away with something. You may not get all that you want, but you need to be acknowledged that something that you were asking for can be agreed upon by the group. 

Relationship Building

Know your triggers, check your bias at the door, remember the reason for your communication, and find common ground. Introspection and mindfulness are very important. And by that, I mean set aside time to understand your biases by taking a personal inventory of them. Once you understand the biases you hold, be mindful that you’re more likely to give in to them when you’re under pressure or need to make quick decisions.

Remember the reason for your communication. How can each person benefit? What are you attempting to accomplish and why is the communication important in the first place? If you can't come up with a reason for what you're about to say is important, then you probably don't need to say that for any reason. Be mindful of what your communication attempt is and what you're trying to communicate.

This holds true for finding common ground. Everybody can find common ground. Below are some ideas for how to seek a "yes" from someone (see Bailey 2022; Hogan 2010) 

• Find a way to make it personally appealing
• Be upfront and honest ~ clarity
• Use inclusive words (know your audience)
• Ask questions and listen attentively
• Focus on gains for all parties
• Understand this is a two-way street, not a one-way road
• Be open to changing your mind or adapting what you want
• Offer a graceful way out

Remember, "People may not forget what you said, but they will never forget how you made them feel." That is my favorite Maya Angelou quote. And I believe that wholeheartedly. Once we have a damaged relationship, it's hard to get it corrected, and it's hard to get people to come back to the table. So, we want to avoid that if possible.

Questions and Answers

When being berated or yelled at in a conversation, what can you do to bring down the temperature?

When people are yelling, that means that their emotional selves have "overloaded" their factual selves. I like to put on my active listening hat. I am no longer listening to respond because in that type of situation, it doesn't matter how I'll respond. They're not going to listen. The first thing I do when someone has gotten angry with me, they've raised their voice, or they've leaned into my space too much is to decrease my volume to a low whisper because people will regulate based on how you respond to them.  If they're yelling, don't yell back. Take a matter-of-fact, low tone of voice. Put on your "listening ears," and stop trying to listen to respond. Continue to modulate with your voice level and with your tone, "I hear that you're saying that that really upset you." And then let them finish. They will modulate based on what you're demonstrating in terms of your own behavior. It's a very interesting phenomenon, but it happens every time. So I always tell individuals if a conversation gets that far off the track, take a moment, put your "listening ears" on, model the behavior that you want to be given in return, and stop interrupting people. When you stop talking, it may take them a few minutes but then they will realize, "Wait a second, I'm arguing with myself." 

What do you suggest if conversations aren't going as planned? Do I regroup? Do I start over? What do I do?

There, again, miscommunication has occurred. You realize you're off track with what you're saying. So I would stop listening for responsiveness and actively listen to what they're saying. Then if they say, "Well, what do you think about that?" Then I would definitely model the voice intonation and level of confidence that I want them to give back to me. I would say something like, "I'm sensing that this has been really upsetting to you. Would it be a great idea to table this conversation and return when we have our talking points ready? What would be the best thing for you? Do you want to continue perhaps after a small break, or do you want to table this conversation and begin again when we're both a little bit fresher, and we have our talking points in place?"

References

American Institute of Stress.  Retrieved on 5/15/2023 from www.stress.org.

Angelou, Maya.  Quote Retrieved from:  https://goodreads.com/quotes/5934-i-ve-learned-that-people-will-forget-what-you-said-people . 

Asis (2022).  How to become a communication chameleon.  Retrieved from:  https://asisonline.org/security-management-magazine/articles/2022/07/how-to-become-a-communications-chameleon.

Au-Yueng, A. (2021).  7 Ways to Ensure Effective Communication at Work.  Retrieved from: https://www.lifehack.org/837296/communication-at-work.

Bailey, L. (2022).  How To Talk To Anyone:  Communicate with Confidence and Charisma, Using Charm, Banter and Better Small Talk.  Lucas Bailey.

Donahue, Wesley, E. (2022).  Fostering Effective Communication in the Workplace:  A competency-Based Approach that Boosts Your Ability to Get and Give Information.  Centrestar Learning. State College, PA.

Ferryman, Claudia (2011).  The Communication Chameleon:  How to Lead, Persuade, and Influence in Any Conversation.  RainMaker Books, Charleston, SC.

Hogan, K. (2010).  The Science of Influence:  How to Get Anyone to Say “Yes” in 8 Minutes or Less, Second Edition. John Wiley & Sons, Hoboken, NJ.

Lyon, A. (2019).  Perception and Communication. Retrieved from:  https://www.youtube.com/watch?v=KE2aZj7OFC8.

Nemco, M. (2019).  Chameleon Communication:  Six Ways to Flex for Effective Communication.  Retrieved from https://psychologytoday.com/us/blog/how-to-do-life/201901/Chameleon-communication.

Paychex, (2019). How to manage multiple generations in the workplace.  Retrieved from:https://www.paychex.com/articles/human-resources/how-to-manage-multiple-generations-in-the-workplace.

Scott, Kim (2019).  Radical Candor:  Being a Kickass Boss Without Losing Your Humanity.  St. Martin’s Publishing Group. New York, NY.

Sheridan, K. (2017).  Managing Generational Differences and Culture at Work.  Association for Talent Development.  Retrieved from:  https://www/youtube.com/watch?v=yojjS0a29-k.

This is an edited transcript of the webinar, Self-Care and Systems Change for Behavioral Health Professionals, presented by Sophie Nathenson, PhD.

Learning Outcomes

After taking this course, participants will be able to: 

• Describe a system-changer is and how it can be applied in a behavioral health setting.
• Identify three factors associated with system-change that contribute to burnout for behavioral health professionals.
• Identify four domains of self-care for behavioral health professionals.

Introduction: Healthcare Systems Change Context

This course will adopt a sociological approach. I hope that you will derive some valuable insights from it, even if it's just the validation of your existing knowledge or the sowing of seeds for new ideas.

In this discussion, we're starting with a focus on the United States, though these concepts can apply globally, particularly in the context of healthcare and behavioral healthcare systems. We're looking at population health, which involves studying the overall well-being of communities and societies, examining the root causes of health issues. These causes include socioeconomic factors and cultural elements. Additionally, we consider the impact of various systems and institutions like government, healthcare, mental health services, media, education, and religion. These systems can significantly influence health outcomes, and understanding their role is crucial in the field of medical sociology.

In this sociological context of population health, our focus isn't on one-on-one approaches. Instead, we emphasize prevention and examine upstream factors - elements of society that have far-reaching impacts on how people handle stress and their health behaviors. Further downstream, we deal with issues that can quickly lead to emergencies or mortality. While it's vital to allocate resources to emergencies, we're also considering the potential of system and community structure adjustments to affect a larger population positively.

A relevant concept here is "structure versus agency." Agency refers to our individual choices, attitudes, motivation, and the extent to which we can make choices. However, agency is somewhat constrained by societal structures or "life chances and life choices." This concept is central to our work in systems-change. For instance, providing education can enhance agency, but if structural barriers prevent individuals from exercising their choices, the success of such educational initiatives may be limited.

In the broader context, legislative changes also play a significant role. For instance, in 2008, we saw the introduction of the Mental Health Parity and Addiction Equity Act, which can greatly affect the ability of individuals and organizations to participate in systems-change efforts. A recurring question in the population health and systems-change realm is: Who bears the responsibility for creating programs and initiatives that can influence the system, whether on a large scale or within a smaller organization or group of individuals?

When it comes to health professionals, especially those in behavioral health like therapists, counselors, and addiction treatment specialists, engaging in system-change work alongside their one-on-one responsibilities can add a significant load to their already demanding work. This process is undeniably collective but challenging because it often requires additional effort beyond the norm. Some of you might already be involved in system-change efforts, while others might be contemplating it. Regardless, it's worth considering, especially in the post-COVID era, as psychology literature increasingly calls for systemic changes. The stress our systems endured during the pandemic spotlighted their broken and inefficient aspects. 

Who is a “System-Changer”?

Now, who qualifies as a "system-changer"? Despite some research, it's unclear who first coined this term. It frequently arises in discussions of social innovation and entrepreneurship, where we explore a spectrum between for-profit, profit-focused organizations and entirely mission-driven ones, rather than seeing it as a strict dichotomy. The notion of a "system-changer" emerges from the idea of shifting organizations along this spectrum, making it a fluid and evolving concept.

A system-changer, when we attempt to define this term, is someone who not only identifies problems within a system but actively embraces this role as a primary focus. Not everyone consistently takes this broad view. Beyond recognizing issues, a system-changer possesses a compelling drive to take action. It's akin to the stages of change in the Theory of Planned Behavior, where the behavior is actively working to adjust a given system, be it on a large or small scale, whether within an organization, group, or at local, regional, national, or international levels. There's a multitude of examples of system-change efforts today, covering a vast array of issues.

Ultimately, system-changers are united by a shared desire and commitment to address broader societal problems. This aspiration leads them to delve upstream, scrutinizing the social, economic, cultural, and political contexts in which these issues manifest within a population.

Characteristics of System-Changers. Expanding on the concept of system-changers, it’s important to recognize the presence of an entrepreneurial mindset in these individuals. This mindset can lead to the establishment of businesses, and many behavioral health professionals have ventured into side businesses. These ventures might involve resource exchanges to provide services that aren’t available within their primary healthcare system or could take the form of nonprofit or grant-funded programs, distinct from their regular work. Importantly, this entrepreneurial mindset involves a willingness to innovate, which doesn’t always mean creating something entirely new; it can also involve revisiting past policies or programs that may have lost funding over time. The ebb and flow of funding in response to legislative changes can significantly impact these initiatives.
Moreover, at the core of being a system-changer is a profound concern for others in society. We’ll delve into how this relates to burnout later, but this sense of being others-centered is what drives these individuals to address the root causes they encounter in their daily work. Often, when providing care, they’re acutely aware of underlying issues that may seem beyond their control but are affecting the effectiveness of the care they provide. This awareness compels them to explore or take action on these matters.

System-changers often possess a visionary outlook, enabling them to perceive alternative possibilities. While recognizing systemic problems is relatively straightforward, these individuals go further by envisioning, independently or collaboratively, how things could be different. They frequently adopt growth-centered thinking, which is essential for their own well-being in the context of system-change. This mindset involves viewing challenges as valuable lessons, embracing feedback, engaging in self-reflection, and maintaining humility when confronted with resistance during change efforts. System-changers can be deeply other-centered and exhibit leadership qualities, not necessarily confined to formal decision-making roles; they lead through example. Additionally, a strong commitment to social justice typically underpins their motivations, a theme we'll explore further in relation to system-change.

What Can or Should Change?  

When considering what can or should change, we confront the question of whether a system is fundamentally broken or if there are opportunities for either cultural or practical change. Practical and procedural changes often become entrenched when cultural shifts don't accompany them. To catalyze change, individuals must envision something different, not merely identifying problems but actively imagining alternatives. This growth-centered thinking is vital for personal well-being amid system-change efforts. It involves viewing challenges as valuable lessons, embracing feedback, self-reflection, and maintaining humility in the face of resistance. System-changers often exhibit a deep concern for others in society, driven by a desire to address root causes that affect the efficacy of care. Recognizing systemic issues typically hinges on noticing trends among clients, patients, or community members that extend beyond random chance.

Change can manifest in various ways. It might involve shifting organizational culture, even if it seems daunting, particularly in situations where divisions like administrators versus employees or employees versus clients persist. Yet, culture is malleable and can transform, even when deeply ingrained. Changes can also stem from shifts in funding structures and performance incentives, influenced by legislative changes such as the Affordable Care Act in 2012. This legislation pushed healthcare systems to prioritize population health outcomes over individual care. The move to electronic health records added to the data available for assessing patient outcomes and identifying issues affecting the majority. Data now includes social determinants of health and disparities among different groups, aiding in targeted interventions. Coordinated care organizations, responsible for a defined population's care and costs, further incentivize population health. Changes in healthcare policies and other policies affecting mental health, addiction services, and drug legalization or decriminalization also play significant roles in system change.

Breaking down silos between sectors is crucial for effective collaboration, as issues often intersect with multiple systems. However, it's essential to be mindful of resource allocation, as an excessive focus on a single problem, like the opioid crisis, can hinder broader, systemic improvements. Collaboration across organizations and sectors is pivotal but demands extra effort. In summary, system-change presents personal and professional challenges, emphasizing the importance of understanding these complexities.

System Change and Social Justice 

System-change is also tied to social justice. For a lot of people, that is a big part of the motivation to engage in system change. So, addressing health disparities. There is a disproportionate prevalence of social problems, social determinants of health, meaning different groups, marginalized populations, disadvantaged and disinvested communities. They have a higher prevalence of mental health issues, behavioral health issues across the board, social problems, interactions with the criminal justice system. So, looking at the social institutions that affect those individuals, looking at the criminal justice system, the healthcare system, behavioral health, those systems are part of the root causes of these disproportionate issues that affect these kind of subpopulations. Looking at networks is also important because networks and social networks are one of the most protective elements that serve as a buffer for interactions with criminal justice, with homelessness, with interactions with behavioral healthcare. 

So looking at those community networks is very powerful and can highlight some of those issues. So, if it's systemic, we're looking at policy, we're looking at culture change, we're looking at social policy to drive some kind of improvement with disparities. Health disparities in some cases are narrowing, in many cases are broadening. And so, we have to ask ourselves if cultural competency is widespread as far as training. And we have all of these initiatives at different levels, the state level, the national level, to reduce health disparities, but we're still seeing them across time, that is really a trend and a set of trends that signals we may not be getting to the roots of those issues. There's also the role of social media, mass media, and we really saw that in COVID, especially when the containment measures were at play and there was a lockdown, we had this interesting situation, it was like a social experiment and we had people across the globe that if they had access to the internet through a computer or phone, they were all tuning in to the same issue, the pandemic. 

And so with all eyes on media during that time, there were a lot of social justice issues that just blew up. And in the field of medical sociology and many other disciplines, disparities have been studied for decades upon decades. So, it wasn't new information to a lot of people, but it was new information to many people in society. And for the first time I was seeing statistics by social factors on the mainstream news outlets. And so, that played a role in highlighting all these issues and spurred this desire to focus on systemic change.

Examples of Systems Change

So now we'll go through some examples of systems-change. These might be familiar to you, they might be new ideas and they represent a range of the small to the large scale. 

"Re-Imagining Mental Health Systems."

The phrase "Re-Imagining Mental Health Systems" encapsulates a notable example of system-change. The COVID-19 pandemic, though not fully in the rearview mirror, has exposed vulnerabilities within healthcare systems, including mental health. This crisis has sparked a renewed interest in system-change efforts, prompting a reevaluation of established models like the bio-psychosocial and ecological frameworks. Researchers are once again turning their attention to the impact of various communities and community characteristics, reinvigorating a research field that had seen a period of relative dormancy.

Addressing the Emotional Capacity of Communities 

Addressing the emotional capacity of communities signifies a significant paradigm shift, moving beyond the conventional individual focus. It entails assessing the potential for change within the social, economic, and political context of a community. This shift prompts us to question the extent of transformation that's achievable, a crucial consideration when engaging in individual therapy and service provision while also participating in group-level initiatives. Understanding how the broader context impacts the effectiveness of treatment is paramount, marking a transition from the traditional individual lens to a broader population-level perspective.

Social Determinants

Social determinants significantly influence mental health disparities among communities, and adopting a population-wide view helps identify key issues. Examining why some communities experience higher addiction rates than others, this analysis extends beyond borders, comparing societies and regions. These disparities are often rooted in social and economic factors like poverty, housing challenges, and racism, both within systems and externally. These stressors can detrimentally affect individuals emotionally, mentally, and physically, highlighting the interconnectedness of mental and physical health. Behavioral health professionals increasingly integrate into healthcare to address these complex challenges, serving as agents of systems change. Collaborative coalitions spanning various sectors work to address social determinants and reduce disparities, providing a platform for behavioral health professionals to advocate for their role and educate other sectors.

Participatory Change

Another example of system change involves participating in participatory change, a practice linked to engaging clients within their communities and obtaining feedback from community members. This approach allows for insights into external issues that might influence the system.

Coalition Driven

System changes often rely on coalitions, as the prevalence of mental health conditions varies significantly from one community or group to another. For instance, a community might show a reduction in suicide rates, but disparities based on race, class, sexuality, or gender identity may reveal an increase in suicidal ideation or attempts among certain groups. Using coalitions with representatives from diverse sectors, including education, local churches, and recreational organizations, provides a way to work collaboratively and establish community priorities and tailored initiatives. This approach to system change is often more effective than applying a one-size-fits-all, evidence-based intervention from one community to another without a nuanced understanding of the population served.

Inclusion of Non-Clinicians

Another critical aspect of system-change, as noted in the literature, is the involvement of non-clinicians as experts within population-serving institutions. The behavioral healthcare landscape comprises numerous fragmented organizations that often lack cohesion. When crafting policy changes, even at the organizational level, it's valuable to engage external experts, community members, individuals from academia, and those within healthcare, considering them as experts. Their input can facilitate the development of novel interventions and drive shifts in how systems operate.

