What is it about some forms of training that inspire people to put evidence and new ideas into practice? We explored the training provided by the Imagine Institute for Learning under the umbrella of the Community Mental Health Action Plan.

This story picks up from where we left off in the Shared Wisdom story, “From enforcement to coffee and compassion: Trauma-informed care at Edmonton City Centre” that described a sea change in how security services are conceived and delivered at Edmonton City Centre (ECC). The shift from enforcement to trauma-informed security was the idea of Pam Brown, Safety and Security Manager for
Oxford Properties Group. Pam understood that vulnerable people seeking shelter at ECC have likely experienced trauma and shouldn’t be treated with scorn and disdain, but rather should be seen, heard and valued as respected customers of the mall and part of the social fabric of the downtown community. They should be treated with care and compassion.

In 2013, the Family Centre (TFC) in Edmonton began collaborating with five other agencies to provide drop-in, single-session mental health counselling (DISSC) in multiple locations. This cooperative effort removed barriers to service and enabled people in crisis to get help quickly. In 2018, TFC lost $100,000 in funding. But despite this setback, the organization managed to increase access to mental health care by an impressive 30 percent, delivering an additional 2500 hours of service!

This 78-year old organization is an exemplar of how creativity, innovation and collaboration can lead to improved service delivery within existing resources. By thinking creatively together and letting go of “the way we’ve always done things”, new possibilities were imagined, and innovative approaches were adopted. In this story, we share some highlights of TFC’s success and lessons learned based on conversations with CEO Pauline Smale.

The Family Centre (TFC) in a Nutshell 

The TFC has a legacy of supporting mental health in the community, beginning in the wartime 1940s. This includes traditional 50-minute counselling by appointment alongside extensive mental health supports provided by therapists, youth workers and social workers in peoples’ homes, schools and community centres. TFC also enjoys a long history of fruitful partnerships with other agencies. In the mid-1990s, for example, TFC partnered with the United Way of the Alberta Capital Region, Big Brothers, Big Sisters and FCSS in an initiative called Partners for Kids (PFK). PFK focused on working together to ensure that three inner city schools serving vulnerable children and families had access to mental health supports. Some “key facts”:

• TFC has provided services for children and families in Edmonton since 1942, including extensive supports for mental health in the community.
• 90 percent of services are delivered in the community – homes, schools or other community organizations.
• 240 full time staff and 100 contractors and affiliates. · 20,000 families served each year.
• Three main areas of service delivery:
  • Collaborative Service Delivery – TFC works closely with Edmonton Child and Family Services to determine what supports children and parents need for a strong family. Every family with Child and Family Services involvement in North-Central and East Edmonton works with TFC.
  • Community-based services – TFC provides extensive support to families, schools and communities; a major component of this work is related to mental health.
  • Social enterprise work – TFC generates revenue by providing employee assistance programs, interpretation/translation services and educational workshops/programming

Advice to others wishing to innovate and improve services

Pauline kindly offered some advice to others who similarly want to be innovative and to improve the services they offer:

• Just be open to changing. Don’t be afraid. Have courage to try.

• When making a change, it is important to read the literature and reflect on what you do well. It’s always a jump when you do something new and changing is hard, but you can gain confidence to move forward by drawing upon the research and your own experience. Building on things you do well gives you faith to move forward.

• Ensure sufficient supports for implementation. Pauline noted how important it is to have managers and staff to immerse themselves in, and oversee “all the moving parts” of the innovation Pauline: “You have to have managers and I don’t mean management positions; you have to have managers… I could have the manager list all the moving parts better than I could list them. There’s a lot of moving parts and so what are the pieces you don’t want to lose and what are the pieces you need in place? And it’s like everything. You start off heavy. My manager sat in the waiting room every day so that she could get a feel for what was going on.”

• Train staff in order to build their skills and comfort. DISSC brought with it some new challenges, and it was soon recognized that people, especially receptionists needed additional training: “Pauline: So, we trained our receptionists. They have suicide intervention training…We’ve always trained everybody on trauma informed care for anything that we do. But they were getting scared that somebody would be suicidal, and not that they were going to do an assessment, but just so they could feel comfortable that they had a better understanding of what people were going through that.”

• Be prepared for tons of surprises, learn on the fly and count stuff. Pauline advised that even though you will have a plan going in, there will always be “tons of surprises”. This makes it important to be able to learn on the fly. Measurement and data are critical, otherwise how do we know if we’re having an impact? Counting stuff helps to do that: “Pauline: “You just don’t know what’s going to go sideways. And you can’t write it all ahead of time. You honestly can never think of it… You have to learn on the fly and count stuff. People don’t like counting. People hate to count. But if you don’t count you miss it. You have to count it.”

Reflections on The Family Centre’s successes

While we can’t say definitively what made all of the TFC’s efforts so successful, a few things stand out:

A strong culture of innovation, ongoing learning and improvement. First, Pauline aptly described TFC as a learning organization. There is strong leadership for this. TFC makes a concerted effort to “think together” – including people from all parts of the organization – and to be open to new ideas, realizing there is always a better way to do things:

Pauline: “We are innovators…Because there’s always a better way to do things. There’s always a better way to do things. We just don’t know, and we’re always handicapped by our limitations of our information, education. We’re always trying to keep the windows open. We’re a learning organization.”

TFC intentionally creates space and time for people to think together. Bringing a diverse group of people with different experiences and mindsets together in a safe space fosters creativity and innovation. We heard this several times during our conversation with Pauline. Here’s one example:

Pauline: “We do a lot of meetings where we just sit around and think. We have marketing, we have programming, we have IT, we have everybody in the room, sometimes too many people in the room. I’m always like, ‘Is this the right use of everybody’s time?’ But, that’s where innovation does happen. Because everybody’s brains are different and actually, often [the ideas] don’t come from the program people. It’s very strange because it comes from other people who don’t have a lot of clinical background but have different experiences.”

Drawing from multiple kinds of evidence to inform practice and decision-making. TFC draws upon research-based evidence, but also wisdom gained from practical experience and an understanding of the local context, feedback from service users and evidence generated through monitoring and evaluation activities.

Commitment to, and well-established mechanisms for, monitoring, learning and adapting. As noted previously, TFC is highly invested in ongoing monitoring and measuring to understand and improve service delivery: “We measure, measure, measure”.

Commitment to employee well-being. Although not discussed in this story, our conversation with Pauline revealed a high level of attention to supporting the well-being of TFC’s people. This includes a wellness policy that, among other things, provides each staff person $500 annually to support their own wellbeing; positive psychology and strengths-based training and supervision; encouragement of reflective practice and mindfulness; concerted efforts to foster trust and humility and emotional intelligence; and more.

A long history of successful collaboration. And last but not least, this almost octogenarian agency appears to have mastered the art of collaboration in multiple initiatives and partnerships. This rare capacity has enabled DISSC to be delivered effectively at five other agencies across Edmonton. The agency’s ability to partner effectively is also demonstrated by its collegial relationship with funders such as the United Way.

Inspired? Intrigued? Encouraged? Want to implement something new in your organization? For a smorgasbord of ideas for how you can make it happen, search for the Resources section of Shared Wisdom for Supporting Mental Health.

The rewards of supporting people in crisis or mental health challenges can be unparalleled. To know we’ve helped someone and made a difference in their lives can impart a deep sense of meaning and purpose to our lives.

But this work can also be intense and stressful. We see and hear so much each day that can wear us down and make our hearts heavy. There is a high potential for us to soak up the traumatic experiences of those we support, or to burn out from compassion fatigue. Pressure to serve more and more people without more and more resources adds further burden. Under these conditions, a work environment that holds and supports us is especially important. We can only give our best to others if we have the personal and organizational supports we need to maintain our own wellbeing.

In this story we describe the Distress Centre Calgary’s (DCC) journey to protect and promote the mental wellbeing of its staff and volunteers in the face of skyrocketing demands for service. Because the DCC is engaging staff in identifying and addressing work-related stresses that are impacting their wellbeing,

the Distress Centre is an exemplar of workplace mental health promotion. A big ‘aha’ has been the importance of building a community of care, including peer support (“scuba buddies”) within the organization. Executive Director Jerilyn Dressler generously invited us in to share their journey.

The impetus for change: Escalating demands for service

The Distress Centre Calgary (DCC) is a not-for-profit social services organization that provides 24/7 crisis support for Calgary and southern Alberta. Historically, the DCC maintained a “small agency feel”. It has been a place where people know and support one another, and where they want to stay and keep engaged. But, in response to demand, the DCC has grown; it now enjoys a culturally diverse workforce of about 100 staff and 250 active volunteers. While this is a good thing, the sheer number of people makes it more challenging to nurture and sustain the rich social fabric of the agency.

Distress Centre Calgary in a nutshell

Mission: “To provide compassionate, accessible crisis support that enhances the health, well-being and resiliency of individuals in distress”.

Vision: “Everyone is heard”.

“We do not define crisis. We do not judge. Anyone can call us day or night.” All services are free.

DISTRESS CENTRE CALGARY SERVICES INCLUDE:

• 24/7 crisis supports by telephone, e-mail, daily chat and specifically for youth, daily text
• Professional counseling for people with issues that cannot be resolved over the phone.
• 211 by phone or chat and now text for people seeking social, community or government services.
• The Coordinated Access and Assessment (CAA) program supports Calgarians who are experiencing homelessness of out the Safe Communities Opportunity and Resource Centre (SORCe).

In the past few years, demands on the DCC have skyrocketed. Between 2015 and 2018, crisis contact volumes increased by 32 percent. In 2018, the Distress Centre responded to 140,000 contacts. At first, DCC volunteers and staff worked valiantly to keep up with escalating contact volumes, but like the proverbial frog in a pot of increasingly hot water, they eventually began to struggle. Interestingly, the Distress Centre’s vision: “Everyone is heard” added to their stress. Strongly invested in that vision, they worked tirelessly to ensure that every caller was indeed heard.

Eventually, DCC leaders noticed that staff were withdrawing, “putting their heads down”, and closing their office doors, trying to just “power through” busy periods; many had stopped taking breaks. And, leaders realized they were setting the tone for this – that they were continually saying, “I’m so busy” and isolating themselves. They began to wonder how the organization could manage if these patterns of behaviour – this “culture of busy” – continued. So, how could staff become empowered to set boundaries in order to care for themselves and each other? Something needed to change.

Jerilyn: “The volumes are going up and up and up and up. Demand is going up and up and up… People were in crisis as they were serving people in crisis because they didn’t feel empowered to set boundaries. They didn’t even feel empowered to take care of themselves and it wasn’t ending. We put our head down to power through busy periods but that busy period wasn’t ending. We had to say, ‘Okay, we need to take a step back, empower people to take care of themselves and each other and get out of that culture of busy’, because the work is always going to be there.”

In June 2018, the leadership team held a half-day, all-staff meeting to discuss these issues and possible solutions. Convening and participating in this meeting took courage for leaders and staff alike.

Jerilyn: “We were all very brave. I think everyone was really brave, not just me and the leadership team, but everyone was very brave and bringing the issues to that meeting and talking about them.”

Provided with a safe environment to speak freely about things that were impacting their wellbeing, staff did just that. They unloaded a lot and it was a difficult meeting. But, as upsetting as it was, getting everything out on the table was crucially important. Otherwise, the leadership team would never have known what staff were experiencing and thinking, and what specifically was upsetting for them. Armed with a better understanding of the real issues, they were then able to look for solutions.

Jerilyn: “Getting everything out on the table was really important…Had we just averted our eyes from what is happening in the Contact Centre – don’t look; it’s scary – we wouldn’t have known… and then we were able to move to solutions.”

No matter how valuable this meeting was, for Jerilyn as the leader ultimately responsible for the wellbeing of the organization and its people, this meeting felt like a “knife to the heart”:

Jerilyn: “[I took it personally.] It’s hard not to. It was knife to the heart stuff. Things are not good. People are burnt out. The turnover rate is rising. It was like a knife to the heart. I was nearly devastated by that meeting… I didn’t know if I could continue. I was like, ‘I’m going to take some time off in the summer to think about what this means for me. I don’t know that I’m the right person… But then I’m so dedicated to this place. I started here as a volunteer, so the Distress Centre is a part of who I am. I was like, ‘I can’t leave it worse off than when I found it. I’m going to fight through this’.”

The leadership team realized that to avoid this level of intensity again, they would need to institute some clear and formalized avenues for staff to communicate with them – to share concerns and be heard in an ongoing manner.

Jerilyn: “It never should have been a staff meeting that we waited for that… My hope is that will never happen again …because we are creating things to prevent that from happening. We are creating feedback loops and communication channels that didn’t exist previously.”

Early responses: Addressing work pressures and promoting self-care

This emotional jolt kickstarted the Distress Centre’s journey to reinvigorate and sustain its longstanding culture of high engagement and wellbeing, but now in the “new world” of overwhelming demands for service.

The leadership team responded immediately, first tackling some of the identified work-related pressures. An initiative that had been generating significant strain was dropped, and other initiatives were modified. Crisis call volumes were stabilized through new policy and technological measures. Staff and volunteers were reminded that the vision, “Everyone is heard” is an aspirational statement, not a mandatory daily requirement. New communication channels have been created through more surveys and more face time with leadership. Jerilyn and Robyn Romano, Director of Operations, strive to attend all of the different staff group meetings. And there was another half-day all staff meeting this year. All of these actions demonstrated to staff that they had been heard and that concrete things were being done to make things better. This in turn helped to build staff trust in the leadership team.

And yet, that growing demand for service wasn’t going to go away, and the likelihood of additional funding was low. Leaders decided to focus on what they could control, and that was supporting staff to take care of themselves. They started to talk about how, in this high stress environment, staff could be empowered to feel more in control of their situation, to feel they could set boundaries with callers and take a break when needed.