Task Sharing

Embracing the concept of task sharing involves moving away from individual or organizational efforts to impact a particular issue or drive organizational change. Instead, it encourages collaboration where people assume different roles. This approach often aligns with public health and healthcare interventions that involve empowering community health workers to enhance their capacity and incorporating backup care. How does this tie into the broader system? Well, even if a behavioral health organization achieves excellent outcomes, disparities between the demand for behavioral healthcare and the supply of professionals can significantly affect a community's mental health status. This challenge is particularly pronounced in places like Oregon, where there's a substantial gap between the number of professionals and those in need of services. Thus, developing strategies to ensure some level of care reaches those underserved individuals and creating pathways to care becomes imperative.

Prevention

Engaging in system change involves challenging the specialist model, questioning hierarchical decision-making, and expanding beyond excessive medicalization to consider prevention within the system. It also entails addressing systemic issues like racism and sexism, applying an equity lens, and transitioning towards trauma-informed care. This might involve educational efforts to inform individuals. While there are many high-level initiatives advocating for the integration of an equity lens, the question remains: How do we achieve this, and whose responsibility is it to make it happen?

The Suffering of System-Changers

Now, let's address the challenges faced by system-changers, which will tie into the discussion of combining system change and self-care. It's important to note that there's a significant issue of burnout among those passionate about system change, and this can negatively impact their career sustainability and overall well-being. While I don't engage directly with the population served, I work closely with program developers, witnessing their idealism, their efforts for change, and the frustration that can follow. This often leads to taking on too much responsibility, which can lead to burnout and disillusionment. The key question is: How can we prevent burnout and prioritize the well-being of those pushing for systemic change?

• Disillusionment; low autonomy or control/influence
• Alienation; lack of peers or support 
• Feeling overwhelmed and stuck
• Imposter syndrome; hesitancy in stance
• Burnout; frustration, perceived lack of effectiveness 
• Can be compounded by other minority or marginalized statuses

Engaging in system change can be mentally and socially challenging. Feeling unheard or thinking differently from others, especially when administrators are heavily focused on funding, can create social stress. Recognizing the system as broken, ineffective, or unjust, and witnessing a lack of empathy or acknowledgment of social issues, can lead to burnout, exhaustion, cynicism, and even dishonest behavior or alcohol abuse. These issues are common among deeply dedicated individuals. Notably, research shows that independent practitioners experience less burnout compared to those in larger organizations, where clashes between hierarchy levels can be more frequent. It's crucial to protect individuals from burnout and its negative consequences.

Measuring Burnout

To recap, measuring burnout involves assessing a combination of emotional exhaustion, depersonalization (developing a negative attitude towards work or the people you serve), and a sense of reduced personal accomplishment. It's not a binary measure; instead, it exists on a continuum. You can experience varying degrees of these feelings, ranging from a state of well-being and vitality to total burnout and detachment from your work. It's important to recognize that individuals can move along this continuum, and burnout is not necessarily a permanent state.

• Emotional Exhaustion (EE): feeling maxed out and not able to offer emotional support
• Depersonalization (DP): negative/cynical attitude towards/of the patient
• Personal Accomplishment (PA):  is reduced, plus escapism
• NOT dichotomous

Pain Points in Systems Change 

System change in the context of behavioral healthcare often involves shifting culture, paradigms, and approaches, which can be challenging and sometimes seen as counter to the traditional medical model, particularly when it involves changing how we view the root causes of mental health issues. These shifts can contribute to the factors related to burnout among system-changers.

Job scope, Time Constraints

Burnout in the context of system change can also be related to short-term coping with workload and feelings of ineffectiveness. It may increase with years of experience and is influenced by the scope of your job and time constraints when taking on extra responsibilities related to system change. Additionally, the global nature of the problems may not always align with your sphere of influence. In response to system change efforts, new professional roles can emerge, often grant-funded, but they might be temporary, coming and going as needed.

Bureaucracy, Hierarchy 

Bureaucracy and hierarchy within organizations can indeed create challenges for system-changers. Conflict between employees and administrators, as well as mismatches between programs or ideas and funding criteria, can add to the pressure. Dealing with bureaucratic red tape is a significant cause of burnout, leading to moral distress when top-level decision-makers may not be implementing positive changes for legitimate reasons.

Organizational Culture

The organizational culture can become a pressure cooker when infighting or tensions arise among different groups and individuals regarding how to approach a problem. This can often be a clash between the biomedical model, emphasizing over-medicalization, and a more holistic approach that includes social factors and policy changes to address disparities. Such conflicts go beyond day-to-day practice. The ethical climate within an organization can also be influenced by this, and many have experienced situations where they were proud to work somewhere with a clear mission and purpose, only to see changes in administration lead to a values mismatch or ethical concerns. When such discrepancies occur, it can be challenging to maintain positive momentum towards your goals, affecting your ability to perform at your best and having a psychological impact.

Self-Care

Self-care is not only important but protective, especially when dealing with the various stressors and risk factors that come with engaging in system change. It's essential to shift the stigma around self-care, viewing it as mission-critical rather than selfish. Focusing on basic needs and avoiding codependency – where you overly prioritize others' needs – is crucial. By taking responsibility for your self-care, you regain power and improve relationships and overall well-being.

Incorporating practices that enhance your overall wellness is key. Additionally, it's essential to separate your identity and self-worth from your career, as tying them too closely can lead to emotional highs and lows that affect your self-esteem and well-being. Decoupling your identity from your career allows you to offer better care by preventing emotional exhaustion. Cultivating emotional and interpersonal boundaries is also important for maintaining your well-being and preventing overwhelm from systemic and individual challenges.

Human Needs

Understanding and addressing human needs is a crucial aspect of self-care. These needs can be categorized into various levels, with physiological and connection with others being some of the top priorities when it comes to self-care. Ensuring your physiological well-being, which includes things like sleep, nutrition, and exercise, is fundamental for your overall health. Likewise, maintaining strong connections with others, such as friends and family, can provide emotional support and a sense of belonging, which is essential for your mental and emotional well-being. Building self-care routines around these needs can significantly contribute to your overall well-being and resilience, especially in the face of the challenges associated with system change work.

Figure 1. Maslow's hierarchy of needs.

Barriers to Self-Care

Engaging in self-care can be challenging due to various barriers. These obstacles include attachment to unhealthy behaviors or addiction, a lack of motivation, difficulty deciding when to adopt healthy behaviors, challenges in maintaining these behaviors without social support, dealing with multiple health conditions (multi-morbidity), experiencing significant life events such as relationship endings or loss, and having an inadequate response to the symptoms of burnout. Additionally, there may be a stigma associated with seeking help for self-care, particularly among health professionals who provide care to others but may hesitate to seek support for themselves. Recognizing and addressing these barriers is essential for promoting self-care and overall well-being, especially in high-stress roles like system-change work.

Self-Care in Practice

In self-care, you can start anywhere, but it's essential to cover various domains. Begin with physical well-being, which you may already be practicing. Next, set healthy boundaries, manage emotions effectively, and release negative feelings to think clearly and make sound decisions. Embracing your inner spirituality, regardless of religious beliefs, can offer a protective perspective that turns life's challenges into valuable learning experiences. This simplified paragraph maintains the core concepts while improving readability.

Physical Nurturing

Physical nurturing primarily revolves around the vital aspect of rest. It's crucial to remember the HALT concept: when you're hungry, angry, lonely, or tired, rest becomes your best ally. This is my catchphrase, "Rest is best." Additionally, your diet, exercise, and physical activity, which can encompass simple movements like standing up and down, dancing, or spending time outdoors in nature, play pivotal roles in regulating your overall well-being. Don't underestimate the significance of basic hygiene practices such as teeth brushing, hair care, and showering; they are integral to your physical nurturing. Lastly, engaging with healthcare professionals when needed and adopting other wellness practices further contribute to your holistic self-care routine.

Boundaries

Let's talk about boundaries, a key factor in your well-being and career sustainability. First, there's work-life balance, where setting clear time limits matters, even if it feels challenging in environments where work bleeds into personal time. Emotions come into play too; it's important to distinguish what's yours from what's others'. Plus, professional boundaries ensure you don't get overly involved with colleagues to the point where you lose your own identity. Remember, boundary-setting can be a lifelong process, especially if you've never learned it before; it often starts in adulthood and takes time to develop fully. So, be patient with yourself as you work on it.

Locus of Control

This also ties into the concept of your locus of control, which involves recognizing what you can and cannot control. This distinction becomes particularly crucial in effecting system-level change. Focusing excessively on things beyond your direct control can drain you emotionally. It's not that you can't contribute to changing the system, but it's important to differentiate between what falls outside your control, such as people, places, and external factors, and what you can control, which includes your responses and behaviors. While thoughts, emotions, and feelings can sometimes feel less controllable, they also fall within your influence and can change over time.

Emotional Regulation and Expression

It's crucial to recognize and identify your emotions. Sometimes, without clear boundaries or when you're overly focused on others, pinpointing your feelings can be challenging. Practicing mindfulness can help create a separation between strong emotions and your neutral inner self. Techniques like deep breathing, talking to a friend, journaling, engaging in art, participating in activities, singing, or even venting can serve as valuable outlets to express and process your emotions, which is essential for your well-being.

Spirituality & Your Inner-Self

To reiterate, spirituality involves connecting with your identity beyond your social and professional roles, potentially seeking support from a higher power when you're overwhelmed or uncertain about your path. This could involve practices like prayer and meditation, which offer valuable guidance. It also includes identifying your personal and professional values, finding solace in nature, and for some, spirituality is intimately tied to the natural world. How does all this help in your daily life? It provides you with a centered foundation, ensuring that the ups and downs of your professional life don't easily toss you about, helping you maintain a sense of inner calm and stability.

Social Support

Social support stands out as one of the most effective preventive measures for mental health issues, especially at a broader population level. This is even more crucial when you're involved in system change efforts. Seek out like-minded support groups, consider individual counseling or therapy, and if you're adopting new health behaviors, having a supportive buddy can be immensely beneficial. Building a strong support network can significantly bolster your well-being and your ability to navigate challenges effectively.

An Appropriate Outlet

In summary, my message, while not from a behavioral health professional, is grounded in real-world experiences involving programs, policies, initiatives, and organizational adjustments aimed at addressing pressing social issues. Undertaking such endeavors can indeed be daunting, but they can also be deeply inspiring and drive meaningful change. Our systems may have flaws, but they are amenable to improvement through ongoing innovations and initiatives, which you can explore through readily available resources.

Self-care plays a pivotal role in this journey because without prioritizing your well-being, progress becomes elusive. However, the key is to identify an appropriate outlet for your efforts. It involves discovering where you can make a difference, whether it's within your current role or beyond it, while understanding your limitations regarding time, workload, and emotional investment. The goal is to find the smallest difference you can make within your capacity, as this will fuel your energy for sustained work. Attempting to tackle something too vast can be overwhelming, akin to getting electrocuted, so the metaphor here is to find an appropriate outlet.

I've provided references for further reading, and I'm open to offering additional resources. Your time is greatly appreciated, and I welcome any comments or questions. I wish you the best of luck in your endeavors, whether they involve small or large changes. That concludes this course.

References

Belkin, G., Appleton, S., & Langlois, K. (2021). Reimagining mental health systems post COVID-19. The Lancet Planetary Health, 5(4), e181-e182.

Balch, C. M., Oreskovich, M. R., Dyrbye, L. N., Colaiano, J. M., Satele, D. V., Sloan, J. A., & Shanafelt, T. D. (2011). Personal consequences of malpractice lawsuits on American surgeons. Journal of the American College of Surgeons, 213, 657-667. doi:10.1016/j.jamcollsurg.2011.08.005

Bruce, C. R., Miller, S. M., & Zimmerman, J. L. (2015). A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics. Critical Care Medicine, 43, 1–9.

Dzeng, E., & Curtis, J. R. (2018). Understanding ethical climate, moral distress, and burnout: a novel tool and a conceptual framework. BMJ Quality & Safety, 27(10), 766-770.

Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Organizational Behavior, 2(2), 99-113.

O’Connor, K., Neff, D. M., & Pitman, S. (2018). Burnout in psychotherapists: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74–99. doi:10.1016/jeurpsy.2018.06.003

Pawson, R., Greenhalgh, J., Brennan, C., & Glidewell, E. (2014). Do reviews of healthcare interventions teach us how to improve healthcare systems? Social Science & Medicine, 114, 129-137.

Reith, T. P. (2018). Burnout in United States healthcare professionals: a narrative review. Cureus, 10(12).

Riegel, B., Dunbar, S. B., Fitzsimons, D., Freedland, K. E., Lee, C. S., Middleton, S., ... & Jaarsma, T. (2021). Self-care research: Where are we now? Where are we going? International Journal of Nursing Studies, 116, 103402.

Welp, A., Meier, L. L., & Manser, T. (2015). Emotional exhaustion and workload predict clinician-rated and objective patient safety. Frontiers in Psychology, 5, 1573. doi:10.3389/fpsyg.2014.01573

Wilkinson, H., Whittington, R., Perry, L., & Eames, C. (2017). Examining the relationship between burnout and empathy in healthcare professionals: A systematic review. Burnout Research, 6, 18-29.

Yang, Y., & Hayes, J. A. (2020). Causes and consequences of burnout among mental health professionals: A practice-oriented review of recent empirical literature. Psychotherapy, 57(3), 426.

Editor's Note: This text-based course is a transcript of the webinar, Balance Over Burnout for Mental Health Professionals, presented by Khara Croswaite Brindle, MA, LPC, ACS, CFT-I.

Learning Outcomes

• After this course, participants will be able to identify the symptoms of burnout.
• After this course, participants will be able to explain self-care strategies for successful restoration for professionals within the mental health field.
• After this course, participants will be able to create a wellness plan against burnout.

Introduction

We will talk about burnout, prevention, and signs of burnout. It will be wonderful, and I know it is very applicable to everyone watching this presentation. You will be able to create a wellness plan against burnout. You will have some tangible tools that will help you and the clients you serve. What I love about this presentation is not only are you getting tools for yourself, but for any professional you might be serving who is experiencing burnout, these tools are also applicable to them.

Limitations and Risks

• Limitations include a Western perspective of burnout, self-care, and burnout recovery that reflects access to resources and some privilege.
• Risks include 1) presented strategies impacting self of therapist where additional support could be helpful. 2) These strategies are not a one-size-fit all approach and do not substitute your own work.

Limitations include that this is a Western perspective of burnout, self-care, and burnout recovery that reflects access to resources and some privileges—recognizing that for a lot of people, burnout recovery is, in fact, about having resources and being able to do something, in particular, to get out of burnout. It does not happen. There has to be some intentionality there. Risks include presented strategies impacting the self of the therapist where additional support could be helpful. By no means, by taking this training, will you have yourself recover from burnout. That would be wonderful, that would be amazing, but for today, we want to make sure that you have the strategies to implement, knowing that you probably have some more work to do if you resonate and realize that you might be in your burnout journey.

These strategies are not a one-and-done, are not a one-size-fits-all approach, and do not substitute your work. Hopefully gives you a sense of direction for yourself, but if you do find yourself in burnout currently or somewhere in the future, these are not the one thing that is going to get you out of burnout. This is the start of the journey, not the end.

Flossing

Burnout recovery is like flossing. Why? How could that possibly be? is what you might be asking yourself. How is burnout recovery like flossing? Well, let's think about it. Flossing is something that we are told to do. We are told it is important. We are told that a long-term strategy is good for our health. Burnout, recovery, and self-care is the other part of this combination. Also, when you ask people honestly how often they floss, they are like, "Eh, maybe not very often. Maybe right before my dentist appointment. Maybe like the month before I am supposed to be seen. Maybe it is sporadically when I remember or have time."

Flossing itself feels like effort, which is for a lot of you. Burnout and burnout recovery, burnout prevention and recovery feel like effort. Maybe when you think about burnout and self-care, you feel like a cringing person. "Ew, I do not like to do this." Versus someone who is like, "I have got this down. This feels good to me." 

In the long run, it is good for our health. Obviously, most of us want to avoid burnout but recognize that it is possible in our mental health profession. Burnout recovery is like flossing. It takes effort. It requires some repetition and self-care practice, which we will cover in today's presentation. As you think through some of these things, you will continue to have a reflection, something to pause and think about.

Self-Reflection #1

• What puts mental health professionals at greater risk for burnout?

Self-reflection number one asks what puts mental health professionals at greater risk for burnout. Thinking to yourself, what shows up? What would your answer be? Is it the possibility of vicarious trauma for mental health professionals? Is it compassion fatigue? Is it directly related to the population that we serve? If we are working with people who have had significant trauma, are we more likely to put ourselves into burnout? These are questions that might be coming up for you. It might not surprise you that 75% of working Americans feel like they have already experienced signs or symptoms of burnout while in the workplace, 75%. That is not even mental health professionals. That is across the whole American workforce. Burnout is common and is on the rise as we come out of a pandemic and build a new life. What puts mental health professionals at much greater risk? For some of you, it is everything you give to your clients and the fact that you want them to be healthy and do well and that you want them to succeed. That comes at a cost, which might be our health and wellness as we look at this further. Notice what comes to mind as you see this question and how you might respond.