Jerilyn: “What we really can control is how we take care of ourselves… because if they burn themselves out, which is, ‘I’ll get to that next call and make sure that all calls are answered’, and ‘Everyone is heard’ is our vision statement. It’s a vision, not a mission. That’s in the perfect reality if we had all the funding we needed. That doesn’t mean we want people to respond to the demand at the expense of their own wellbeing. That’s when we really started focusing on, ‘Okay, this is a high stress environment. How can we empower people to set boundaries so they can feel like they’re in control of what’s happening for them?’ That’s the number one determinant for job satisfaction, is the internal locus of control, right? How can we help them feel empowered to set boundaries with the callers and to take a break when they need it?”

Reception area of Distress Centre Calgary (DCC). Photo courtesy of DCC.

Embedding self-care into the organization’s strategic plan

To ensure all of this would get the sustained and focused attention it needed, the leadership team embedded self-care into the organization’s strategic plan. This was approved by the DCC Board in January 2019.

Jerilyn: “So, we had the great idea of embedding self-care into the strategic plan. Okay, we need to make sure that this is a pillar of the work that we’re doing, because we can’t do anything without people who are well and healthy. So, we did embed it into our strategic plan, and it was very high level, you know, ‘We’re going to talk about what self-care means to us as individuals, as a group’.”

And yet there were some “nigglies” about this focus on self-care. Was it right to put all of the on us on employees?

Jerilyn: “We were putting all of the onus on our employees, and one of our newest managers, Mike Velthuis Kroeze, the Crisis Program Manager, questioned, ‘But, what are we doing as a leadership team? What policies do we need to put in place to make sure staff can care for themselves?’”

Epiphany: Self-care isn’t enough

And then, the March 2019 terrorist attack on two Christchurch, New Zealand mosques happened. In a Facebook post, Muslim activist Nakita Valerio commented on the tragedy and peoples’ response to it: “Shouting ‘self-care’ at people who need community care is how we fail people”.

That comment really struck Jerilyn – it was a “a big light bulb” helping her to realize that self-care for Distress Centre staff wasn’t enough either and rather, that a collective approach – a community of care where people support each other – was essential:

Jerilyn: “We have to create a community of care that supports other people; that encourages people to access support; that is also shared collectively and there is shared ownership of it. I can expect support from my colleagues but also, I expect that I will give support and provide that support and feedback and everything that goes with having a healthy, diverse, open culture at the Distress Centre.”

Jerilyn explained that a community of care is all about human connection and mutual support. She described this as being like “scuba buddies” – a community of like-minded people driven by the same mission, who believe in and truly understand the work and what you’re going through. You don’t go scuba diving with someone who doesn’t understand scuba diving – you go with someone who knows all about it and who can support you when needed:

Jerilyn: “They say you never go scuba diving alone. You always have a scuba buddy. You have someone who knows you don’t go scuba diving with a snorkeler or someone who’s going to sit on the beach. You go scuba diving with someone who knows how to scuba dive…having like-minded people who are driven by the mission and believe in the work and understand that there’s tough days and there’s good days and that’s very rewarding. But you need to have someone who understands what you’re going through. That often means within this environment, somebody sitting next to you, doing the same job as you. Peer support – it’s all about peers – scuba buddies.”

Not one to just sit on an idea for long, Jerilyn decided to take her idea out to her colleagues and see what they thought of it.

Another all-staff meeting…

In June 2019 Distress Centre staff and leaders came together for another all-staff meeting. The leadership team began by describing how they’d responded to staff feedback from that difficult 2018 all-staff meeting.

Jerilyn: “What we said to them this year, ‘We’ve changed things a lot since last year, based on your feedback… look what we did with your feedback’.”

Then they focused on the notion of a community of care and generating co-owned ideas for creating and sustaining that: “What ideas do you have for creating a community of care?”. Interestingly, most of the suggestions put forward were no- or low-cost – simple things that anyone could do at any time.

Here’s some examples of what came up:

• Checking in with each other (raised by many).
• Time and space for checking in with each other.
• “Create space: my door is open if you need to talk”.
• Ask people what they need.
• Words of gratitude.
• “You deserve a break; take a break”.
• Smiles and laughter; creating a fun, happy work environment where we tell lots of stories and have lots of fun.
• Wellness days to focus on different aspects of wellbeing.
• More activities by the Wellness Committee.
• Information sessions (e.g., lunch and learns).

Ideas about work practices and policies were also put forward:

• Creating clear expectations – What do you expect of me? What should I be working on?
• Setting an example (e.g., managers not sending work emails at night).
• Change “sick” days to “personal wellness” days so that people don’t have to feel guilty calling in “sick” when they actually just need a mental health break.

As with any stakeholder engagement process, DCC leaders made it clear they would consider all ideas and try to implement as many as possible. However, with limited resources, not all could be addressed, and priorities would need to be determined. Following the meeting, staff were asked to complete a priority-ranking survey. By the end of 2019, DCC leaders expect to have some action plans for self-care and a community of care, based on staff’s prioritizations, in place.

The Distress Centre is also integrating the notions of self-care and community of care into the physical design of its workplace. In early 2020, the Centre is moving to a new building. The new offices are intentionally being designed to include ample space for people to debrief and a quiet room where people can meditate, pray or just generally relax.

Some of the staff at the Distress Centre Calgary. Photo courtesy of Distress Centre Calgary

Essential pieces of the puzzle, and moving forward

Stepping back and looking at their work to date, Jerilyn noted that this combination of things – self-care, a community of care and peer support, the ability to set boundaries and take a break when needed, and a physical space to enable this – are all essential pieces of the puzzle of creating a mentally healthy space:

Jerilyn: “There’s some actual physical space that we’re creating in hope that people will mentally create that space for themselves. All of these different things, not one of them is enough. They all have to work together.”

To assess progress, the Distress Centre will add some new questions to an annual employee satisfaction survey. The survey will be conducted this year to capture baseline data, and it will be repeated next year, once some initiatives have been rolled out. And so, through continued listening and a participatory approach, this work to support the mental wellbeing of DCC staff and volunteers will continue.

We’re certainly looking forward to seeing how it all unfolds!

Why the Distress Centre’s approach is so exciting

We think the Distress Centre’s approach to supporting mental health in the workplace is exciting and exemplary in many ways. First, the leadership team has fully invested in employee mental wellbeing and has ensured it will remain a priority by embedding it into the organization’s structure and policies (strategic plan; communication channels/feedback loops; physical design of the workplace). These new structures complement existing programs to support wellbeing, including a Wellness Committee and an employee assistance program that was expanded as a result of the participatory process with staff.

The second thing that’s so great about this work is recognition by organizational leaders that it’s the work that is largely problematic, not simply the inability of its people to “manage stress”. Even within fiscal constraints, they found ways to make the work less stressful, and in so doing have helped to protect employee mental wellbeing.

Third, in true health promotion fashion, the DCC is authentically engaging staff in identifying issues that are impacting their wellbeing, and in finding solutions; they are working with staff, rather than “doing to” or “doing for”. This is a process that fosters empowerment where people realize their own “power from within” to take control of factors that impact their wellbeing – the overarching goal of health promotion. Also congruent with mental health promotion are efforts to address factors that may contribute to ill-health, and the DCC’s intent to sustain its supportive environment for mental wellbeing.