Overview

• Burnout
• Values
• Self-Care
• Wellness Plan

Today's presentation will cover four topics: burnout, values, self-care, and a wellness plan. As we started to talk about already, we are looking at burnout prevention, but all four of these exercises are going to hopefully help you in either burnout prevention or burnout recovery, depending on where you are in your professional journey.

The first exercise to introduce to all of you is values. If you have had a values exercise, you might have had it in undergrad and grad school as part of a psychology course, or as a mental health professional, you might have introduced a values exercise to your clients because it can be a very powerful tool. For some of you, this might look familiar. For others, it might be completely new. All of the exercises from today's presentation have handouts attached to them. You will have access to those.

Exercise #1 Values

For right now, let's look at them here. There are about 40 values here in Figure 1.

Figure 1. Forty values from https://www.leadingfromwithin.net.

If you were to complete this exercise, the first thing I would have you ask yourself is, what value describes you as an individual? Looking back at this list, most people must start by narrowing down all these values. Your first task might be to narrow down your top 10 values because this is quite a list. From there, maybe you have a strategy to get down to your top five, then your top three, and then your top one.

Values and Burnout

• Think about what value describes you as an individual.
• What value describes you in your career?
• What value would you like to strengthen or improve?

What is a value that describes you as an individual? In my experience administering values exercises for the last decade, I will say that most people's values do not change significantly as they age. Maybe you have done a values exercise before and recall what those values showed up for you.

They tend not to change very often as you get through your lifespan. Thinking again, what value describes you as an individual? Is that value different from than one that describes you in your career? For example, as an individual, your top value is personal growth, but then in the workplace or in your career, it is maybe education is important to you. Recognizing how those differ in your individual life and your professional life. The third one to think about is what value you would like to strengthen or improve. Is it one of the two you have already named, as our example, personal growth versus education, or is there a different value that you would like to strengthen or improve?

Self-Reflection #2

• What are your top three values?

As you think about your top values and identify those top two or three, there is an overlap for many people. Even when you look at this full list, there are things that you might say, "Oh, I can say that both are important," but pick one to narrow it down. That is one strategy. For today's example, let's say personal growth versus education. Maybe for that third question, I say, "I want to strengthen leadership." As you start to notice those, how does that contribute to your burnout? If personal growth is important to you as an individual and education is important to you in your career, is it possible that they contribute to your burnout somehow?

Are you pushing yourself in an educational space to take on more than you can hold? Are you trying to pursue multiple degrees at once? Are you taking on a dozen pieces of training as a mental health professional? Notice how that might show up as part of your top value of education. Do you feel you always have to learn something and push for personal growth? Are you doing your therapeutic work as you support other clients in their mental health work? How does that contribute to burnout for you? Remain curious as you do this exercise to see how that might contribute to your burnout or burnout recovery. As we started to think about it, name what your top three values are now.

The examples I gave today personal growth, education, and leadership. If leadership is the one I want to strengthen, what does that imply when it comes to my burnout journey? Are your top three values showing up in your life right now? If we take this to the next level, what happens or what does it mean to you if your values are absent or neglected? If my top value is personal growth, but I have not done anything to feel like I am growing in the last year, how could that impact me? If I think leadership is important, but I have not done anything in the leadership arena or taken on a leadership role, how could that impact me?

Next Level With Values

• What does it mean if your values are absent or neglected?
• What can you do about it?

As part of this values exercise and how it ties back to burnout if you have these values and you are telling yourself they are important, but they are not present, that could be a warning sign for you. Something is amiss if we say they are important and not there. Something is off. This is part of why we want to start with values because values are part of who we are as professionals, mental health professionals, and people. If our values are not present, that could be a contributing factor. What you can do about it is another question to ask ourselves. Some of you might start to say from this exercise I remember my three values, and now I feel motivated to keep them present. I am going to do something in personal growth next quarter. I am going to figure out something in education. I am going to step up and go out of my comfort zone into a leadership role. Those might be examples that you might do to say, "This is how I am showing up and embodying my values." Then add goals specific to those values in the next three, six months, and next year to see how that might shift how you feel as a person and as a professional. Jot down a few things about what you think you can do if your values feel neglected or absent. How can you bring those back to the forefront for yourself?

What is Burnout?

Figure 2. Images showing burnout.

As we move into the second part of the equation, we have started talking about burnout. Burnout is a buzzword showing up everywhere. I said that burnout's on the rise. We have talked about 75% of the American workforce has experienced burnout symptoms. What is it? Maybe if you look at these first three images in Figure 2. You will start to get a sense of what you think burnout is. What could it be? Maybe you are writing down some of those things that are coming to mind. Is burnout a loss of focus? Are burnout, stress, and anxiety-like this middle image? Is burnout isolation being withdrawn? Is burnout about feeling overwhelmed? Many things go into the burnout experience. What if I told you there are more than 40 symptoms to keep track of for yourself and clients experiencing burnout? We are going to look at those.

Exercise #2 Burnout Symptoms

Exercise number two is about identifying the symptoms of burnout for yourself or, if you were to work with a client on this, having them identify them for themselves. Here on this list in Figure 3 are 40 symptoms of burnout.

Figure 3. Forty symptoms of burnout from www.Vitalhearts.org.

I can tell you, as a professional that has gone through burnout one and a half times in my career far, I knew about quite a handful of these, but there were still some that caught me by surprise. Let's talk about the ones that we kind of know and that have been normalized in our community. Number two, "I feel more irritable than I would like?" Short-fused might be how a client describes this to you. Maybe it is about feeling like you have no energy.

Number eight, "I have no energy to listen to my family when I get home." Maybe it is about number 21. "I do not share my work with my friends. They do not get it." Especially as mental health professionals, it is hard to feel we have to hold for confidentiality, but also that some of the things we hear are super heavy and traumatizing. We cannot open up to our friends or family about what we have done daily as mental health professionals.

Maybe you resonate with number 25. "I feel pessimistic as the result of my job." Well, there is that vicarious trauma, compassion fatigue combination that, if you are working with intense trauma or abuse, or neglect, can impact your worldview and how you see the world outside of the work you do as a professional. Some of us avoid violent movies, dramas, or TV shows that feel like work. I can tell you, as a professional myself, I do not like watching heavy content because it feels like work. I would rather have light and fluffy, funny movies, comedies, rom-com, something that feels lighter than the reality of what we do for a living.

Maybe it is number 31. "My health has declined." In my first professional burnout experience, I can admit that it took about two years to recognize I was in burnout and about a year to recover. That is disheartening for some of you to hear because a year feels like a long time to recover from burnout. Yet I went two years as a mental health professional ignoring my symptoms, being able to talk to clients about their health and wellness, but ignoring my own. I kept chalking it up to, "Oh, I am stressed. I am stressed. It is fine." I was working with a difficult population at the time. I had justified all the things.

It took my declining health to wake me up. For some of you, it might be a medical crisis or your health declining in some way for you to say, "Oh, this is not chronic stress. This is something more, and I want this to feel differently." My personal favorite on the list is number 35. "My road rage has gotten worse." Some of you might be like me and say, "Oh my gosh, I did not even realize that was connected to burnout," and yet it is. As part of that short fuse, irritability, number two can manifest as "I am angry on the road. I have a short fuse while driving or a low tolerance for other drivers." 

When I went through my first burnout recovery and started processing this number 35 with colleagues, I said, "Wow, that is eye-opening." For some of you, you might feel called out, and it is like a more playful way. As you look at this list of 40, notice what shows up for you. Which ones would you endorse? Which ones would you say, "Yep, I have experienced that"? Are there any that are missing from this list for you as you think about what it would be like to create your list of symptoms for burnout? If you have experienced it, maybe you have experienced and have healed from it, maybe you are in the midst of it right now, or even as part of burnout prevention, are these the things you are going to be looking for to make sure that you are paying attention to the warning signs?

I would love for people not to go through two years of ignoring it, like I did, to get the support and wellness they need. You are all here because you want to avoid that burnout.

Self-Reflection #3

• What’s one symptom of burnout for you?

As you reflect on this, what is one symptom you related to? What was one symptom from that list of 40 that you are like, "Yep, that is me." Even if it is not here and now, is there something in the past that would have shown up? If you find yourself stuck and not recognizing a symptom, you can always ask someone who knows you well. A loved one, a spouse, or a child. Hopefully, an adult child, we do not want to add stress to them.

Somebody who knows you, "What did I look like at that time in my life?" Sometimes they are the ones to say, "Oh, you were irritable. Oh, you ate a lot of sweets. You did not want to talk about work. You slept a lot more." Whatever it is. Sometimes our loved ones can be the ones to hold up the mirror, saying, "This is what you looked like." Burnout is not about having one symptom. If so, we would be done. As you saw, there are 40 symptoms because they all interplay with each other.

Next Level Burnout

• What does burnout look like for me?

If we were to take this to the next level, the next worksheet that I would want you to consider is the one that says, "What does burnout look like for me?" What does this look like, customized for you? Or, if you were to engage a client, how would you walk them through this worksheet together in Figure 4?

Figure 4.  Burnout worksheet (Croswaite, K., 2017). 

There is something very powerful about the visual of seeing all of your symptoms organized this way. Starting with physical, what would be some burnout symptoms for you or a client that would show up in the Physical box? What are some examples? Physically is it that they gain weight, have no energy, break out with eczema, or are losing their hair? Maybe they feel like they have a puffy face, are pale, or are moving slowly. Their limbs are very heavy. Recognizing that those are some quick examples of what might show up physically, what would you put in your box?

As we move to Emotionally, what does burnout look like for you? Is it that short fuse or irritability? Is it a loss of focus? Is it you cry much easier? I hear a lot from clients and colleagues that it shows up under the surface. Maybe you feel numb. In contrast, maybe you are not crying. Maybe you are dumb. Do not feel anything at all. Recognizing the Emotional box can also be eye-opening if you have already completed this for yourself or a client.

Intellectually, what shows up for you when you are in burnout? Are you having trouble with deadlines, again, unable to focus? Do you feel you are distracted easily and cannot retain information? Maybe you are trying to learn something new, and it is not sticking. Intellectually, noticing how you function in the workplace. Is it about having that tip-of-the-tongue phenomenon where you are like, "I can remember the thing, but I cannot articulate it"? Are you tripping over your words? Are you noticing that your brain is moving faster than your mouth, and you are feeling discombobulated? Those are some examples of what might show up in the Intellectual box.

Spiritually, now for this box, I always put the disclaimer that spirituality is not specific to religion. It might be spiritual. How you show up in the world: mindfulness, beauty, being present. Spiritually, when you are in burnout, what happens? What do you look like? Are you going through the motions? I had one client who described they were stuck on their phones. They were not noticing their environment. They did not notice the colors of the leaves changing, it was getting dark outside, or there was snow. They were focused on the phone. Spiritually, not being able to appreciate the things around you. Beauty, seeing different things, and smelling different things. How would burnout show up for you spiritually if you identify with religious practice? Are you questioning your beliefs? Are you feeling dejected? Are you feeling, you know, a different way about your religion than you normally would?

Additionally, the Work box is specific because most people, when we think about burnout, think about work. That 75% of the American workforce is thinking about work, yet burnout shows up in all different parts of our lives. That is what we saw with those 40 symptoms: they do not apply to work. They ripple out into our relationships, personal lives, and4 interests or lack thereof. I wanted to separate our work from the physical, emotional, intellectual, and spiritual because work might look very different. Your burnout shows up differently at work than at home, or at least that is my experience as someone who is through professional burnout.

At work, how do you show up? Are you now a workaholic because you are compensating? There is a running joke for mental health professionals that we would rather focus on other people's problems than our own. I say that with love and a smile because sometimes that is what keeps us going is focusing on someone else. As we are crashing and burning at home, maybe we are feeling solid at work because we are focused, and this is where our energy is going. At work, maybe your burnout is showing up as workaholism. Or are you checked out? Are you a disengaged employee or contractor? Are you fantasizing about selling your own business? Are you fantasizing about starting over or doing something completely different outside of mental health?

Those are all things I can normalize in the work that I have done with fellow clinicians. In your relationships, how does burnout show up? If we have that short fuse or are quick to cry, how does that show up in relationships? That is an example of some of the symptoms. Are we checked out? Is our tank empty because we give it all to our clients? We have nothing to give our family, loved ones, and pets when we come home. Is it about avoidance? "I do not want to talk about anything deep. I do not want to fight with you. I am exhausted." Is it about conflict because we feel that short fuse? However this relates, the hope is if you were to take this exercise to heart, you would fill it out so it is completely representative of your experience, not anyone else's.

If you decide to apply this with a client, what impact would it have to see all of those things listed in each box for them to say, "Wow, I did not realize my burnout showed up quite like this," or, "Now it feels more real." Is there motivation to do something about it? This exercise is about putting it on paper and seeing a whole picture of how burnout shows up in all the different spheres of your life.

Self-Care Strategies

Figure 5. Self-care strategies.

Now that we are aware of our burnout and have reflected on our values, self-care is the third category. For any of you who decide to see my TEDx talk, you will know that I hate the word self-care because of the pictures you see in Figure 5. Self-care has been commercialized. And for mental health professionals, many of us would say we do not do it well. We stuck at it. I say that with love and zero judgment because that is me, or it was me in my burnout journey. If you are thinking about this with clients or want to give yourself some self-compassion, identify that self-care has shifted but, for a while, looked like these things. These pictures represent some of the commercialized self-care we expect to d? Everything from meditation or yoga practice to travel, massages, manicures, and pedicures, bubble baths. Like, we have got all these stereotypes of what self-care could be.

Now, if you were a mental health professional at the beginning of the pandemic, you saw all these things go out the window quickly. It was like, "Nope, cannot do any of them. Cannot leave. Have to stay home." All of a sudden, self-care, by this definition, was not accessible. That is a problem. That is a problem for you and me. That is a problem for our clients. Self-care should not be these things. Self-care should be specific to what works for each person. Many clients we serve do not have the mental or financial resources to go on vacations, take time off of work, or have a massage. We need to get more crafty with our self-care strategies that are not the stereotypes you see here.

Exercise #3 Self-Care Wheel

Before we do that, we should probably start with the foundations of what self-care could be. Figure 4 shows the Self-Care Wheel that I love from Rachel Lane.

Figure 6. Self-Care Wheel (Lane, R., 2017).

I have used it for years and years because I think it is a powerful representation of our self-care when it comes to the traditional categories of functioning. Not massages and vacations, but here is how you show up in everyday existence. If you were to engage in this exercise, I would first encourage you to define each category for what it means to you, or if you were to do this with a client, what it means for them.

For example, in the top-right box, getting restful and enough sleep. One person's answer could be, "I get enough sleep if I get eight hours." Another person's answer could be, "If I fall asleep before 2:00 AM, that is a victory for me." Keywords "restful" and "enough" and having them measure and quantify those. What is restful and enough? Is it about not waking up five times? Is it about going to sleep quickly? Is it about a certain number of hours of sleep? have the person define that first before they jump into the exercise fully. as we work our way around the wheel, another personal favorite is what about exercise? What do clients think we are asking when we say, "Tell me about your exercise?" 

Well, for the most part, in my experience, it has been, "Oh, I must be failing that exercising because I do not go to a gym." Now, I work with clients of all different financial backgrounds. A gym is not a high priority, financially or otherwise. We want clients to challenge themselves to think about exercise from a different lens. Is it about how often they are moving around? Is it that they work a job on their feet, for example? Are they walking to the bus stop and back? Do they have a pet that they walk after work? Those are all forms of exercise that have nothing to do with the gym. That could be another way to define this category before they make assumptions about, "I am doing it well" or "I am doing it horribly." 

As we move around the circle, socializing with friends is a category. Pretty self-explanatory. What do they like to do with their friends? Do they like to play video games? Do they like to go out? Do they like to eat? Do they like to watch movies? What do they enjoy with their friends? Now, even introverts can socialize with friends. It might be less time. It is not a big part of their self-care, but it is still a part. What do they enjoy with their friends, even for a couple of hours versus a whole day? The bottom two are personal favorites for me as a mental health professional because you can have your client define this any way you want and for yourself.

Keeping a positive mindset and perspective might be all about boundaries, right? As mental health professionals, we love boundaries. What does keeping a positive mindset and perspective look like? Is it having healthy boundaries with other people? Is it about doing a gratitude practice? Is it about journaling? Is it about sharing your victories and your goals with others? Like, how do we keep that positive mindset? For many people, it will be unique to each of them, but maybe it is about gratitude and saying out loud what they have accomplished as two possibilities. In contrast, protecting your energy from negative influences still has that boundary component about who we share our energy with and our time. Especially if we are in a burnout place, we do not have a lot of energy, to begin with, let alone how are we going to give it to others or spend it on others?

Protecting your energy might be, "I am going to limit how much time I spend at that family function," or "I am going to bookend this heavier conversation with a colleague with something positive after, taking a walk or taking a nap to reset." Those kinds of things. For those that usually say, "Well, I have some pretty heavy interactions with family." We cannot necessarily restrict all of that, nor should we. Maybe it is about being intentional with what you do before and after and even how long you spend with that person so you do not feel completely zapped after the fact—using music or movies to soothe your stress. I would also add reading to this category.

If you have people who love to read, that could also be in this category. It could be read as music, reading, or movies to soothe your stress. And what does that look like? Is that something they enjoy? Is there one particular thing they like over another? Having people define that category for themselves. Moving up to eating well, another favorite 'cause what the heck is eating well? Each person's going to define this differently. One client will say eating well is remembering to eat at all during the day. Another client will be like, "I feel victorious if I have eaten breakfast." Another person might be, "I like to snack all day, and that feels good to me," versus someone who says, "I want three meals a day." 

Eating well can be defined completely uniquely to the person before they even go into how they are showing up in this arena. We want to make sure it is very clear to them how they define it before they jump in. And last but not least, engaging in humorous and fun activities feels like a repetition of socializing with friends, but as you will notice, this could be independent and separate. These could be things you do by yourself. To me, it is about, you know, watching a funny show, listening to comedy, doing something playful like dancing around your house. Does not require others. For the introverts in the room, this category might be yours. "I enjoy doing things by myself," and that is why I think Rachel Lane separated this into a different category.

We have defined all of the categories. The next step is to identify the number and numerical value we would put on each. On the worksheet you have access to, the directions say 1- completely dissatisfied and  7 -completely satisfied. Recognizing this is a snapshot in time, this wheel will look different from moment to moment, day to day, week to week, and month to month. If you were to use this with a client, it is a visual snapshot of where they are in the moment that you are talking to them or as their homework, depending on if you like homework. For yourself, if you were to do this with me at this moment, it is a visual snapshot of where you are right now.

Having a person circle the numerical value they feel fits where they are in this moment. 1, completely dissatisfied. 7, completely satisfied. Going around the wheel, circling off the numbers, with the last instruction to connect the dots. What is powerful, why I like this visual much, is the question asks us, what kind of shape did you make when you connect the dots around the wheel? It is very rare for me to see a circular shape. I usually see a starfish or some geometric shape where there are some solid numbers, like 5, 6s, and 7s, and then a couple of 2s and 3s. It looks a little more jagged. The question to ask ourselves is, if this was a wheel, how well would it roll?

For most of you, if you are a visual learner like me, that is a powerful question to ask. If I have a zig-zagged, jagged shape, and we are asking how well it would roll, it would kind of start-stop, clunk along, where there is maybe a rounded edge and then a big old chunk missing. In terms of self-care, we are not looking for perfect 7s. In 12 years of doing this, I have only seen one where it was perfect 7s, and I did not even believe them because they did not put a lot of thought into it. I could tell that this was not an exercise they had a lot of value in. For everyone else, because we see that weird shape, we can say it is about having balance.

Keyword balance. We are not looking for perfect 7s. We are looking for a well-rounded, well-balanced shape. If we have a lot of 6s and 7s on humorous activity and enough sleep but 2s and 3s on protecting negative energy and keeping a positive mindset, how do we balance that out? Those are questions to ask ourselves.

Self-Reflection #4

• Pick a category you feel you can focus on this week. What category did you pick?

As you think about your wheel, if you went ahead and decided to try this exercise and put your numbers out there, what is one category you feel you can focus on this week? What category did you pick? Coming back to our wheel, let's say you say, "Okay, I wanted to focus on socializing with friends. I was at a 3 or 4.

I would like to see that higher. My friends are important to me. I have not had a lot of time lately. I am going to pick that as my homework, my self-care homework." Maybe it changes your whole outlook on spending some time with your friends. Does it hold you accountable to say, "I need to reach out and schedule a lunch or a dinner, a walk with a friend," and see how that improves your mood and self-care? By no means are we taking all of the categories and saying, "Fix all of them right now," but you might have some intentional homework for yourself around, "I am going to pick one or two categories to improve upon and see if that changes my whole self-care strategy." 

That can be the powerful element of watching your wheel get a little bit more well-rounded from your efforts. If we were truly to take self-care to that next level, this is where I would redefine it when I said I hate the word self-care. If I could scrap the word self-care, I would. I redefine it as rest versus restoration. If people are saying, "Self-care, do self-care," we have been hearing this since grad school, "Do self-care, do self-care," but none of us knew exactly what it looked like. If we can redefine it this way, I think we can be more effective in doing and implementing it.

Next Level With Self-Care

• How do you define rest?
• How do you define restoration?

(Croswaite, K., 2021)

What do I mean when I say rest? What comes to mind for you? Rest could be everything from having nothing on your calendar to having a day off of work to unplugging from your technology and turning off your phone. For many Americans, it might be, "I am going to sit on my couch and watch a show or binge-watch a show and order takeout and relax." If that is your definition of rest, that does have value in our self-care plan. However, it is common for clients and colleagues to come back to me after a weekend of rest and still not feel great. Maybe they are saying, "I feel worse now than ever because I went from 60 miles an hour work-week to zero, and now I feel like I have been hit by a truck." 

Rest is a part of the equation, but we are missing a component: that restoration that has helped many of us through the pandemic and beyond. Yes, we want some rest in that recipe, but we also need restoration. What is restoration? When I introduce this to clients and colleagues, restoration energizes you, reinvigorates, boosts you up, and makes you feel alive again if you are feeling depleted. With that very quick definition, what would you put in your restoration for yourself? What restores you? What kinds of activities would show up here? If the rest is, "I am going to hang out and not have anything on my calendar after feeling scheduled or overscheduled all week," that is a part of it, but what will restore you to having that free space in your calendar?

Is it taking a nap? Is it dancing around your house? Is it doing something playful? Is it in nature? For some of you, it is baking. Others might be jigsaw puzzles, art, gardening, or dog walking. Each person's unique in what they will answer as restoration. For many of you, it is about starting to craft your list of things that do restore you. That is what I invite you to do with this slide define your rest and what that could look like, but then also define restoration and have some examples at the ready. When you have that next intention of, "I need to do some self-care," you have got some ideas right there that make it that much easier to do the self-care we are all told to do.

Wellness Plan

Figure 7. Wellness Plan.

Our wellness plan is our last exercise to cement all these things together. We have talked about values and how those show up and put us at either greater risk of burnout or prevent burnout if we are living in our values. We have talked about burnout symptoms. Now we have talked about self-care and what that can look like now, more than ever. The last piece is to put it all together with a wellness plan. Now, some of you have heard of wellness plans before because there is something called a Wellness Recovery Action Plan, a WRAP plan, and that is what we are modeling in this next portion of the presentation. The images in Figure 7 show a big contrast to the self-care images when we think about wellness.

Self-care, we saw meditation or yoga, vacation, and massages. What is being embodied in these pictures? Is wellness about connection? Is wellness about nature and movement? Is wellness about laughter and joy? Hopefully, it is all those things for you because that would be a nice balancing act for the self-care strategies we are discussing.

Exercise #4: WRAP

Let's look in real-time at what a WRAP plan would be. I call it a Personal Wellness Plan. It is a Wellness Recovery Action Plan, and this is one of your handouts from today's presentation in Figure 8.

Figure 8. WRAP Plan (https://brss-tacs-decision-tool.samhsa.gov/DA_files/LearnMore_Wellness_Toolbox.html).

It is similar to our burnout worksheet: boxes, nice white space for you to jot down a few things. Starting in the top-left, what does it look like when I am well? Pull in some of that information from the burnout conversation, pulling it from your awareness of yourself. Physically, what does it look like when I am well? How do I know when I am doing well emotionally, intellectually, and spiritually? Super powerful when working with clients for them to have self-awareness on this question. Do they know what it looks like when they are doing well? Maybe it is easier to start on the right-hand side with what it looks like when I am not well. Sometimes they are opposites of each other. If they start with a, "I am not well, physically I am lethargic, I am feeling heavy, my body hurts," maybe on the well side, "I feel energized, I feel like my posture is better, I am not in pain," might be the contrast.

Emotionally, what does it look like when I am not well? Again, tearfulness, short fuse, irritability, numbness, checked-out verses, in contrast, "I am present, I am engaged, I am animated." Sometimes clients are aware of their facial expressions changing from flat affect to being present again. That could be powerful to see on paper. Intellectually, that loss of focus, taking in new information, remembering deadlines, remembering important things, having someone repeat themselves versus a lost train of thought. All those kinds of examples there versus that spiritual component. Yet again, not about religion, but about spiritual showing up in the world, presence in the world. Can I notice beauty? Can I notice changes in my environment versus being stuck looking at my feet and phone? Going through the motions?

Internal warning signs are similar to some of the safety planning you have done in other training. Warning signs, internally, what shows up for you or for a client if you are doing this with a client? What shows up on the inside that tells 'em that they are not doing well? Things like restlessness, irritability, feeling like they are on pins and needles, and feeling physically off. One client described it as their muscles jumping, and they had all these muscle ticks and twitches happening, which was very distracting. Other warning signs like negative thoughts, suicidal thoughts, catastrophizing, and black-and-white thinking might be warning signs on the internal side for you or a client.

In contrast, triggers are external things. What is happening outside of you or a client that would be adding to them not feeling very well? Maybe it is a fight with a partner, a trauma anniversary, a recent event, a political component, or something that stresses them out. Maybe they are having financial hardship, or they are having a hard time at work. Maybe their relationship is rocky. Maybe their dog is sick. You know, different things would contribute to them not feeling very well at this point in their life. Again, a snapshot in time.

The next would be My Supports as we move further down the list. My Supports has a primary, secondary, and then a relationship that I want to improve or, like, have more contact with. Who are your primary supports? Would this be a spouse or partner? Would this be a nuclear family member versus extended family, or a mentor or godparent versus friends, colleagues, or coaches? Having people think about who their supporters are. This one can be a mixed bag of emotions for folks, especially if they feel they have avoided or withdrawn from people as part of their burnout. Be very careful about how you tread on this topic because some people will get a little bit heavier, realizing that they have let some of their relationships go or have ghosted as part of their burnout, holding some compassion for that.

When Things Are Breaking Down is my favorite box. When things are breaking down as in, how do they know when things are spiraling out of control? We can have "I am not looking well" warning signs and triggers, but when does it get to that next level where it is, "Ew, I need some support, or I need something to change, or this is going to spiral out, and it is not going to be good." Maybe now they are picking fights, maybe they are self-sabotaging, maybe they are using substances or other negative coping skills. Maybe they are trying to attend to their grief through compulsive shopping or things of that nature. Noticing self-awareness, what would they put in this box for that reason?

As people are crafting these boxes, there are two more below this: What Do I Need from Others, a very powerful box to ask or to fill out, I should say. I am asking it of you. Hopefully, you are filling it out. What do I need from others? Do I need them to leave me alone? Do I need a hug? Do I need support? Do I need a distraction? Do I want someone to, you know, help me tackle laundry? What will help the person feel like they are returning to a place of wellness? And that is a vulnerable question of, "What do I need from others?" I recognize that can change from moment to moment, "I need a distraction" versus "I want to be left alone" are the two contrasts I hear—holding space for all of that if you do this with a client or for yourself.

Self-Reflection #5

• What’s one idea in your plan of action for when things are breaking down?

As you have crafted your wellness plan, what is one idea in your plan of action for when things are breaking down? You know, is there something you want to do to stop the spiral? Is it reaching out for support? Is it talking to a friend? Is it talking to a colleague? Even someone who has been through this. Who has been through their burnout? Can you understand how tricky it can be? Because it is hard to recover from something when you are still living in it. Is there a step you want to take? Taking some time off, if you have that ability?

Does that cause you stress and anxiety to think about taking time off? is it more about being intentional with the time off on your weekends or your scheduled days off from work? Thinking about what is that one idea in your plan of action for when things are breaking down and how we implement that would be that next step. Recognizing that this wellness plan can be as much, it can be as helpful or as unhelpful depending on how much you put into it. How much energy do you put into it? To take that to the next level, I have some suggestions. It does not become another piece of paper that you have written some stuff on and forget about, because, I say, again, that with no judgment because that happens.

Next Level With Wellness Plan

• Accountability Buddy
• Feedback from Others
• Month Check-in
• Compassion Satisfaction and Fatigue Test

http://www.isu.edu/bhstamm

Here are some ideas to have the wellness plans serve you the best possible. First of which is an accountability buddy. When I first learned how to do a wellness plan, they had to sit alongside someone and had to share all of those components in each of those boxes, not from a place of vulnerability but that someone could, like, ask clarifying questions, recognize, "Okay, is there an action step that we have forgotten?" "You said this is important, but it is not in this box." That can be empowering to have somebody sit alongside you but also check-in and ensure the things are represented. In those action steps, the accountability buddy can say, "Hey, did you take that time off?

Did you do some rest? Did you do a restoration activity? How did that go for you?" Many of you are familiar with accountability for lots of different therapeutic exercises. This is another area where that could apply. it is about getting feedback from others. If you find yourself trying to fill out your wellness plan and you have a mental block or writer's block in trying to put something on the sheet, who can you ask that can help you fill out and flush out what you look like when you are well, unwell, what the triggers and warning signs are? Who knows you the best? Who can help you with this? Now, the biggest task of vulnerability is asking someone who knows you well to help fill in the blanks if you feel like you cannot.

Sometimes what they have to say is somewhat painful, "Oh yeah, that is true." "Ouch." Feedback from others matters. Sometimes it is about flushing out the areas you cannot think of or addressing that writer's block if you have it, but it can be a very powerful tool in connecting with people around how you are doing. I use them in therapy a lot, the mirror image. Holding up a mirror and showing us how we are showing up to others and having a trusted person do that is powerful. I encourage .you to identify someone in your life who can hold up that mirror and say, "Hey, here is how you are showing up."

Here is how you are looking right now," and give you a chance to adjust and reflect. The monthly check-in is like the accountability buddy, but more, it could be a monthly check-in with yourself. What would it be like if you crafted it, handwrote your wellness plan, or typed it up? Putting a reminder in your phone to revisit it in a month and see how it is applying? Is it a gentle reminder to keep doing a couple of things? Is it, "Oh my gosh, I did none of those things?" Is it, "Oh, I forgot about this completely, let's try some goals for next month." By doing a monthly check-in, it stays fresh.

It does not be a one-and-done. You can revisit it, revamp it, rewrite it, whatever it takes to feel like the wellness plan is serving you or your client if that is the person you are doing this with. Last but not least is the Compassion Satisfaction and Fatigue Test. Now, this is a public document, that is. I believe 63 questions long. It is quite robust that way, but it is a document that people can administer to check in on satisfaction versus fatigue when it comes to compassion. A powerful weighing out of both compassion satisfaction and fatigue. I enjoy doing this with teams to ensure that my team is healthy. It gives them a chance to give me, you know, kind of an almost anonymous way of saying, "I am not doing well," or, "Here is where I am feeling good about my client work," "Here is where I am struggling," but also gives them that visual.

It can be a mile marker of, you know, here we are, and then six months from now, how is that looking? Did your satisfaction come down? Did your fatigue go up? Is there vicarious trauma we need to adjust and navigate in that way? Great for teams, but it also can be another touchpoint for you as a clinician to gauge your functioning. Where are you in satisfaction versus fatigue? Of course, it has a category of burnout as well. That document is also part of your handouts for this presentation to grab and utilize how you see fit. Again, 63-plus questions give us a sense of some powerful things we can ask ourselves but also measure that satisfaction-fatigue and burnout combination.

Other questions that come up before we do our wrap-up. The big one I started to talk about is how long it takes to recover from burnout. In most people, at minimum, it is going to take a year because it is one of those things that requires intentionality, like flossing, right? You gotta create a habit out of it. They say any good habit takes at least 30 days to cement. And if we are talking about that and then having to build off of different habits to get to a place where you do not feel like you are in burnout any longer, it is pretty easy to see how that could take a year or longer for us to do.

It does not mean you have to do it on your own. For that reason, you can have the support of colleagues, friends, supervisors, coworkers, consultants, and coaches to have someone hold you accountable and help you keep slowly chipping away at that burnout and getting back to a place of wellness. That is one of the biggest questions. Another question that I get a lot is, is there anyone who is not at risk of burnout? I do not think that happens. I do not think burnout discriminates. I think burnout is a human experience of being overworked and out of balance when it comes to work and life. I know work-life balance is another buzzword, and I want to introduce you to another concept: flow.

Instead of work-life balance, now we are talking about work-life flow. And some of you might like that terminology better because balancing implies that they have to be equal, right, that work has to be an equal amount of time to home life. For many of us who identify as entrepreneurs and mental health professionals, that might not be possible. Maybe it is more about permission, "I am going to work hard for six weeks and then take a week off," or "I am going to be in the flow because I am going to have this strong flow of working with clients for a couple of weeks and then have a flow of taking some more downtime." "Or going into the holiday season where I have fewer clients, or summer where I have less to do," and giving yourself permission to go with the ebb and flow.

Some of you might like that terminology better: work-life flow instead of balance. Other questions that come up. What is another one? What prevents burnout from happening? That is a huge one. Probably not a one-and-done situation, but a couple of things help prevent burnout from being such a high risk for folks, including us as mental health professionals. The boundary is a big part of it, but in any workplace, there are a couple of other things to name, one of which is feeling like you have autonomy. Some of the research that is come out is saying if you feel like you have a say, if you feel like you are being appreciated, if you feel like you are valued in the workplace. These three things would prevent burnout because now we feel emotionally invested in our work and appreciated for our work.