But taking this open-ended approach took courage. As Jerilyn experienced, this is not for the faint of heart! For leaders, it can be extremely difficult to open oneself up for whatever comes out – and to hear that things aren’t perfect under one’s command. And for staff, there must be a high level of psychological safety in the organization such that they feel safe to express “what’s really going on”. We suspect the DCC’s longstanding culture of engagement and the value placed on reflective practice and ongoing learning have been instrumental in the DCC’s ability to engage staff and get to the heart of the matter.

Jerilyn concurs:

Jerilyn: “This challenge and the way we approached it was not only my doing, but our 48/49 years of history as a social work agency and emphasis on human connection, supervision and reflection… we have always been a teaching and learning agency. We work with volunteers. This is heart work, and we have to be kind to each other. All of this contributed to us taking this course of direction.”

And finally, recognition that “self-care is not enough” and that what is really important is a community

of care is exciting because it recognizes the power of relationships to support mental wellbeing in organizations. This is highly resonant with the research of William Kahn, an organizational psychologist who has studied holding environments in organizations. Holding environments are created when work colleagues make time and space to “hold” or support coworkers who are upset and together, work through that “upset” in caring and supportive ways.

Kahn has more recently written about resilient caregiving organizations – those that have the capacity

to absorb stress and continue to function effectively. Becoming a resilient organization is not easily achieved; however, it appears that the Distress Centre Calgary is well on its way.

“Resilient organizations, like individuals, have the capacity to absorb stress and difficult emotions without being so harmed that they cannot function effectively. They may sway and bend under the weight of what they absorb but they do not break; they maintain the capacity to right themselves… In resilient cultures, members have figured out how to learn and grow in the midst of difficult, sometimes painful environments; they have learned to remain connected rather than disconnected from one another and careseekers. This is not a simple proposition, and many caregiving organizations struggle to make it true.”

Want to support mental wellbeing in your workplace? Some thoughts…

When asked for advice about supporting mental wellbeing in the workplace, Jerilyn’s key piece of advice was to “don’t look away” and to “work as a team”:

Jerilyn: “It is important to not look away. The old adage, “Courage is not the absence of fear, but action in the face of fear” is certainly appropriate here. We were all feeling so overwhelmed in 2017-2018 – I was a brand-new ED working with a leadership team in new roles. It was hard to lift our heads up and look at what was happening elsewhere in the agency. But we carved out the time and approached it as a team.
I have big shoulders, but I couldn’t have possibly taken that on myself. The leadership team helped facilitate smaller groups to make sure everyone had the opportunity to express themselves and be heard. We took it on together and proceeded together…I remember debriefing with Robyn and David from my team late in the afternoon/into the evening after the June 2018 meeting. The “knife in the heart” was so much easier to take because they (and the other members of the leadership team) were right beside me.”

Another important learning is that this process doesn’t need to be expensive. Staff’s expressed needs were predominantly about shifting a mindset or being more mindful of mental wellbeing in the workplace, rather than expensive new programs or supports. This is good food for thought!

In closing, if you want to better support mental wellbeing in your own workplace, here are some questions you might ask yourself to get started…

• How are we really doing in terms of mental wellbeing at work? Are we really seeing what is going on? Are there signs of distress? Are we afraid to “really see”? If yes, why?
• What supports do we already have in place for supporting mental wellbeing in our workplace? For individuals? For all of us as a community?
• What things in our work or work environment might be impacting our mental wellbeing?
• How “safe” is our workplace for talking about difficult things? How can we make it safer for people to say what is really going on and to raise any concerns they might have?
• What example am I/are we setting in regard to mental wellbeing at work?
• How can we work together to better support our individual and collective mental wellbeing?
• How will we know if what we’re doing is making things better?

End notes

i See for example, Canadian Mental Health Association. Mental health promotion: A framework for action.

ii See, for example, Bishop, A. (2015). Becoming an ally. Breaking the cycle of oppression in people. 3rd Ed. Black Point,

Nova Scotia: Fernwood Publishing, for a discussion of “power over” and “power with”.

iii Kahn, W. (2001). Holding environments at work. Journal of Applied Behavioral Science, 37(3); 260-279.

iv Kahn, W. (2005). Holding fast. The struggle to create resilient caregiving organizations. New York: Brunner-Routledge; pg. xi.

“One of the reasons I enjoy working at Aventa is we are always ahead of the curve.”

“We’re constantly looking at best practices.”

The complexity and dynamism of the people and communities we serve, the issues they face, and the systems we work in makes optimizing the results of our efforts – making a difference in the lives of people we serve – a daunting challenge. To achieve the best possible outcomes in this environment, organizations need to continually learn, adapt and improve. Building and sustaining these abilities or capacities requires dedication and effort and we can learn from the experiences and wisdom of those who have succeeded in this regard.

For decades, the Aventa Centre of Excellence for Women with Addictions has fostered and sustained a culture devoted to ongoing learning and quality improvement. In this story, we map out how this award-winning organization has managed to make it work.

This story began with another about how Aventa integrates gender responsive trauma informed care (GR-TIC) into everything it does.

As Capri Rasmussen, Clinical Administrative Manager, kindly described Aventa’s efforts in that regard, the organization’s commitment to ongoing learning and quality improvement shone through. We heard about the strength of leadership around not only GR-TIC, but also around learning and improving. The terms, “continuous quality improvement” and “PDSA cycles” surfaced innumerable times. So did the importance of training and ongoing professional development; of reflective practice through clinical supervision; of monitoring and evaluating efforts; of continually seeking new ideas, evidence, and understanding what other organizations are doing – all in the interest of improving the care and services provided to women living with trauma and addiction.

Capri: “I think it’s an underlying philosophy, continuous quality improvement. People who are not afraid to try new things. We’re not afraid to go, ‘Okay, it didn’t work, we’ll try something else’…We have that freedom as a team – people come up with suggestions like, ‘Oh well, why did we do it this way?’ Well, let’s look at that, and understand.

And I think staff bring up those suggestions a lot, too. We get suggestions from clients that we respond to and try to incorporate wherever possible…. It’s just continuous quality improvement. Looking at, ‘What’s the evidence?’, ‘What are our partners doing? What are they expecting? What’s Accreditation Canada expecting? What are new developments from Stephanie Covington and things like that. We always make sure, for instance, that if there’s any curriculum changes, we buy the latest materials. We’re not using old materials.”

We returned to Capri and asked if she would tell us more about how Aventa sustains its culture of ongoing learning and improvement. She described numerous practices and structures that we have organized into two sets of “key ingredients” that seem to make it work. The first is organizational abilities or capacities that enable learning and quality improvement to occur. The second set of key ingredients is the processes through which learning and ongoing improvement occur.

Organizational supports for ongoing learning and quality improvement

At Aventa, a number of organizational supports or capacities provide the foundation for learning and improvement. These include the commitment of leaders and champions to ongoing learning and quality improvement; supportive values; a continuous learning environment; dedicated resources and formalized roles.