As a mental health professional, I do not think that it is a foreign concept to be like, "Hey, everyone wants to be appreciated. Everyone wants to feel valued."  We are providing a safe space for clients to echo that, and now we are looking at it for ourselves in our burnout recovery and prevention. If you are desperately trying to prevent burnout as part of your professional journey, you know, making sure that you are in a workplace that respects you, values you, provides autonomy and allows you to grow. These are the points of contact that people are noticing that prevent burnout from happening. Hopefully, that resonates, and it does not make completely nonsensical sense because we all want those things as humans.

Those things come up. Let's see, what else can I tell you that people have asked a lot about? Oh, here is a good one. in addition to those 40 symptoms of burnout, there was one significant thing that happened in 2020 that was another sign of burnout that we had not seen before: cracked teeth. According to US American dentists, we saw more cracked teeth in 2020 than we would see six years prior. Wow, more cracked teeth in 2020 than we would see in all six years prior. Well, that tells you we are under immense stress. It was the beginning of the pandemic. That was a factor. It was people working from home. Another factor was a lot of the stress and the poor work-life balance or poor work-life flow.

That all got tossed up in the air and disrupted as part of that pandemic. Not only are we looking at road rage and comfort in sweets and irritability and avoidance and all these things we have named, but we are also now looking at cracked teeth as a sign or symptom of burnout. That is pretty wild, too. With all this being said, if you are looking for additional strategies for your burnout recovery, we have looked at five today, right, four in real time, plus that Compassion Satisfaction and Fatigue Test. There are also some other great trainings out there. One I like to reference today would be the VitalHearts training. It is compassion fatigue training, also called secondary trauma training.

That is a two-day intensive where people get a look at their burnout symptoms but also start to recover from those symptoms. That was part of my burnout recovery journey. I did mention I have been in burnout 1.5 times. I playfully say one and a half because I started to see some of those same warning signs we talked about today, and I had to change to not go back into burnout a second time. I want to normalize that for everyone.

Wrap Up

Burnout is a challenge. It is an ongoing thing we must monitor, like self-care. As we look at the next steps, do not forget to floss is the analogy again. Creating habits. Habits take 30 days. Implement some of these strategies for clients, if not for yourself, because burnout does not discriminate. Anyone who is in the workplace or going through any amount of significant stress has the risk of burnout. That is something to think about. Noticing how we can make a difference and make burnout not part of the mental health experience as much as possible.

Question and Answer

That is interesting that you talked about cracked teeth. About 2021, when we were still having COVID issues, I started having a lot of teeth problems. I had to have wisdom teeth removed, and they said I was grinding my teeth. I did not have any issues with my teeth before that.

I appreciate you sharing that. I think people were more likely to say they were grinding teeth or would have tension headaches because they were clenching their jaw much with the stress of everything we were going through. If it was not cracked teeth, it was one of those other two, of tension headaches or grinding their teeth down to nubs. Mouthguards became popular again, and we were all trying to navigate it in a way that the dentists were saying, "What is happening?"

My dentist said, "You are grinding your teeth." I said, "Well, I have never grinded my teeth. I have never done that before, but now I notice it." If I have any stress or tension, I will feel it is very tense back here. That is a very interesting thing that they found in that study. It reminds me of one of my favorite activities, which is very simple, in the mental health sphere that I am sure participants here would appreciate if they are not already doing it, which is a lot of times when we are trying to drop into a space, whether it is work or being with a partner, getting ready for sleep, or winding down. It is doing a quick body scan, putting our feet flat on the floor, noticing our feet, and slowly coming up the body. Every time I get people to their chest, they recognize, "Oh, I am not breathing very deeply," and then they will start to breathe better. We get to the jaw, and I say, "Soften our jaw." They say, "Oh my gosh, I was clenching my teeth, and I had no idea I was clenching my teeth until you said, soften it." That can be something that can be a gentle reminder for each of us at night or whenever to let's do a quick body scan. Let it all loosen up and soften the jaw because most of us do not even recognize that we are carrying our jaw that way. I want to normalize that.

One of the first things they say when you are in a yoga session is, "Everyone, open your mouth and let your mouth hang open," releasing that tension. I always thought that was strange until I realized why they were doing that. Another thing I have been doing to help me sleep is I love lavender. It relaxes me. I put that on as hand lotion when I go to bed. I am a side sleeper and have my hands up by my face. I think it helps me to sleep.

Are there other tips or tools that you have similar to that engage the senses?

I think the sleep piece was a huge disruption and continues to be a disruption in burnout, where people are either sleeping too much, getting poor sleep, or not sleeping enough. I love lavender, essential oils, and things like that. It is all part of what we call sleep hygiene. What is your routine to get ready for bed to tell your body it is time to wind down? Everything from 20 minutes off your electronics, which is hard to do, to lavender or brushing your teeth or any of the things that would be a routine. To your question, one of my favorite activities is activating all five senses and figuring out a coping kit with all five senses accounted for.

I usually start with what you like to look at that brings you joy or comfort or calms you down. It might be pictures of family, pets, or nature that you could pull up on your phone when you are stressed. What are smells? That could be lavender or a familiar cooking smell, grass. Sometimes people like nature smells, like, fresh rain. Having them walk through all five senses can create a coping kit where they can start compiling those things to have them handy. If it is nature, it might be, "I need to get outside and take a walk in green grass." "I need to pull up a picture of my mom." Make it accessible.

My favorites are the sense of taste because those are the most intentional. Do you like mint and have that on your desk? Can you have like something spicy if you like spicy? Do you chew gum? Any of the things that people are not thinking about can have a significant impact on them feeling more relaxed quickly.

Did you find once you incorporated some of the sleeping and things in your journey, you felt better later on? For example, going back to work, did that help relieve some of that pressure?

For me, it was the boundary of not working 24/7. I had to set a regular bedtime and get up even though I did not feel like getting up. I know it is hard for many of us when we are feeling depleted, but I learned very quickly that I needed a certain number of hours of sleep to feel functional. I would not even say happy but functional. I had to start there. Then getting up every day, even on weekends, I had to get up at the same time. I would not do that whole, "I want to catch up on all my sleep and sleep until noon," but that did not work for me, and for most of my clients, it does not either because it is disruptive.

If you get up at 6:00 on a weekday, you are getting up at 6:00 on the weekend. That does not mean you do not get a chance to have a nap. By all means, have a nap. Letting the body have that rhythm, "Oh, this is when we wake up, this when we go to bed," has been helpful for mood and burnout.

References

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O’Connor, K., Neff, D.M., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53. 

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Tanios, M., Haberman, D., Bouchard, J., Motherwell, M., & Patel, J. (2021). Analyses of burn-out among medical professionals and suggested solutions—a narrative review. Journal Of Hospital Management And Health Policy, 6. doi:10.21037/jhmhp-20-153

Learning Outcomes

After this course, participants will be able to:

1. Identify the physical and emotional symptoms of burnout.
2. Distinguish if they are currently experiencing or have experienced burnout by asking themselves specific and measurable questions.
3. List manageable coping mechanisms and self-care practices to combat burnout.

Introduction

Today's presentation is navigating burnout, managing your own stress while taking care of others during a pandemic. We keep thinking the COVID pandemic is over, but instead it feels like wave after wave. Many of us allied health providers feel as though we have been running on empty for the last two years. Some of us, including me, came from a mindset of "give until you're empty and then give some more'.  It took the pandemic, when I was working seven days a week, answering every email, and taking on every new client, when I started to have the physical symptoms of burnout. I realized that I could not sustain the pace any longer. My hope is that by using my experience with burnout and running a group practice, that I can help other professionals. We are doing important work and there is no end in sight to the need for our services.

 ]I am a licensed clinical social worker. I have a master's in education, curriculum and instruction, and I have a graduate certificate in organizational and executive coaching. I am the founder of Forward In Heels, an intersectional feminist group therapy practice that empowers all women to stand tall and own their worth so they can light up the world. In my twenties, I was the classic overachiever, with multiple graduate degrees and fellowships.  I was always looking for the next gold star to make me feel valid. I was constantly making lists and plans only to have to rewrite them when something unexpected came up, as it always does. I would go to a therapist and after three sessions, they would say, well there's nothing wrong with you, which I know now was the worst thing I could have heard. I'd think, clearly I just have to work harder. Finally, I realized that I suffer from high functioning anxiety, and that just because I'm often able to sublimate my anxious tendencies into achievements doesn't mean it is not negatively impacting me.

I created a practice that recognizes that being a badass doesn't mean you never have doubt, and that being the strong one doesn't mean you never need to be checked on. Being the one everyone always goes to for solutions doesn't mean you're never vulnerable. What makes me come alive is seeing women realize the unrealized, unlimited potential in them. When women can take care of themselves personally, their light shines through, and the best version of themselves shows up professionally.

I specialize in combining cognitive behavioral therapy and psychodynamic approaches to help stressed out, overachieving women overcome imposter syndrome and dissatisfaction. As a result, women go from chasing the brass ring to achieving sustainable happiness in every aspect of their lives. This may sound similar to how many of us chase that next thing, but what we have to recognize is that the search towards self actualization is not one that we're ever going to reach.

Pre-pandemic studies showed that two in 10 US adults experienced an episode of mental illness or chronic mental illness each year. One in 10 US adults reported symptoms of anxiety or depressive disorder from January to June 2019. These statistics are from the Kaiser Family Foundation (read the issue brief here) who does ongoing reports of the state of the health in this country. During the pandemic, about four in 10 adults in the US have reported symptoms of anxiety or depressive disorder. That is an increase from about 50 million people in 2019 to just over 100 million people in 2020. No wonder therapists have waiting lists and clients seem to multiply by the day.

Think about a time when you've been in a car and you've experienced a near miss, where you and the other driver don't actually collide. Your nervous system doesn't immediately calm down. It could take minutes or hours before your heart rate stabilizes and your breathing becomes normal again. That example - a near miss car accident - is when a short term threat appears, disappears and doesn't return. Now, realize that your body and your brain on an unconscious level have been perceiving a permanent threat for over two years due to the pandemic. Think about how that situation elevates all of the emergency response systems in your body to a new baseline. When we are no longer in a pandemic, but in an endemic (meaning that this virus will be with us always but managed by vaccines and treatments like the annual flu), we will still have a long road ahead of us.  It will take a long time to change how our bodies and brains are perceiving our environments.

Fight, Flight, Freeze, Fawn, Fold 

We are familiar with "fight flight freeze", and there are some more recent add-ons like "fawn or fold".

For many of us, instead of getting stuck in one response of fight, flight, or freeze, we've been cycling through them. This may sound familiar to you or your clients: You're lethargic all day, you have trouble finding motivation to do anything because nothing really seems to matter. The work keeps piling up no matter how much you do, and the laundry always needs to get done. You feel stuck on a hamster wheel. You're stuck in freeze all day, conserving energy for some imaginary future fight. Then when it's finally time for bed, you're wide awake. Your mind is racing and you can't fall asleep no matter how many sleep hygiene strategies you use. Your brain thinks it's time to fight. When you finally do fall asleep, no matter how long you sleep, you don't wake up well rested. This is because instead of letting your brain get into deep REM sleep, your flight response is keeping you closer to the surface, just in case a threat attacks in your sleep, and you might have to jump out bed and run.

You're essentially catnapping. You know how when a cat seems asleep, but you walk by and they open one eye just to make sure you're not a threat? That's what cats are supposed to do evolutionarily, but humans are not. We are supposed to get into deep REM sleep. No wonder we're burned out. When our brains are overburdened, we can't think critically and our executive functioning is compromised. When we are in fight, flight or freeze the blood rushes from our brain to our bodies - our muscles and our heart and our lungs - in case we have to fight or run. We need to think about strategies and problem-solving when we're feeling calm. 

What is Burnout?

What is burnout? This word is everywhere, but let's dissect it. Before burnout is languishing, which is a fairly new phrase that has been created by Adam Grant. Grant is a researcher and public figure in the field of self-help, mental health, and self-care. Languishing refers to a state where you still have some level of energy and maybe some hope, but you feel joyless and aimless. It's the opposite of flourishing. It's a sense of stagnation and emptiness. When you're languishing,  you may feel like you're muddling through your days, looking at your life through a foggy windshield. The symptoms of languishing can mimic depression, but they are externally caused by your circumstances. The next step is burnout if you don't address or recognize languishing.

Burnout is a state of emotional, mental and physical exhaustion caused by excessive and prolonged stress that can leave an individual feeling helpless, disillusioned, and exhausted. As the stress continues, you begin to lose interest and the motivation that led you to take on a specific role in the first place. Many of us got into allied health professions because we care about people and we want to make the world a better place. When we feel like we are being crushed under the weight of all of our expectations, both personal and professional, we stop remembering why went into healthcare. Jobs with higher pay and fewer hours start to look really attractive when you're burned out, as does quitting altogether.

Burnout can also lead to long term problems with your body that make you more vulnerable to illnesses like colds and flu. How does burnout affect productivity and energy? It reduces productivity and zaps your energy, leaving you feeling helpless.

Other signs of burnout include:

• Anger/irritability
• Exhaustion
• Frustration
• Impatience
• Decreased ability to be flexible with unforeseen changes

Regarding anger and irritability, it may show up as something that might have bothered you only a little bit before, bothers you a lot more when you are burned out. 

Regarding exhaustion, I mentioned that when you are stressed, your body does not get the restful sleep that it needs, and is not replenished. Think of yourself like an iPhone battery. When your phone battery is depleted and you have 0% battery left, you don't expect that you will be able to continue making calls and using apps. You are the same as a battery. You cannot keep burning yourself out, going down to zero, and then expecting yourself to keep going. 

Frustration and impatience are similar to anger and irritability.  When you are frustrated, you don't have patience with yourself, let alone others, to keep doing things that are hard. Maybe you don't have the time tolerance to do anything longer than watch a TikTok video. These are all symptoms of burnout because your brain is attempting to conserve the energy that it needs to keep going for life. Your brain is really meant to keep you going for as long as possible. Burnout is like you're running a sprint, not a marathon.

Another sign of burnout is a decreased ability to be flexible with unforeseen changes. Many people had to reschedule vacations, weddings, family events, over and over again during the pandemic. Understandably at this point, people are done with it. They are sick of having to reschedule, only to have one more curveball thrown at them. They may not have the capacity for more unforeseen changes.

Burnout can look like distancing yourself from social activities, and from friends and family. If you're experiencing excitement about upcoming projects, feeling well rested after vacation or able to maintain your empathy and compassion, you're likely not experiencing burnout. However, that doesn't mean you might not be on your way there. Look at this holistically. Maybe you still have hope for some future project at work, but you find yourself starting it and then abandoning it after 20 minutes instead of an hour.  That may be a sign that you are starting to burn out. 

Burning out can also have physical symptoms like exhaustion, hair loss, and digestive issues.

Other ways that burnout can show up in yourself and others include:

• Missed deadlines
• Poor communication
• Poor conflict resolution
• Less proactive behavior
• Great Resignation
• Calling out more often
• Poorer work quality 

Missed Deadlines

Burnout shows up practically in many ways including missed deadlines, and a lack of drive. Maybe things you cared about don't seem important anymore.  You may have an important presentation at work and think, "Who cares if the slides are not perfect; millions of people are dead of COVID." Or, "Who cares if my kid's permission slip is late?"  You see dinosaurs at a museum and you think they represent a fast-approaching dystopian future. While these examples may sound dramatic, they're the kinds of things I hear over and over again from clients. And if I'm being honest, sometimes they are part of my own internal narrative. It can be frustrating as a practitioner to sit in front of someone who is saying, "What's the point of all of this?" and to recognize that you don't have a great answer.  You can't give them a simple solution because they are concerned with global issues, war, political discourse and other complex problems. That makes me feel very helpless, which as a practitioner is something that I don't often encounter because I usually have ideas and solutions for clients to try.

Poor Communication and Poor Conflict Resolution

As social workers, we have graduate degrees in human behavior. However, during these past few years, I know for me, it sometimes seems like all of my communication skills have gone out the window. I have seen some of the worst behavior in communication in Facebook groups, exclusively made up of therapists. We're all burnt out and all of those skills we spent years honing feel useless in such a time of acute layered crises. Everyone has spent the last two years in some ways alone in an echo chamber of their own thoughts. Our worlds got smaller, even if you live with people, and even if you kept working.

If you think about a day in the life previously, it included so much more social interaction. For me, I started my day getting coffee from a barista first thing in the morning, interacted with a security guard, and then with colleagues. I would come to work with a bounce in my step. During the pandemic, a lot of us were (and maybe still are) alone in a room, whether it's at home behind a computer screen or in a safe sanitized version of our old offices. Things have changed and all those intangible communications that we used to have, don't exist anymore, so everything takes on higher importance. Poor conflict resolution goes along with poor communication.

Less Proactive Behavior 

A lot of people that I've worked with have big questions. They have expressed concerns such as, "Why should I save for retirement if the financial system will collapse and there will be no social security, that I have spent my life contributing to?" They are asking why they should exercise and be healthy if they followed all the rules and still got COVID. Maybe grieving family members who "followed the rules" still died. Understandably, that can lead to less proactive behavior and more reactive behavior.

The Great Resignation

My clients seemed to have one of two experiences during the pandemic. Some were laid off or furloughed. They felt that no matter how hard they worked, how highly they performed, or how they did everything right at work over the years, external forces were at play and their efforts didn't matter. They were in the same boat as colleagues who didn't work as hard. The other experience was one. where companies had more business during the pandemic. These clients began working even harder, 24/7, to keep their companies afloat. The lines were blurred between home and work. People started working on the weekend to try and get ahead because they had nothing to do in their personal lives, but the emails kept coming and the work kept coming. At the end of the year. maybe they saved their company or had record profits, but the individual received no raise and no promotion. These clients realized that no matter how hard they worked, the promise of a reward that was commensurate with the work they put in was a mirage. Regardless of which experience clients had, they came to a the same realization: it's futile to work hard and care so much about work, because much of what happens to me is outside my control.

This led to what has been referred to as the "great resignation". People left their jobs, and some people found new jobs. Some people who were asked to return to an in-person office wanted to continue working from home, and some companies have been inflexible about that.  Some people are not leaving the workforce entirely, but leaving the strict corporate structure to do their own thing. This has been coined the "great reshuffle". You might see this in healthcare providers - many therapists have left community mental health centers, agencies, and hospitals to go into private practice. In private practice, they can organize their schedules around their families, and they realized they can do much of their work at home as they did during the pandemic. Other people are having realizations that life is short, and they are leaving their jobs for work that is more meaningful. While that could be a great thing, it is also a time of fear, uncertainty, and tumult for many od our clients.

Calling Out Sick / Cancelling 

Another thing you might see is calling out sick more often. Clients might say, I just couldn't get up. Sometimes we do that because we can plan something restful or restorative like a planned mental health day where we get in a few doctors' appointments and then maybe work in an enjoyable activity. Other times, it's a last minute panic-induced choice of opening your eyes in the morning and thinking you just can't go to work. That is when we're reaching that point of burnout.

If you find yourself canceling with clients or being grateful when a client cancels, you might want to examine if you're reaching that point of burnout.

Poorer Work Quality

In the case of burnout, poorer work quality is not the result of being lazy or not caring. For a lot of people it's because their brain is overtaxed and they just don't have it in them to keep performing at that 100% level hour after hour, day after day. It's not that they're trying to deliver poor quality work. As a social worker, maybe you are I'm so tired, overworked, and overburdened. I need to look at my schedule and see what I can control. Maybe I can shift people around or take a longer break. Maybe I just have too many clients and I have to think about that referring out or doing something differently. If you are also managing people where all of these behaviors are showing up, it might be incredibly frustrating.

New Perspective

If you are able to view these effects as the result of the trauma responses of fight flight and freeze, could it change how you approach caring for others and for yourself? What would you do if you viewed poor work quality as a trauma response? If you've ever had an employee come to you in a crisis, did you treat them differently?  If an employee disclosed a serious illness, discussed exitting a violent relationship or experienced a miscarriage, did you treat them differently while they were experiencing their crisis? Were you more understanding, more accommodating or more flexible?

What if we could take that perspective and energy and change the expectations for ourselves and the people around us? What if we zoom out and say, we need to draw the results we need from ourselves and others without criticism. We still have to get these results to our clients. We still have to design this project for our stakeholders. Both things are true- we understand that we're coming from a trauma brain and that we also still have to work towards a larger goal. What would it look like to be understanding, but not to be excusing?

Which of these symptoms have shown up for your clients in the past few years? Here are the results of the poll of attendees from the live webinar format of this course:

• 43% missed deadlines
• 57% poor communication
• 61% said poor conflict resolution
• 54% less proactive behavior
• 21% great resignation
• 25% calling out more often
• 43% poorer work quality

Self-Care Strategies 

When we go back to the basis of what makes us better or worse at conflict resolution, it often starts with how we're taking care of ourselves or how we're not. What can we do at the individual level? I care very much about immediately actionable stragegies. It's important to me to start with the why, to find out what is happening and how we notice it. The next step is what we can do about it. This is the macro level of the Cognitive Behavioral Therapy (CBT) and psychodynamic approach that we take in my practice. Self-care is more important than ever because we are living through an epidemic of anxiety and depression. Self-care allows us to better cope with daily stressors, such as trying to keep up with the pace of daily life, technology loneliness, and it includes ability to unwind.

Our bodies and our minds are intricately connected. Self-care allows us to take positive steps to tend to our physical, emotional health. The practice of self-care allows individuals, families, and communities to promote health, prevent disease, maintain health and cope with illnesses alongside the support of a healthcare provider. I am sure you have seen the research that shows time and again tne of the number one predictors of health and longevity is community.  The actionable strategies I will discuss today include: Thought Stopping, Box Breathing, Physical Grounding, Focus on What You Can Control, Wait 24 Hours, Positive Reframing, and Gratitude Practice.

Thought Stopping

I often hear a spiral that sounds like this: "Oh no, my boss scheduled a 15 minute meeting with me at the last minute with no context. That's never happened before. Obviously I royally messed up on the last assignment, and I'm costing the company money. You know what, I've bankrupted my company, I'm getting fired. I'm probably getting sued, too.

I'm sure many of us have heard a version of that from our clients or we recognize that type of thinking in ourselves. Thought stopping involves saying the word "stop" loudly and forcefully. You can also tie a rubber band around your wrist and snap it when you notice the thoughts start to spiral. Hearing the word "stop" (or feeling the snap) jars you, and stops that spiral in its tracks. At that point you're not going to actively resume the spiraling thoughts, because you've noticed that it's not working for you. You can start replacing those thoughts. Maybe you think, I did mess up on the last assignment, but I have boss to give me feedback so that I can correct it and do better for next time. Meeting for 15 minutes would probably not be long enough to tell me that I ruined everything and I'm getting fired and sued. And, I don't see Human Resources listed as an invite to the meeting. I'm probably not that powerful to bankrupt the company, anyway. The purpose of thought stopping is not to get too caught up in the story until we have actual information and evidence to know which direction to go. The purpose of replacing the thoughts is not to paint a rosy picture and tell yourself everything is amazing. The point is to pause and focus on the information you have without continuing the spiral.

Box Breathing or Four Square Breathing

Box breathing (also called four square breathing) is one of my favorite practices that I use, when I can't fall asleep, or I find that my heart is racing for whatever reason. It involves exhaling to account of four, holding your lungs empty for a four count, inhaling for a count of four, and holding air in your lungs for a count of four before exhaling and beginning the pattern anew.

This simple technique forces your brain to focus on one repetitive thing and to slow your breathing, which leads to a calmer nervous system and a more relaxed mind. It's basically a shortcut meditation and it can increase resilience to stress, decrease feelings of depression and increase positive feelings. You can do it almost anywhere - on the subway. in your car, at your desk. You can pair it with a literal box that you can see. If you're sitting at your desk, you can use your eyes to trace around your computer monitor while you do this and no one will notice. You can do this yourself and pretty quickly, to slow your breathing down, and then your brain will resume focus.

When I say this technique is simple, I want to clarify simple is not the same thing as easy. A plank is simple, right? You get down on the floor, put hands on the floor, and put your feet on the floor. A plank is not easy. By simple I mean the practice has one action or very few actions.

How do you encourage clients who say that they already know everything about breathing techniques? I pose the question back to the client and say, tell me what's working for you. Often, they may know what to do but they're not actually implementing it. Ask them questions; ask them to walk you through that sequence. Validation is important, but then get more information. Find out what hasn't worked, and bring it back to the client as the expert in their own self.  Validate their expertise and then find out how it's working in a noncombative, non-confrontational way. Sometimes you will hear a client say, "well I haven't done it in a while or maybe I rushed through it", and that's why it's not working for them.

Physical Grounding

I'm a big fan of forcing physiological changes, although force sounds like a strong word. When we start to feel panicked, it can lead to what is described as an out of body experience of feeling disconnected. This intensifies the panic, leading to flush cheeks and feelings of dizziness and warmth. You might find that you're describing yourself as feeling heavy, disconnected or out of body. By using an external source - like drinking a glass of really cold water, splashing your face with it or holding that cold glass in your hands -  you bring your body back to stasis. You're reminding your body that all of those panicky experiences are temporary and can be altered with intervention. Another physical grounding technique is sitting up straight in a chair, putting our feet on the ground, our hands on the armrest and our backs flush against the back of the chair, to remind our bodies that we are tethered to earth and that everything is tangible.

Focus on What You Can Control

Anxious feelings and panic often arise from feeling like we're out of control. We often then try to choose to control something we actually can't because we're not thinking clearly in those moments. In the early days of the pandemic, I would find myself spiraling into thoughts about the virus on a global scale, and feel despondent and hopeless about a vaccine ever being developed. I worried if I'd get to meet my niece or nephew, whether or not I'd get to see my parents again, whether or not I would get to have my wedding, and so forth. All of those thoughts give our brain something to do, but it's not the same thing as being productive.

The people who fared best focused on things that they could control, such as I can wash my hands and use sanitizer, I can wear a mask. I can go to the grocery store when it opens, I can creatively meal prep with what I have instead of going shopping again, I can think strategically about my space as it exists and use it to improve my situation. Drilling back down into what is within individual control was helpful for me and for a lot of other people.

Consistency/Routines

This is not a strategy that will go viral and be the latest TikTok sensation: Consistency and routines. Nobody likes to hear that we should go to bed and get up at the same time every day, but there's a reason routines are always recommended during times of struggle, The more consistent we can be, the more our brains can perform these routines on autopilot, which frees up our brain space to do other things that are more taxing. If you think of your brain like a computer, some programs will run in the background and some are actively working. When you have too many tabs open, what happens? Your computer overheats, processing is slow, and it shuts down. The same is true with your brain.

Hierarchy of Needs

Consider Maslow's hierarchy of needs. The basic needs at the bottom of the hierarchy are physiological: Food, shelter, sleep and clothing. Then comes safety, job security, medical care, and home safety. Next is love and belonging, friendship, and connection. Then we have esteem, mastery, achievement, recognition, and finally, self actualization. Self actualization is the pursuit of realization of a person's potential and self fulfillment; it is seeking personal growth and peak experiences. This level is the desire to accomplish everything that one can and to live up to one's fullest potential. When those bottom needs aren't met - food, shelter, sleep, clothing, safety, job, security, medical care, home safety - how could we possibly pursue higher needs? We often jump to fulfillment,  achievement and potential, and we don't recognize that we're not eating right, or our sleep is erratic. Basic needs must to be taken care of before we can move on to the higher level needs.

Wait 24 Hours

This is truly one of my favorite strategies for when I'm feeling in high conflict. It was taught to me as a child back when waiting meant writing a physical letter and putting it in a drawer before sending it. When we are in conflict or we sense that we're in danger, we enter a heightened state of arousal. This has protected our species for millennia.

That's why your hair stands up when you hear things that go bump in the night, it's why you pull your hands away from a hot stove or from a boss who's been criticizing you for the past 45 minutes. This built in alarm system is called the diffuse physiological arousal system. When your body is in diffuse physiological arousal or DPA, your heart speeds up, blood flows to your gut, your kidneys slow down, and adrenaline starts to pump. Ultimately you move into the fight, flight or freeze response. Think about any time you've fired off a response via email or text in the heat of the moment. Have you ever looked back and cringed at what you wrote once the adrenaline wore off? Practice writing your response in a draft that cannot be accidentally sent. For a text, put it in your notes app or for an email, put a whole new window with no recipient attached so that there is no danger of accidentally sending it. If after 24 hours, you still feel that way, go ahead and send it, but in my experience, I have never sent the first draft. I might take things out of it and say it differently, but I can't think of a time where I've went ahead and sent that first draft.

Positive Reframing 

Positive reframing is not toxic positivity. It's not pretending everything is fine when it isn't. It's also not about stopping yourself from experiencing negative or painful thoughts or emotions. Instead, it means evaluating whether or not you want to believe a thought. Based on your decision, you can decide to support yourself instead of constantly criticizing yourself. For example, rather than say "I hate my job. I hate my coworkers, I hate everything. I don't want to adult anymore", replace that with, "Things are tough right now and I'm feeling pretty disconnected from work. I wonder if I can change anything about my job, my situation, or my expectations and start to feel better." It doesn't take away from the fact that you hate your job, but it focuses on and what you can do within your control.

Gratitude Practice

This is something I love. I tried to do a gratitude practice a few years ago and I found that it was kind of a chore after a few weeks, and I was repeating things. When we express gratitude, we often do it generally such as "I'm grateful for my health." After a few days, this gets rote. Instead, I practice specific gratitude. Today I might say, "I'm grateful that I woke up today with clear lungs to open the window and breathe in the fresh spring air." Tomorrow, I may say, "I'm grateful that I woke up today with clear lungs so that I can go for a run." Gratitude for something specific keeps it fresh and novel. 

These are simple practices and you could do all of them in one day, or you could do one per day, whatever works for you. What I like about these strategies is that you don't have to remember complicated things. They don't ask our clients to do really complicated things. They are simple but they're not necessarily easy.

Separation and Boundaries

We talk about boundaries, but we sometimes forget how to set them. Let's review boundaries from a few different perspectives.

Creating Physical Space

If you're continuing to work from home or you're part of a hybrid model, think about how you may need to redesign your work environment to be optimally productive without burning out. Maybe you could set up room dividers, white noise machines, noise, blocking headphones, or even use peel and stick wallpaper. When I was in my old space, which was not conducive to work from home, I put a room divider in a corner of my bedroom so that when I was facing my computer, I couldn't see my bed. I put peel and stick wallpaper behind me so that it looked like an office when I was working with clients even though I was cramped in the corner of my bedroom. It worked for me while I was in that apartment. I moved because I had the opportunity to create a different physical space. 

Creating Emotional Space

Create emotional space with family or roommates. You can use timers and tell your children or family, when this timer goes off, you can come interrupt me, but not before then. You can also use nonverbal signals. I find a lot of success with colored sticky notes on the back of a laptop. A red sticky note might say, do not interrupt unless you're bleeding. A yellow sticky note might say, if it's really important, you can interrupt but I prefer that you didn't. Green says, I'm open to chatting, come interrupt me if you need. You don't have to stop what you're doing for someone to know which stage that you're in. With roommates or family it is sometimes helpful to have personal schedules. You may keep a shared Google calendar, similar to what is used that in an office setting. These solutions can be simple but really effective.

Creating Mental Space

Take breaks while you are working. I love the Pomodoro Technique, which is also called the tomato timer. This method involves working in set intervals separated by breaks, and you can vary the lengths to your preference. The way I do it is 25 minutes of work and five minutes of rest. Rest means getting up, walking away from my computer, stretching and taking the full five minutes without returning back to work. No matter if you're in the flow while working, you still stop at 25 minutes. And if you're done with your break after three minutes, you still go for five minutes. It's very effective. Build in yoga and stretching breaks. You can do Yoga with Adriene on YouTube or a 5- or 10-minute Peloton work out. You don't have to come up with your own routine - you can do a guided activity.  

Take PTO time off strategically to get the most out of it. Don't wait until you get to the point of you don't want to go to work today. Plan it out - think about scheduling a day off in the middle of a week to get things done so maybe you can feel less overwhelmed. 

Self-Care is Not Selfish

Self-care is not selfish. The message about self-care is that it's a reward for working ourselves to the bone, when actually self-care is mandatory for allied healthcare providers. We need self-care to ensure we don't do harm to others. When we give until we're empty and then try to give some more, we think we're being martyrs. If we are always available, always flexible with reschedules, always gracious when someone is late or a no show, it sounds like we're being caring, right? In actuality we are building exhaustion and resentment inside of ourselves.

How can we show up and be present attentive and empathetic and focused, if we're not taking care of ourselves? We could actually do permanent, irreparable harm. Balance is a word people use a lot, but they usually use it to imply perfection. Balance in yoga means the space between effort and ease. Think about your everyday life. You're never fully standing and equally distributing your weight on both legs, you lean on one side, on one leg. When that gets tired, you shift to the other leg. That's balance.

Work-life balance is not equally distributing your time everywhere. Sometimes work takes more. Sometimes home takes more, sometimes family takes more. Sometimes friends take more. Sometimes you take more from all of those areas and you don't have a lot to give. Balance is picking up the slack when the pendulum needs to swing in one direction for a while. The problem with the pandemic is that no one has the ability to give right now. As allied healthcare providers, we are often praised for how giving we are. The thing no one talks about is that we can do harm if we're trying to give from an empty vessel. My job as a therapist is to hold space, to observe and reflect, to validate and challenge and to actively listen. If I am stressed out, burned out and not nourishing myself, I can do actual harm with a thoughtless response.

We can't fix anyone's problems in one day, but if we're in a bad head space, we can exacerbate them and possibly do permanent damage. Taking care of ourselves has to be part of our ethical obligation. For that reason it has been added to the National Association of Social Workers Code of Ethics in 2021. The code was amended to include new language in the purpose section that says professional self-care is paramount for competent and ethical social work, practice, professional demands challenging workplace climates and exposure to trauma warrant that social workers maintain personal and professional health, safety and integrity. Social work organizations, agencies, and educational institutions are encouraged to promote organizational policies, practices, and materials to support social worker's self-care.