Leaders, champions and commitment

Aventa has numerous formal and informal leaders who are committed to ongoing learning and quality improvement for the purposes of optimizing care, services and outcomes for clients. There is an obvious passion for being on the forefront, for always seeking ways to improve.

Here are some things these leaders do to encourage and sustain a culture of learning and improving:

• Continually reinforce the importance on ongoing learning and quality improvement – the desire for excellence, for the benefit of women with trauma and addiction.
• Place strong emphasis on training and professional development.
• Sustain an environment conducive to learning (see continuous learning environment below).
• Enact the commitment to learning and improving by providing tangible resources including, for example, dedicated time for learning and reflection; purchase of the most up-to-date treatment curricula; resources for training; and dedicated roles to support learning.
• Place a strong emphasis on clinical supervision/reflective practice (for clinical staff).
• Monitor and evaluate efforts and use the findings to improve care and services.
• Seek external validation of quality by maintaining accreditation with Accreditation Canada.
• Share learnings and knowledge with partners and other organizations.

Values and a continuous learning environment

Continuous quality improvement and a commitment to lifelong learning as individuals, as an organization, and even for the entire sector are part of the culture of Aventa. There is constant discussion about new ideas and what changes could be made. A core value is, “Excellence: incorporating safety and best practices in the delivery of client-centred programs and services.”

Another consideration is that as a non-profit organization, Aventa has less “red tape” to navigate, making it more nimble and able to adjust practices more quickly and fluidly. This may help to positively reinforce improvement efforts as results can be seen and evaluated more quickly.

Capri: “I guess maybe it’s a culture thing – we talk about continuous quality improvement. We have a quality improvement committee – so we’re always talking about what’s a new idea, how do we make change and whether that’s in our training or policies and procedures. So, I just think we’re just open to that and we’re nimble as a non-profit; we can move quickly. We don’t have a lot of red tape. Maybe big organizations might not? So, we can respond to that and if it doesn’t work, we can go, ‘Okay, that didn’t work, so let’s try something different’.

It’s about that continuous quality improvement. So, as we respond to both the issues, the feedback, the staff, clients and families and what’s available, too – just that continuous. It’s kind of an evolution, right? Lifelong learning, individually and collectively as an agency and a sector.”

One of the foundational requirements for organizational learning is psychological safety – “a climate in which people feel free to express relevant thoughts and feelings”. While that might sound simple, it’s not! In fact, being able to seek help and tolerate mistakes while colleagues watch can be very difficult. Aventa recognizes this and aims for psychological safety through a continuous learning environment:

Capri: “We even talk about that as part of trying to have a no-fault environment. So, obviously not malicious type things, but basically having people be willing to say, like, “Oh, this happened, and this is a near miss, and this is what we can learn from it.” … it’s all of that; this just seems normal to me.”

Alongside this is ongoing attention to staff wellbeing and sustaining a sense of “team” where people know and respect one another. This probably helps create a space where people feel safe enough to speak frankly about things that might not be working so well and that need to be improved without fear of being sanctioned for speaking out.

Formal roles and dedicated resources

Capri: “I do think you have to have some dedicated resources, you have to have someone who’s responsible for components of that to make sure it happens and it is spread around the agency.”

Embedded in Aventa’s organizational structure are formal roles dedicated to ongoing learning and quality improvement. These include, for example:

• Executive Director, Kim Turgeon, who champions and sets the tone for learning and improvement and provides concrete supports to enable it to happen. “We are firmly rooted in a framework of evidence-informed practice and accountability. As a centre of excellence, we strive to provide excellent care that is responsive to our clients’ ongoing and emerging needs.”
• Program managers who work with staff, including clinical supervision, to improve practice.
• A PhD prepared clinical supervisor [Dr. Beverly Frizzell, PhD, R. Psych] who facilitates weekly group clinical supervision with counselors to work through practice-related issues.
• A Clinical Administrative Manager (Capri Rasmussen) who looks at training, and drafts policies and procedures to reinforce that training. This person also identifies and organizes new training, and coordinates accreditation processes, which includes training requirements.

Aventa has several internal committees with membership of staff from across the agency. The purpose of these committees is to provide feedback to the Senior Management Team and Aventa Board of Directors as it relates to agency policies and procedures. Some of the Committees include:

• A Quality Improvement Committee: This committee discusses quality Improvement themes, makes recommendations, and implements quality improvement initiatives.
• Ethics Committee: This committee encourages reflection and increases the level of consciousness about ethical issues among staff with the Aventa Ethical Framework, discussing ethical themes and making recommendations, and arranging staff education activities.
• Joint Health, Safety & Risk Management Committee: This Committee consists of staff and management representatives working cooperatively to improve health and safety performance.

The commitment of the organization to ongoing quality improvement includes allocation of dedicated resources to make it happen. This includes providing time, resourcing and dedicated roles for professional development and clinical supervision, and for monitoring, evaluation, quality improvement and accreditation processes.

The Aventa Centre of Excellence for Women with Addictions. Photo by Fraser GermAnn, Community Mental Health Action Plan

Learning and quality improvement processes

Undergirded by the foundational supports described above, learning and quality improvement occurs through numerous processes at Aventa. These include training and professional development; clinical supervision; “intelligence gathering”; and monitoring, evaluation, and accreditation.

Training and professional development

Great attention is paid to competencies, ongoing learning and professional development. There are formalized positions to support training/professional development, clinical supervision, and evaluation.

Clinical staff at Aventa typically have a bachelor’s or master’s degree in helping services and thus fall under the Health Professions Act which requires professionals to undertake several hours professional development each year. Aventa makes sure that staff are responsible for doing this and provides opportunities for them fulfill this requirement. Nevertheless, this means that while the organization has a focus on learning, so must its staff:

Capri: “We make sure that staff are responsible to keep their licenses, but we give them opportunities for that, so professionalization and the regulation of the Health Professions Act does spur [learning]… so, it’s not just the agency then; you individually have to have an attitude of continuous learning.”

For clinical staff, Aventa has determined that four critical areas of understanding are gender-responsive trauma informed care, addiction, mental health, and process group counseling. Once hired, clinical staff receive extensive training, including experiential learning around facilitating group processes. Beyond induction training, Aventa provides numerous professional development opportunities, including foundational topics but also topics relevant to current issues or challenges (e.g., most recently, opioid use).

See the story, “Trauma-Informed Care is Our Foundation” for more information about training and professional development at Aventa”

In reflecting upon all of the attention given to training at Aventa, Capri observed that it is all important because it builds a culture of continuous quality improvement, it reduces mistakes, improves staff morale and skills and development, and it probably also saves time:

“It’s all important because it builds a culture of continuous quality improvement. And, that’s just the way it is… I think it also reduces mistakes. And I think having a responsive approach to training improves staff morale and skills and their own development whether they intend to be a practitioner at Aventa long term or even their career development when they leave here one day. It just adds to a more competent sector in workforce…. And I don’t think it has to necessarily cost a lot of money, per se because there is going to be induction training, there’s going to be costs and time associated with that. But there’s also going to be costs and time associated with [not having training and] people being slower to be able to uptake and get ready to go, too.”