Creating Separation and Setting Boundaries - Example

To create separation and set boundaries:

• Take the onus on
• Align and join together
• Explain clearly and without apology
• Validate

To create separation and set boundaries, first I take the onus on. Then, I align myself with the client who's asking me for more than I can give. I align and join together with them using a lot of "we" language. I explain clearly, but without apology. And, I validate.

Here's my standard response when clients text me at a time that's outside of business hours, or email me to share something that's personal. I have younger clients who might share a video with me, which is very sweet, but is not what our relationship should be.

I take the onus on, and explain that I want to clarify why our policies are the way they are because I think transparency is important. I say that the reason I have specific hours and modes of communication is that I would hate it if on a Friday night they had an expectation that I would be available to respond and they contacted me expecting a response. Maybe I would be out to dinner with my family and possibly had a glass of wine at dinner. I'm aligning and joining with the client by saying I would hate that for you. I tell them that I would then have to choose between answering them, which would be unethical and not in their best interest, or ignoring them, which would make them feel rejected. I explain without apologizing.  I say that it works best for everyone to know when and how to communicate so that I can be fully present for our work together, which is validation. As a practitioner in private practice, I am often seen as being available all the time so this is the boundary that I have established.

Questions and Answers

Do you have any suggestions for working back from the place of burnout?

That's one thing that I didn't have time to cover, which is what if you're already burned out? That's tough and I'm not going to pretend that we can just say, "Do this and you'll feel great". I think it starts with zooming out and taking the 30,000 foot view of your life. Break it down into domains, such as family, personal, professional, friends, health, etc. Start listing out all the ways in which you would like to live. Ask yourself what would it look like if you were actually doing those things. For example with health, I would love to work out five days a week, but let's be realistic. Is that really what you want that would make you feel best? Maybe it's three days a week for 45 minutes. Block out that time.

Make adjustments and then ask what would it look like for you to say to your family, I need 45 minutes (or maybe an hour so you can build in some buffers) three times a week. Often we don't set boundaries because we are afraid of the answer. We're afraid that the people that we love won't show that they love us enough back by doing the thing that we've asked. Then we're not telling people how to show up for us. I hear this all the time from my younger clients who are dating. They say, "I can't say that to them because then they'll break up with me". Then we have the conversation of whether they want to be with someone who can't respect their boundaries or can't listen to them.

You may do a lot for other people maybe out of a sense of obligation or because you think it's what you are supposed to do. And maybe that actually isn't the best answer for everyone involved. You may think about stepping back from a project at work, but find a solution for who can take it on. Maybe you can delegate and support a junior person in learning how to take the project and run with it. Unfortunately, coming back from burnout is specific to each individual but in general it will involve looking at the big picture and determining where you are giving without receiving reciprocity and figuring out where you can find support. Boundaries are not about rejecting people and saying "stay out".  Rather, boundaries are an invitation of where you can meet and work together.  

My contact information is in the slides and I'm always happy to talk with other practitioners if you want to have further conversations. 

References

A complete list of references is available in the course handout. 

Editor’s note: This text-based course is an edited transcript of the webinar, HIPAA for Allied Health Professionals, presented by Kim Cavitt, AuD.

Learning Outcomes

After this course, participants will be able to:

• List the main components of HIPAA.
• List the 18 pieces of protected health information.
• Identify specifics of the Privacy Rule and explain how it applies to texting, email, and marketing in a healthcare setting.

Components of HIPAA

HIPAA was a bipartisan piece of legislation in the Clinton administration. HIPAA stands for the Health Insurance Accountability and Portability Act of 1996. The main website for HIPAA information is https://www.hhs.gov/hipaa/, but you will see specific links in this presentation (copy and paste them into your browser) that will direct you to additional information typically from Health and Human Services in the Office of Civil Rights, specifically related to the government and HIPAA. As links often change, please search from the main website previously listed if the link doesn't work.

After 2013, HIPAA has civil and criminal penalties and addresses the following:

• Standard Transaction and Code Sets
• National Provider Identifier
• National Employer Identifier
• HIPAA 5010
• Security
• HITECH (Breach Notification)
• Privacy
  • Marketing
  • Business Associates

The first thing to think about regarding HIPAA is, are you a covered entity under HIPAA? A general rule of thumb is if you transmit any information electronically, then you are subject to HIPAA rules. You are a covered entity anytime you're submitting a claim to a third-party entity or submitting health information or medical records to a third party.

Standard Transaction and Code Sets

Let's start with standard transaction code sets. HIPAA requires that all covered entities use standard transaction and code sets such as CPT (Current Procedural Terminology), ICD 10 (International Classification of Diseases, 10th revision), or HCPCS (Healthcare Common Procedure Coding System), which are the codes for hardware and the services surrounding the hardware or the pharmaceutical (or that type of entity). These are the code sets that you're supposed to follow. 

National Provider Identifier (NPI)

Your national provider identifier (NPI) is your unique personal identification number that is now going to follow you for your entire career. That is given out by the national plan and provider enumeration system, or NPPES. You can go to their website at https://nppes.cms.hhs.gov/#/ to get an NPI or look up an NPI, especially if you need it to go out on a claim. Just like the NPI, this number moves with a provider from employer to employer throughout their career. If you submit the information correctly the first time, a new NPI number is usually generated in one to three hours. 

National Employer Identifier

The next item is the national employer identifier (EIN). The EIN is a unique number that's assigned to your business by the Internal Revenue Service. It's oftentimes also known as your tax identification number. Every business has an EIN except for businesses that are sole proprietors, where the business is operating under the social security number of the owner. Your practice or organization needs an organizational NPI. Remember, the NPI is going to be given out by the NPPES system and the EIN is going to be given out by the IRS.

HIPAA 5010

HIPAA 5010 was a systems update that went into effect in 2012. This change allowed for the additional characters of ICD 10 and really affected office management systems, electronic health record systems, electronic medical record systems, software vendors, and clearinghouses. Also, this is where they made the switch from working in a CMS 1500 format, where the electronic format mirrored the form, to working in a format now that's called an 837P format.

The 837 claims submission format was set forth by HIPAA 5010. You should ask your office management vendor or electronic health system (EMR) vendor how your system operates. Many systems, except for certified EHRs, still operate in a 1500 format. Your clearinghouse is doing the conversion to the 837 format. The CMS 1500 format is everything around the paper form that's read, including its electronic version. If your system operates in the 1500 format, or you're still using paper, everything is going to be converted to an 837, either at your clearinghouse or the payer. 

Protected Health Information (PHI)

Let's talk about the 18 pieces of protected health information. All 18 pieces are equally protected. That means that they cannot be shared without the patient's authorization except for three exceptions, which we'll talk about in a moment.

• Names
• Street number and name, city, and last two digits of the zip code
• Dates directly related to the individual (birthdate)
• Phone number
• Fax number
• Email address
• Social security number
• Medical record number
• Health insurance member number
• Account numbers
• Certificate or license numbers
• Vehicle identifiers and serial numbers
• Device identifiers and serial numbers
• URLs
• IP addresses
• Biometric indicators
  • Finger, retinal, and voiceprints
• Photos
• Any unique identifying number, characteristic or code

Someone's first and last names are protected. In my case, Kimberly Cavitt is a piece of protected health information. Your street number, name, city, and last two digits of your zip code are protected. For example, 2480 State St., Chicago, 60 is protected. Any dates directly related to the individual, such as a birthday, are protected. Your phone number, whether cell or landline, and your fax number are protected. Your email address and social security number are also PHI. I want to really reiterate here that someone's name is equally protected as their social security number. Your medical record number, health insurance member number, account number, certificate or license number, and vehicle identifiers or serial numbers are protected as well.

Any device identifiers or serial numbers are included as PHI. If your patient has hardware, such as a hearing aid or an augmentative communication device, that has a serial number and that number is uniquely assigned to that patient, that serial number is protected. In addition, URLs, IP addresses, and biomedical indicators including finger, retinal, and voiceprints are protected. I cannot stress enough that a patient's image is protected. Before you put a video with a patient on social media, you really need to make sure that you get the patient's authorization to use their image. Again, any unique identifier number, characteristic, or code is also protected.

HIPAA Security Rule

The Security Rule is an extension of the Privacy Policy and went into effect on April 20, 2005. HIPAA security is about protecting the electronic formats that are controlling patient information. Electronic patient health information is called ePHI. HIPAA security is around ePHI and everything that you store. When it comes to security, you have to think about everything in your office that stores or transmits patient information. Providers need to have administrative safeguards, physical safeguards, and technical safeguards. You also need written policies and procedures related to these security provisions. In addition, you need to document how people have been trained and what your audit and sanction processes are in your security policies. We're going to break this down a little bit.

Risk Assessment

The first thing you need to do is a risk assessment. What do allied health professionals need to think about when they're thinking about HIPAA? You need to think about computers, phones, tablets, fax machines, and answering machines. Remember, a patient's voice and any protected health information they've shared on an answering machine are protected and you need to go through a risk assessment on it. Also think about any test equipment that stores or transmits ePHI as well as your EHR, EMR, and OMS vendors because they have access to your information. While NOAH is unique to audiology, it would also be included in this list. You need policies around anything that is storing or transmitting information and how that information is being protected.

Administrative Safeguards

The first step is administrative safeguards. What do you have in place to reduce the risk of breaches of protected health information that is stored electronically? What policies and procedures do you have? Every practice needs a security officer. You need to know who is responsible for the securitization of this ePHI. If we are talking about a hospital or large clinic, you probably have a security officer that is the head of IT or the CIO at your entity or facility. Those of you in private practice or nonprofit, you are going to need to assign someone as your security officer. If you have a practice manager in a bigger entity, they or the executive director of a nonprofit would be your security officer. If it's an ownership of a private practice, it's typically the owner that is the security officer.

All the security officers and every facility need to regulate who has access to protected health information and by what means. For example, what equipment can they access PHI on? Can they use personal devices or access the PHI at home? Can every employee access it or do some folks have more access than others? It's all about minimally necessary access. You need to look at each one of your staff members and determine for that position, how, where, and when can they access electronic protected health information. You need training and accountability. You should authorize and document either by individual name or by position who has access to ePHI including where, when, and how. You need to train staff on these policies and procedures once they're created. Audit your staff to make sure you're following the policies and sanction staff who do not comply. That sanction has to be documented. I strongly recommend that you have a process of sanctioning that's outlined in your HR materials including employee manuals. It can include firing or termination.

Physical Safeguards

Physical safeguards are about the actual hardware that is storing and transmitting things. You have to limit access and control to that hardware. Think about who can have access to the equipment, when, and how. Are laptops and other hardware locked down? How can people move laptops or personal devices from location to location? Can they take them home? You need to have facility access and control over any hardware that stores and transmits EHR. You should have workstation and device security, including proper use of electronic devices and workstations. Ensure that you have policies and procedures related to the transfer, removal, disposal, and reuse of both ePHI and the hardware that is storing ePHI. How do you get rid of a laptop? How do you get rid of a personal device that has access to ePHI? You have to have this all documented for your practice.

Technical Safeguards

Technical safeguards include how we control access to the software. That is typically through password protection or authentication. How are you gaining access from a software perspective to systems that hold ePHI? One thing that a lot of entities are looking into is two-step authentication so information is not just password protected. There's a second step of authentication. You're going to need to audit and determine how you are going to take your policies and make sure your staff is following them. You have to audit how your policies are being followed. Be sure that whatever electronic system you are using to store or transmit ePHI does not allow things to be improperly altered or destroyed.

If you are using a notation system for your notes, you need to have a system that doesn't allow those notes to be permanently deleted. Certified type systems, like if you had a certified EHR, will let you hide things that you've amended, appended, or modified, but they never can be deleted. They can never permanently go away. It's something that you can always see and pull up if need be. You should never be operating in any form of an electronic patient management system that lets you delete information. I know I'm saying this repetitively in a lot of different ways, but it's really important. You should never be working in a system where you're just putting notes, for example, in Notes on an Apple device or in Word or in Excel and then you can just delete it and wipe it. You have to be able to be in a system that cannot be altered. Then you need to put in place all of the software around transmission security so that you can reduce the risk of being hacked.

Mobile Devices and HIPAA Security

HIPAA has a lot of implications and things you have to consider around using mobile devices. I'm going to consider mobile devices for us today to be a laptop, a tablet, a phone, or a smartwatch. We have to be very cognizant of all of the rules around these mobile devices.

Every practice needs to consider if they want to allow, by policy, their staff to access ePHI on mobile devices that the facility or practice does not own? That's your first decision. If you do allow that, then you need to make policies around those two separate pathways. Many entities that work in large medical facilities would never allow people to access ePHI on a personal device. They have a lot of rules around that and you have to log into a portal to be able to do anything using multi-step authentication. You have to determine what the rules are for your practice. Let's say you are allowing access to ePHI on a mobile device. You need to make sure that you use a password or user authentication. There have to be steps to be able to open the device itself before getting into the software. The first step is having to use a password to get into the laptop or other device.

You need to enable and install encryption. We should not be communicating any ePHI to any entity, including the patient, without going through an encrypted service. You can communicate with the patient about an appointment. You can communicate with the patient about services they need, such as a COVID test, what your policies are, or reminders. But you cannot communicate any ePHI, any test results, or anything specific to that patient without going through an encrypted service.

Install and activate remote wiping and/or remote disabling. I am an Apple person, so that's what I'm going to give an example of. Essentially,  that's where you find your iPhone and you kill your iPhone remotely. At any point in time, you can go to a third-party site and literally make that device a brick so that it doesn't actually function anymore. That's what you need to be able to do. If you have a device that is transmitting or storing ePHI, you need to be able to remotely shut that device down and remotely wipe it.

Disable and do not install or use file-sharing applications, such as Dropbox that multiple people, including people outside your facility, can access or utilize. This is especially important in your home or other location. You don't want to use file sharing when you're communicating about ePHI. The entity that might be file sharing with you may not be allowed access to that ePHI. The rule of thumb is to turn off all file sharing unless you're keeping everything internal-only in your practice. 

Install and enable a firewall as well as security software, such as Norton or another protection software. Keep your software up to date. When your service vendor provides a software update, whether that's Microsoft, Android, or Apple with an iOS update, make sure you download it and keep your software updated. Many times the iOS updates are around bugs and security fixes. That's why you always want to keep that up-to-date and current.

Maintain physical control. If you have a device that you're traveling with that stores or transmits ePHI, you want to make sure you keep that device on your person as much as possible. If you are doing work and accessing ePHI, you should not be on a public Wi-Fi network, whether that's at the library, Starbucks, or in your own hospital. You should never be doing report writing or communicating with your patients or anything that involves protected health information on a public unsecured network. Make sure that before you recycle a laptop, a tablet, your watch, or a phone you have completely wiped that device. Delete everything off the device before it's either recycled or destroyed. 

Telehealth and HIPAA Security

Medicare defines telehealth as "the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.” Store-and-forward means that it is recorded and stored, and then it is forwarded to another entity. Store-and-forward is asynchronous because it's not happening in real-time. That's an important distinction because many health insurers don't pay for asynchronous telehealth. Telehealth can include streaming media and terrestrial and wireless communications such as online, telephone, and video. Synchronous is real-time telehealth. Asynchronous is typically store-and-forward where it's not happening in unison.

Before they begin providing telehealth, allied health professionals have to ensure that their transition systems meet all the HIPAA security requirements and that they are able to maintain the confidentiality, integrity, and availability of ePHI that they create, retain, maintain, or transmit. You are responsible for making sure that the transmission from your end is secure. You cannot control the patient end. If it is with your facility, whether from you to the patient, a technician that might be with a patient, or a student, or somebody at another location that works for you, you are responsible for controlling the security of those transmissions. The only transmission you are not responsible for is if the patient is doing telehealth in their home or office and the transmission back to you.

As a general rule of thumb, we cannot use FaceTime, TikTok, Facebook Live, Messenger, Google Hangouts, Twitch, SMS, Skype, Zoom, or unencrypted email (to store or forward) for telehealth. When I say all of these things, I'm talking about software that is free, such as the free versions of Skype and Zoom. Skype and Zoom also have healthcare versions. I'm talking about their free versions of things or any unencrypted email for telehealth. That is the general non-COVID rule of thumb. As I mentioned before, you can buy paid services through Skype and Zoom that are HIPAA compliant. Those free versions, as a rule of thumb, are not allowed for telehealth because of HIPAA security provisions. There have been COVID allowances that will expire when the public health emergency expires. So if in your state your public health emergency has already expired, a lot of those provisions have already expired.

At the time this course was created, the federal government, which is the main controller of HIPAA, has not gotten rid of the public health emergency yet. When they do, those HIPAA allowances will go away. The HIPAA allowances for COVID included allowing FaceTime, Messenger, Google Hangouts, Zoom, and Skype. As a general rule of thumb, those are not allowed under the HIPAA compliance provisions. I recommend to people before they get into telehealth that they hire an IT consultant to make sure that their transmissions are secured. Have someone help you set up a program at the outset to make sure you're going to meet all these HIPAA security provisions.

Business Associates

A business associate is a person or organization, other than a member of a covered entity's workforce, that performs certain functions or activities on behalf of, or provides certain services to, a covered entity that involves the use or disclosure of individually identifiable health information. Business associate functions or activities on behalf of a covered entity include claims processing, data analysis, utilization review, and billing.

To break this down, a business associate is someone that you are sharing protected health information with during the processing of your business. For example, you might share PHI with a vendor if you are ordering a product for the patient. The patient gave you their information as a covered entity and now you are giving it to a third party. That third party is a business associate. You as a provider are responsible for your business associates securing your patients' health information. Every practice needs to have a business associate agreement between themselves, one that you and your practice generate, and the business associate, the entity that you are sending protected health information to.

This needs to be supplied by you, not the vendor. Many vendors may want you to sign their business associate agreement, but that means that they're the covered entity, and it's going to all be adjudicated in their state. You are the covered entity who has gotten the information from the patient. They should be completing your business associate agreement. Some common business associates include medical device manufacturers and vendors, such as those who manufacture or sell hearing aids, augmentative communication systems, or compression equipment for patients. Other business associates are your accountant if they have access to ePHI through your QuickBooks or your attorney because you're transmitting information to them. Your EHR, EMR, or OMS (office management system) vendors are also business associates.

Your clearinghouse, the entity between your computer and the computer of the payer, also needs a business associate agreement since you're giving them ePHI. So does your cloud services provider, because they again are storing your information, and any IT consultants you may hire that you're bringing in and giving access to your systems. If you were in a buying or management or cooperative group where you're sharing information with a business development team, they need to sign a business associate agreement, because they're typically able to access your systems. You can see a sample business associate agreement when you go to the HHS.gov website that can be customized to a degree.

Hitech-Breach Notification

The HITECH-Breach notification applies to both paper medical records and electronic medical records. It addresses how to handle a breach, which is an impermissible or unauthorized use or disclosure of PHI. This is a good time to give you my general rule of thumb about HIPAA. You want to do unto others as you want to be done unto you. We are all HIPAA consumers and we are all someone's patient. Before you do an action, you want to think about what you would want someone to do for you. I really want to bring this up as we talk about a breach. If someone lost your medical record or sent your information to the wrong person, what would you want to be done for you? The government requires you to do a risk assessment if you believe that there is a breach. The risk assessment is taking a look at what the risk is of this ePHI or PHI being used for illicit or nefarious purposes.

I'm going to give you a few examples. Let's say you were going to fax or email a report to a physician and you sent the report or patient information to the wrong physician's office, either by email, mail, or fax. In this case, I would consider it low risk. You are sending information to another entity, which is also a HIPAA compliant entity. I would think the risk of that information being used for illicit or nefarious purposes would be very low. In this case, you would contact the physician's office that you sent it to incorrectly and request that they destroy it by whatever means, either deleting the email or shredding the fax or mailed copy. Then you would go into the affected patient's medical record and document that breach. Next, you need to go to the portal at this link. Here you will document the breach including what occurred and that it was a low-risk breach. You have to document all of your breaches.

Now let's look at another situation. You emailed or mailed a report to the wrong patient. You sent information or documents from a patient's medical records and put them in the wrong envelope or sent it to the wrong email address. In this case, you don't know the end entity and what they could use that information for. In that case, I would consider it a moderate to high risk and you should notify the patient. You have 60 days from the date of a breach to notify a patient of that breach and you have the burden of proof to show that you notified them. You want to notify them in a way that you can prove receipt. If you can do that by email and you have systems that you feel like you can prove receipt, you could do it by that mechanism. Lots of folks do it by certified mail because they can prove that the person signed for it and received it. If business associates have a breach, they have the burden of proof to tell you, but you have to notify the individual within 60 days of the breach. You also then need to give them identity theft protection. The standard in the industry is for you to give them a year of identity theft protection.

Let me give you another example. Let's say you are still working with paper charts and records and you lose a paper chart. I can tell you from my experience of being in this industry for a while, that's actually where I've seen some of the biggest HIPAA problems and things being used illicitly. Someone stole a paper chart and then tried to take on that person's identity. I've seen that more with paper records, but I've also seen that with electronic records on small, singular breaches. I recommend that you try to find the lost chart. If you don't, consider that a high or moderate breach and notify that patient accordingly.

Let's say someone hacks into your system. Many of you may have gotten a letter in the mail from a health system saying that someone breached their systems. If someone hacks into your system, and it's a large breach of over 500 people, you have to notify your local media and health and human services. That large breach is absolutely something you have to report in the portal. Any breach, no matter the size or if it's at low risk, needs to be reported in the portal at the link I provided earlier. Big breaches must immediately be reported to your local media, to health and human services, and then all the affected patients need to be contacted. Again, think about how you would want someone to treat you.

Privacy Rule

The privacy rule is really the hallmark of HIPAA. This was the first thing created, and it is the meat and bones of HIPAA. All of the other things are equally important, but this is the one that really affects us the most in daily practice. It protects both electronic and paper formats and was first set forth in 2003 and later updated in 2013. We should expect an update to HIPAA in 2023 from the government. Every time the government makes an update, we typically have to make updates to our notice of privacy practices in all our forms, documents, processes, and procedures. Everyone needs to be prepared that there could be an update in 2023.

HIPAA privacy protects "individually identifiable health information" including demographic data. In a nutshell, it's everything that's in your medical record. Everything that's stored either by paper or electronically in a patient's medical record is subject to HIPAA privacy. Everything that's there, even things from other providers is still covered under the HIPAA privacy umbrella. This includes an individual's past, present, and future physical and mental health or conditions, the provision of their healthcare, their past or future payments, all payment information, and any of those 18 pieces of individually identifiable health information. All of that is protected under HIPAA privacy. It's the 18 pieces plus all of their records, chart notes, test results, inventories, inquiries, and invoices that the patient has access to and is protected under privacy.

Notice of Privacy Practices

Every practice needs to have a notice of privacy practices. These are your practice's rules and policies around the privacy policy and protecting health information. You can find a template on the health and human services website. You have to have the patient sign an acknowledgment of the receipt of your privacy policy. Most patients will never read it, but you have to be able to give them the opportunity to read it if they so choose. Most big healthcare systems are constantly changing their privacy policies and updating privacy officers so they typically have people sign it every visit. There is no requirement to have people sign at every visit. The requirement is that any time you make any change at all, whether it's a word, letter, or you make something plural, you have to have the patient sign a new acknowledgment and all changes need to be dated. You always need to have the date on your privacy policy reflect the last time it was changed. Acknowledgments need to be replaced every time you change your privacy policy, even if all you did was change your privacy officer, all your privacy policies need to be updated.

If your privacy policy is dated prior to 2013, it isn't valid. That should have been updated with 2013 information. If your acknowledgment was signed prior to 2013, it's not valid. You need a new, signed acknowledgment. The notice must be readily available to your patients so you must prominently post it in your office and you must have copies available if the patient wants a copy of your privacy policy. In the practice I used to run, we had a supply of printed copies for patients who requested a copy of the policy. We could just hand it to them. Some people have posters in their offices and others have a brochure of it that is in a brochure holder. Some people have it bound in a booklet that sits in their lobbies and exam rooms. You just have to make it prominently available. The biggest way you make it prominent is to put it on your website. Everyone's website needs to have their notice of privacy practices on the site. You have to make a good-faith effort to get the acknowledgment of the notice of privacy practices signed. If that cannot be obtained or the patient refuses, you need to document that in the patient's medical record. You have to document what happened and why you didn't get it signed. It's very important that that documentation exists.

Transfer From Paper to Electronic Records

Some people ask me all the time, what happens when I transfer records from paper to electronic? The first thing you have to do is always consult your state's medical record retention laws. HIPAA's requirements are to retain records for six years. But many states have rules that exceed that. You need to know what your individual state or territory's medical record retention policies are. My next question is, was it a one-to-one transfer? What that means is, was every piece of paper in the paper file transferred over and scanned in electronically? If the answer is yes, you can properly destroy the paper file. If the answer is no, you need to retain the paper record through the state medical record retention policies.

Disclosures that Do Not Require Authorization

There are three times that you can disclose protected health information without the patient's written authorization. They are for treatment, payment, or health care operations. Let's take a closer look at each of these.

You can disclose PHI without the patient's written authorization if you are communicating with the ordering and referring physician or the physician or healthcare practitioner you're referring to because that's all-around coordination of care. I am always going to tell you to err on the side of being conservative. Here's an example. A physician referred a patient to your practice. You could send results back to that physician and not need the patient's authorization to do so. But let's say a different physician reaches out to you and wants a copy of the patient's records. You should get authorization from the patient to send to that new entity or to transfer your records to another provider. You should get authorization from the patient. Let's say a school system reaches out to you. I would not send results to a school without the patient's authorization.

You do not need a patient's authorization to send claims to their insurance company. It's important to note that patients can restrict disclosures to their insurance company and waive their insurance benefits if they want. Health care operations generally include anything around your business. This could be administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business. Remember, you're going to have business associates' agreements with your accountant and your attorney, things regarding accreditation, and insurance or other audits and you do not need the patient's authorization. You can disclose information that's in your medical record that was provided by another provider because it's now part of your record.

Privacy Rule Specifics

Regarding the privacy rule, there are several specific things you need to do. You need to keep disclosures to the minimum necessary. You need to have a privacy officer. I would have that privacy officer be consistent with what I had spoken of about the security officer. It could be the practice administrator, executive director, owner, or manager. All your staff needs to be trained on privacy. This includes all new hires within 90 days of hiring and all of your staff that should be trained annually on privacy. This course can be used for that purpose. You must have a complaint process that is clearly documented on your notice of privacy practices. That is complaining both to you, the practice, through your privacy officer, and directly through health and human services or the office of civil rights.

You must have record safeguards for the storage, disposal, and access of protected health information. You can think back to some of the security provisions, but think about how would you secure things for paper? How is your paper stored? It doesn't have to be locked if it's got a staff member in front of it all the time. If not, is it locked up? Is it somewhere behind a secure door when your business is closed? Think about how those things are stored and secured. How are you going to destroy them? HIPAA records have to be kept for six years from the last encounter with the patient. Remember, state record retention policies really vary and they vary a lot around children so you want to be very aware of what those are.

I'll give a disposal example. I was always taught that if you're going to dispose of medical records, you pulverize them. When I had medical records in my office here in Chicago, I hired someone to come destroy them. I can account for what records I was having destroyed. They were scanned into a secured system. Mine was batched by dates and not by individual names, so I wouldn't have ePHI held in my system, but you could have it by individual records. Once the information was scanned in, I literally had it pulverized into dust and then that vendor gave me a receipt to show what had happened on which date. Then I scanned that in with the documents that I had destroyed. You should always keep a record of what was destroyed, when, why, and how.

Texting and Email

Again, ePHI should only be submitted through encrypted email service providers and text providers. Your practice needs a written policy and email and text need to be mentioned in your notice of privacy practices. Again, you need to have an email and text consent from your patients that you can communicate ePHI via text and email. Some patients may not want that. That's why you need to give them the opportunity to opt-in. I'm going to tell you the same for telehealth. You need to have a telehealth informed consent policy that states patients want to participate in telehealth systems.

Use and Disclosure

Use and disclosure is the HIPAA version of a medical release. Again, this includes who information can be disclosed to and what can be disclosed. It's a very specific HIPAA form. It allows the patient to list what they want to be disclosed and to whom. They can also restrict disclosures here if they don't want some information disclosed to certain parties.

Marketing

The Privacy Rule defines marketing as making a communication about a product or service that encourages the recipients of the communication to purchase or use the product or service. The HIPAA marketing provision only applies to a communication sent to your database. HIPAA is very clear that if a third party is paying in whole or in part for communication, then that becomes marketing, even if it's merely educational. It's really important that if you are going to communicate to your database, you pay for your own communications.

Testimonials

It's also important that you have the patient's acknowledgment if you are going to use testimonials in your marketing. You can't share ePHI in a testimonial, published review, or response review. You really shouldn't respond to negative reviews online without consulting your attorney and having them give you guidance on how you should best respond. You need a patient's authorization to use their image, their review, or their name. Your notice of privacy practices needs to outline your use of testimonials and reviews and all your staff needs to be trained on these policies and that training must be documented. One physical therapy practice had a pretty hefty HIPAA fine of about $25,000 over the inappropriate use of testimonials in their communications.

Marketing Versus Education

Let's talk about the difference between marketing and education. Marketing requires authorization. It is always going to be marketing if a third party is paying in whole or in part for the communication, if you're trying to get a patient to purchase an item or service, or if you're marketing a specific price, product, or promotion. That is marketing, and it requires authorization. Education is when you're just training people. That's when it's informational only. You don't talk about a specific product, price, brand name, or anything of that nature. You are talking about general healthcare topics or general information about your practice locations and staff. That's educational. That's allowed without authorization. But the minute you're trying to drive a purchase, whether it's the purchase of your services or purchase of a product, it becomes marketing. Again, HIPAA marketing provisions only apply when you're communicating to your database. 

Marketing Authorization

There are two different types of marketing authorization. Let's say you want to market to your database. There are two different requirements based upon who's paying for the communication and if money is exchanging hands. You can have a short authorization that you get at intake. See the example of a short form below. The short form is used when there is no remuneration, in cash or in kind, and no money is exchanging hands in any form for products you market. If you are marketing something and paying for it yourself or marketing another product and they aren't giving you anything back in return, such as free training, a lease, a loan, or a trip, you can use the short form. Once you receive anything of that nature you need to disclose it on a long form marketing authorization.

Example of short form:

By initialing this section and signing below, I authorize Clinic A to send me educational and/or marketing information on the products and services offered by Clinic A. No remuneration is involved in this communication. I understand that I may revoke this authorization, in writing, at any time.  

You need a long form the minute any money, in cash or in kind exchanges hands. You have to disclose to your patient what you got in return, and who paid for what. It is a very long form that you're going to need your attorney to help you create. I will tell you from experience that patients are not going to be excited to sign that form. It has a lot of perceptions of your practice. A great rule of thumb that I really want you to take away is if you want to market to your database, get a short form marketing authorization. You cannot market to them without authorization.  Pay for every one of those communications and pay for everything around your business yourself. Don't let vendors pay for them.

Omnibus Rule

The Omnibus Rule was a change to HIPAA that became effective in 2013. It meant that business associates are responsible for notifying you of breaches. That includes business associates and their contractors and subcontractors. If you store protected health information electronically, the patient has the right to access it and receive it electronically. They have the right to request that you send a copy of their electronic medical record, often as a PDF, to them through secured encrypted systems. They have the right to restrict disclosures to their insurance company and waive their insurance benefits so that you are not sending any information to them. You will need a specific insurance waiver form.

Marketing has been redefined as any patient communication where a third party is paying for that communication in whole or in part. Even if it's educational it's deemed marketing and you have to go through the marketing provisions. You can't sell protected health information. There must be a defined breach notification process where any breach, even a minor one, has to go through a risk assessment process and be documented, both in the patient's record and to the government.

Omnibus allows for broader uses of ePHI for fundraising and research. Again, in those situations, I would have your attorney involved to help define it for you and your situation because sometimes state laws can come into play. Finally, the penalties for HIPAA got bigger because people were just saying, well, I'll just pay the fine. Now they've made the fine up to $1.5 million per calendar year, and now you can go to jail because they have criminalized HIPAA provisions.

HIPAA and Social Media

Remember, don't disclose any ePHI on any form of social media format. This includes sites such as Facebook, Twitter, LinkedIn, Instagram, Yelp, Google, etc. This includes, but isn't limited to, responding to reviews. Responding to a review confirms the patient was seen in your practice and could be deemed a privacy violation. Always start by contacting that patient who gave you the review directly and not in a public forum. If you've worked it out, ask them if they'll remove their review. Before you post anything on social media around a patient, ask your attorney because this is a complaint-driven process. You want to make sure that you know how this should legally be handled before you start responding online, posting testimonials, patient pictures, or patients' test results for feedback. Remember, patients' test results are protected. You can't just post it on social media to get feedback from your colleagues without the authorization of the patient.

Examples of HIPAA Violations

Here are some examples of HIPAA violations within healthcare.

Physical Therapy:

Additional examples:

• https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/index.html
• https://etactics.com/blog/social-media-hipaa-violations
• https://www.hipaajournal.com/hipaa-violation-cases/
• https://healthitsecurity.com/news/ocr-settles-with-dental-provider-for-potential-hipaa-violation-on-yelp
• https://assets.hcca-info.org/Portals/0/PDFs/Resources/Rpt_Privacy/2016/rpp0716.pdf

Resources

Here are some professional resources from your associations. If your profession isn't listed here, it's because they don't have specific HIPAA guidelines or those HIPAA guidelines were behind a member-only firewall that I could not access. If you are a member of a national association in your profession, see if that association has HIPAA provisions that can help guide you specifically to your profession.

• American Physical Therapy Association: https://www.apta.org/your-practice/compliance/hipaa
• American Speech-Language-Hearing Association: https://www.asha.org/practice/reimbursement/hipaa/privacy/
• National Association of Social Workers: https://www.socialworkers.org/About/Legal/HIPAA-Help