Staff meeting room. Photo by Fraser Germann, Community Mental Health Action Plan

Clinical supervision

Clinical staff also participate in various clinical supervision activities, including a weekly group session to discuss challenges in practice. This is a critical aspect of learning and improving. [See the story, “Trauma-Informed Care is Our Foundation” for more information about clinical supervision at Aventa [insert link].

Intelligence gathering

Capri: “Our evidence is fed from many directions.”

“We’re not afraid to respond to what other people identify as being a good practice.”

The people at Aventa are continually gathering intelligence – scanning the broader environment for new ideas, new practices, new research, and so on. They often look to see whether good practices underway in other organizations might be a good fit for Aventa.

Monitoring, evaluation, quality improvement and accreditation, and reporting

Capri: “And then… we do our own evaluations about the outcomes that we want to see change and improve for the women.”

Alongside training and professional development processes, monitoring, evaluation, accreditation and reporting play a central role in ongoing learning and quality improvement at Aventa.

Capri spoke about PDSAs (plan-do-study-act) being a fundamental way of learning how things are working and adapting them in order to improve. PDSAs are ongoing cycles of planning, acting and reflecting on how things went, then adapting and trying again. The key parts are the simple questions: Well, how did that go? What can we do differently? These two simple but rich questions are a foundation for continuous learning and quality improvement. At Aventa, this process is applied both to small and to large change efforts. What likely makes it work, however, is Aventa’s strong culture of, and investment in, learning and continually improving.

Evaluations are completed for areas of our practice that we want to trial and improve. This includes, for example, new training. When Aventa started some new online training related to its curriculum, staff were asked to reflect on the pilot. Feedback was used to make adjustments, and then the program was fully instituted.

In terms of client experiences and outcomes, Aventa develops a client outcome report each year. This report includes benchmarks and quality improvement indicators for the next year. The larger internal document is shared with staff. A synopsis of this report is released to the public on the website. [Click here for the 2017-2018 report.]

In 2011, Aventa became an accredited organization through Accreditation Canada. The organization has “Exemplary Status” from Accreditation Canada. The decision to become accredited was not a requirement, but rather, a desire on the part of Aventa to seek an external validation of the quality of its services. It is evidence of Aventa’s commitment to evidence and quality improvement:

Capri: “Our commitment to the evidence and quality improvement and that kind of evolution is why we became voluntarily accredited with Accreditation Canada…we have an external validation of quality.”

Accreditation Canada’s standards and requirements direct data collection and staff training in some regards. In this way, the accreditation process has a become another foundational support for ongoing learning and improvement. [Click here to read the 2018 Accreditation Report for Aventa.]

Inspired? Intrigued? Encouraged? Want to make similar changes in your practice or organization? See Shared Wisdom for a smorgasbord of ideas for how you can make it happen.

Trauma-Informed Care Resources

Alberta Health Services. Trauma informed care modules. https://www.albertahealthservices.ca/info/page15526.aspx

Alberta Health Services. Why Welcoming is Important handout: https://www.albertahealthservices.ca/assets/info/amh/if-amh-ecc-why-welcoming-is-important-qrs.pdf

Arthur, E., Seymour, A., Dartnall, M., Beltgens, P., Poole, N., Smylie, D., … Schmidt, R. (2013). Trauma-informed practice guide. Vancouver, B.C: BC Provincial Mental Health and Substance Use Planning Council.

Barnett Brown, V. 2018. Through a trauma lens. Transforming health and behavioral health systems. New York: Routledge.

Bloom, S. & Farragher, B. 2013 Restoring sanctuary. A new operating system for trauma-informed systems of care. New York: Oxford University Press.

Canadian Centre on Substance Abuse Trauma Informed Care. http://www.ccsa.ca/Resource%20Library/CCSA-Trauma-informed-Care-Toolkit-2014-en.pdf

Harris, M., & Fallot, R. D. (2001). Envisioning a trauma-informed service-system: A vital paradigm shift. New Directions in Mental Health Services, 89, 3-22.

Manitoba Trauma Information and Education Centre (MTIEC). 2013. Trauma-informed: The trauma toolkit (2nd ed.). Winnipeg, MB: Author.

Manitoba Trauma Information and Education Centre: http://trauma-informed.ca

Poole, N., & Greaves, L. (Eds.). 2012. Becoming trauma informed. Toronto, ON: CAMH.

SAMHSA. 2013. TIP 57 Trauma-informed care in behavioral health systems. Author.

Sometimes when supporting mental health in the community, we run into situations where a particular practice or program isn’t getting the results we’d hoped for, and where there aren’t any other tested or suitable alternatives. In these cases, we need to innovate – to try something new and different. In this story, we describe how the Distress Centre Calgary (DCC) did exactly that. Realizing their telephone-based teen distress line was underutilized, DCC decided to try something new, and became the first organization in Canada to offer an online peer chat and texting service for youth in distress, now known as ConnecTeen.

“We were the first in Canada. It was exciting!”

[Jerilyn Dressler, Executive Director, DCC]

The impetus for change: Low call volumes in a telephone-based teen distress line

The DCC introduced its telephone-based distress line for teens, called Teen Line in 1983. In 2009/10, the DCC reviewed its data regarding the nature and number of calls received by the program. They learned Teen Line was averaging less than 1000 calls a year – a fraction of the DCC’s total annual volume of 75-80,000 distress calls.

In reflecting upon the low call volumes for Teen Line, DCC leaders briefly contemplated shutting the program down. However, they agreed that supporting teens was critical and in fact, supports should somehow be broadened. Recognizing the growing preference of youth for online interactions, they decided to explore the notion of online chatting and texting.

Finding a workable solution and “just starting”

To inform this effort, the DCC scanned the literature to see what people in other jurisdictions were doing to support youth in crisis – and found very little of relevance. They did, however, discover a texting program in Reno, Nevada and contacted the program to learn how it worked. Deciding to implement something similar in Calgary, the DCC worked with their IT vendor to select a chat and texting interface. And that’s where the real learning – and the sharing of lessons learned with others – began.

Jerilyn: “There was nothing out there… There was very little of it happening across North America. So… we kind of just went into it and started learning for ourselves and started sharing what we were learning.”

“A whole new ball of wax”: Revisiting assumptions and changing course

The DCC started out small with online chats, and subsequently added texting. An initial assumption was that chat and text interactions could be managed in the same way as phone calls. But almost immediately, this assumption was shattered. Online chatting and texting with youth turned out to be a “whole new ball of wax” and it was clear that assumptions about how things would work, and implementation plans needed to be re-crafted. Here are four examples of how things needed to be changed.

• Expecting teens in high risk situations to phone the distress line was not realistic. It was originally planned that if teens were in a high-risk situation, they would be asked to phone the distress line. But it was soon learned that youth would not talk by phone – that’s why they were chatting or texting in the first place! And so, volunteers needed to learn how to support youth in high risk situations via the online environment rather than by telephone.
  

  Jerilyn: “We thought we were just going to re-create what we do on the crisis lines on chat and text. Well, it was very, very different. It was so different. We were like, ‘If it’s a high-risk situation, we tell them to call the phone.’ We say, ‘No, you’re going to have to call the line.’…[Teens] wouldn’t do it. They would not do it. They don’t want to call; that’s why they’re chatting or texting… because they don’t want to pick up the phone and call. And that’s why we created the program. Why would we force them to phone? If there’s a high-risk situation, it just doesn’t make sense.”

• Building rapport in an online environment is different from telephone and appropriate language is important. Initially, DCC volunteers found it difficult to build rapport with teens in the online environment. This was largely because they were communicating too formally, using the professional language they’d been trained to use when documenting telephone distress calls.
  

  Jerilyn: “Because we’re training people for professional documentation, they were not building rapport. Rapport was next to impossible to build online because they were very formulaic and using very perfect grammar – not reflecting peoples’ language back to them. We were taking the good things about peer support out of it by training them on professional documentation.”

  Once this challenge was recognized, the DCC developed new communication tools and strategies (e.g., “tips and tricks”, a list of acronyms) and trained volunteers how to connect with people online. Volunteers were encouraged, for example, to reflect teens’ language back to them and to write in a conversational tone that would build rapport. Once this happened, they realized it was actually easier to build rapport with teens online.

  Jerilyn: “It’s very, very different. Very different. Like, the use of short quick terms… the acronyms. We have a whole cheat sheet on the acronyms. It’s reflecting their language back to them, you have to somehow build rapport. And it’s actually easier when you know the tips and tricks, it’s easier to build rapport online.”

• Online chat and text conversations are more likely to be of a high-risk nature. Another early insight was that chat and text conversations were also much more likely to be of a high-risk nature. In fact, when the DCC analyzed data about ConnecTeen contacts, they found that chat and text conversations are over ten times more likely than phone conversations to be related to self-harm, and more than twice as likely to be related to suicide. This is related to what is known as the “online disinhibition effect”:
  

  Jerilyn: “About 10 percent of our phone calls and about as high as 24 or 25 percent of our chats and texts are related to suicide. And it’s the online disinhibition effect.”

  Jerilyn pointed out that in part, these results are related to the fact that youth are more likely to talk about self-harm and suicide, but even when age is accounted for, the percentage of contacts related to suicide and self-harm is still significantly higher in chat and text contacts than in phone contacts. What this has taught the DCC is that online chat and text are valuable toolsfor getting at risks that people often aren’t willing to talk about in person or by phone. The Centre suspects that youth who text and chat are not more likely to be suicidal, but rather that they’re just more comfortable talking about these matters online.

Jerilyn: “People are more likely to share more openly [online] because it’s less scary.”

• Chat and text conversations can be super-long. Another unanticipated consequence was that chat and text conversations can go on for hours. Having to stick with one conversation that could have prolonged periods of silence left volunteers bored and disengaged. They asked to be able to engage in more than one conversation at a time, but this didn’t jive with an established principle of “no juggling of text conversations” – one conversation at a time. But, in consideration of the volunteers’ request, the “no juggling” principle was revised to allow them to conduct two chats at a time. This has worked well to keep volunteers engaged and satisfied.

Jerilyn: “We said, ‘No juggling of text conversations’. Well, the volunteers were like, ‘Ugh’. They were so bored. If you have ever been to an empty restaurant, you get the worst service because the server is not engaged in what they’re doing. They’re chatting with the bartender, whatever. So, it was the same thing for our volunteers. They weren’t engaged… So, okay, you can do two chats at a time. And that actually really helped them get engaged.”

ConnecTeen today

As the DCC continued to collect data about the number and nature of ConnecTeen contacts, and spoke with volunteers and staff about their experiences, a great deal of learning and troubleshooting occurred. Things that weren’t working well were identified and rectified, and today, the program runs smoothly.

• Today, peer support by phone, chat and text is available from 5 to10 PM, Monday to Friday, and from 12 PM to 10 PM Saturday to Sunday. Youth can contact the DCC during these hours to talk with highly trained youth volunteers.
• ConnecTeen volunteers offer a confidential and non-judgmental space for teens to talk about what is going on in their lives. They don’t tell teens what to do but rather, encourage them to make safe decisions; they often suggest connecting with a trusted adult. Volunteers will also connect teens to relevant resources if they want additional supports.
• Teens can also text or chat from 3 to 5 PM on weekdays, but during those times, adult volunteers or staff will respond.
• The telephone distress line is available 24/7 for teens but outside of peer support hours, adult volunteers answer the calls.

It’s working! Evidence from ongoing monitoring

• In 2017, demand for ConnecTeen services grew by 82% and demand for texting increased by 148% over the prior year.
• By 2018, demand had tripled from 2584 contacts to 7699. However, this massive increase appears to be an anomaly as the number of contacts in 2019 stabilized at 5528 total contacts.
• Nevertheless, in 2019, the number of ConnecTeen contacts was more than twice the number
  of contacts in 2016.

Some other interesting statistics include:

• In 2019, 43% of all contacts came through text messaging and another 21% were through
  the online chat feature.
• Text and chat conversations are 4 to 5 times longer than phone calls. More resources
  (volunteers, computers, physical spaces) are required to manage this volume of contacts.
• Self-harm is a presenting issue on approximately 20% of all contacts. Anecdotally, many
  youth use ConnecTeen as a coping method in place of self-harm.
• Approximately 3% of contacts in 2019 required emergency intervention to ensure the safety
  of a service user.

Foundations of successful innovation and implementation

By “just starting” – just trying something new and collecting information about how things were going along the way, the DCC successfully innovated and implemented Canada’s first peer chat and text service for youth in distress. Here are some reflections on factors that seemed to promote the DCC’s success (and there are likely many others!).

• A culture of ongoing learning and improvement. Jerilyn notes that as a social work agency, the DCC has, “always been a teaching and learning agency that emphasizes human connection, supervision and reflection”. This culture seems to include some of the following key characteristics of psychologically safe organizations for learning: leadership that encourages and makes space for reflection and learning; openness to (and actively seeking out) new ideas; comfort with challenging assumptions; willingness to take risks, to experiment and to fail; and the ability to learn by doing.
• Consideration of the unique needs, concerns and preferences of teens. By recognizing teen preferences for communicating, the DCC was able to develop something that teens would actually use. And when they learned more about teen preferences for interactions (i.e., little or no interest
  in using the telephone for high risk situations), they adapted their practices accordingly.
• Courage, patience and persistence. It took significant courage to try something almost entirely new and untested. Implementing chat and text was a difficult journey but the DCC found ways to address emerging challenges and better prepare volunteers for the nature of texts and chats, including their higher risk nature. Now, they are well-trained to manage these dynamics.
  

  Jerilyn: “We knew we had to do this; this was a trend in communication, we should probably jump on that and be an early adopter. It was hard. I hope we did more good than harm in those early days. It was, at the time, very hard to build rapport because we hadn’t equipped people …we didn’t know the differences. We didn’t know how different it would be… Now we train people for that and prepare them for the higher risk nature of chats and texts…
  We didn’t know any of this before we started. It’s like we went in totally blind. Went in like, ‘This is good to do because youth don’t like calling anymore and they want to text and chat so let’s go’, and it’s a totally different ball of wax.”

• Collection and use of data about services provided. Finally, the DCC is dedicated to collecting data about their services, and this data has been instrumental in guiding implementation and improvement efforts. Jerilyn explained that while personal information isn’t collected from ConnecTeen users, DCC volunteers and staff do record a “guesstimation” of age and the general nature of each conversation. This focus on data collection and analysis is part of the DCC’s culture of ongoing learning and improvement.

A chilly gray April day. Standing outside the locked, barred door, pressing the bell. Waiting. What is this place like? What are the people like? Another door. Another set of uncertainties, the unknown.

But what a relief upon stepping inside! Warmth. Comfort. Safety. Pretty things – a giant turquoise glass vessel on a coffee table; wall-sized abstract prints of navy and white, reminiscent of the sea. Cushy soft leather chairs. Fluffy cushions. No hint of “institution” or “facility” here. This could be someone’s living room or a boutique hotel. And then there’s Lisa, who smiles warmly and says, “Hello!”.

How many women, struggling with addiction and the trauma it buffers, have stepped across this threshold and felt the safe, warm embrace of Aventa? How many have left feeling strong and full of hope? Thousands.

Nestled amongst the towering spruce trees of Calgary’s Mission community, the Aventa Centre of Excellence for Women with Addictions has been serving women with addictions for almost 50 years. From its humble roots as a volunteer-run home for women struggling with alcoholism, Aventa has grown and evolved over the years, earning a longstanding and excellent reputation for providing gender-responsive, trauma informed addiction treatment services exclusively to women.

The Aventa Centre of Excellence for Women with Addictions. Photo by Fraser GermAnn, Community Mental Health Action Plan

Today, Aventa has 65 community-based beds and offers three phases of live-in treatment; another live-in program for young adults aged 18-24; an FASD Transitions Program; and a program for pregnant or parenting women with addiction concerns. In addition, Aventa offers a wide array of on-site supports for wellness, and after-care groups to support women in their recovery. [Click here to see a full listing of programs and services.]

Aventa’s mission is: “To improve the lives of women and their families affected by addiction, mental health and trauma through treatment, advocacy and education, in a safe and supportive environment.” Aventa materials often include the statement, “When women are healthy, families are healthy and communities are healthy.”

Capri Rasmussen, Clinical Administrative Manager and Kim Turgeon, Executive Director, Aventa Centre of Excellence for Women with Addictions. Photo courtesy of Aventa.

In 2007, Aventa adopted a gender responsive, trauma informed care (GR-TIC) approach, based on the work of TIC pioneer, Stephanie Covington. Twelve years later, the people at Aventa say that, “trauma informed care is our foundation – it is the core of what we do”.

This story is about what gender responsive TIC (GR-TIC) looks like at Aventa and how the approach has become embedded throughout the organization.

Aventa’s journey to gender-responsive TIC

By the early 2000s, staff at Aventa had long recognized that most of the women they served had experienced trauma at some point in their lives. Trauma was addressed wherever and whenever possible, but many felt there was a need to do more, to make more room for the women’s’ stories of trauma to flow and be heard. There was a receptivity to something better; a readiness for change.

In 2007, a convergence of events and insights further opened the door for that “something better”. There were changes in personnel, Aventa had recently moved into a new facility, a needs assessment determined that Aventa clients would benefit from a trauma-informed curriculum, and Aventa staff heard Stephanie Covington, a leader in TIC, speak at a conference.

Multiple sources of evidence – staff insights and experiences, client experiences, a needs assessment, a consideration of contextual factors, and exploration of research evidence – pointed the way forward. Covington’s holistic and gender-responsive approach seemed a perfect fit. Funding was secured to bring her to Calgary and train Aventa staff, launching Aventa’s journey to gender-responsive TIC, numerous awards, and positive outcomes for the women served by its staff and programs.

What is gender-responsive TIC?

A gender-responsive or gender-specific approach means that TIC is tailored specifically for the gender of people receiving services. This is in recognition that gender-related social roles, relationships, opportunities and identity shape peoples’ experiences and that people of different genders may have different realities and experiences[i]. Specifically, they may experience different forms of trauma and respond to and recover from trauma differently[ii]. It has been demonstrated that addictions in women typically exist for different reasons and manifest differently than for men with addictions. This underlines the need for gender-specific care[iii].

Covington[iv] describes gender-responsive TIC for women this way:

“Being gender responsive means creating an environment through site selection, staff selection, program development, content, and material that reflects an understanding of the realities of the lives of women and girls and that addresses and responds to their strengths and challenges.”

Aventa exclusively serves women, so programs and approaches are tailored to meet their needs. Capri Rasmussen, Clinical Administrative Manager at Aventa says, it’s about, “What’s your experience and how can we better respond to it?”:

“There’s a need to be gender-responsive, culturally responsive – all of those types of things. It doesn’t mean, ‘Not for you’, but it means, ‘What’s your experience and how can we better respond to it?’ It doesn’t mean that men don’t have these types of trauma – we know that they do. But, we’re saying that the women we work with do, so we’re responding to that. We’re serving women… so the programs and approach are customized toward the experiences of women with trauma and addiction…it’s about understanding the lives of women and girls.”

Additional programming to meet the needs of women at Aventa include parenting, female-oriented birth control, sexual abuse counseling and even financial literacy. There is also a strong focus on relationships and helping women to build healthy connections with others.

Some of the materials used in Aventa’s programs. Photo by Fraser GermAnn, Community Mental Health Action Plan.

So, what does GR-TIC look like in practice?

Aventa is an exemplar of how GR-TIC can become integrated into the very fibre of an organization.[v] GR-TIC is not only manifested in the care and services provided; it is also expressed and perpetuated through a web of mutually reinforcing organizational practices and processes – leadership, values and a philosophy of care, roles and responsibilities, hiring practices, training and professional development, policies and procedures, staff wellbeing, monitoring and evaluation, and the physical environment. Below are some examples of these practices and processes.

Interactions and relationships with clients – enacting TIC principles.

TIC principles are enacted in numerous ways. Some examples are listed below.

• Trauma awareness. With TIC as the foundation of all its work, Aventa addresses trauma awareness in numerous ways, particularly education for staff (and other agencies as well) that emphasizes how common trauma is, how it impacts people and how they may adapt their behaviours in order to cope and survive.
• Emphasis on safety and trustworthiness. Physical safety is ensured in numerous ways, including compliance with established safety guidelines and accreditation criteria. As a residential addiction treatment facility, physical safety is also assured through security features such as locked doors and security cameras.

Psychological safety and trustworthiness are addressed in many ways. A central focus is on building trusting and respectful relationships. While skills and interventions are important, the connection made between two people helps in the change process, as does demonstrating compassion and an understanding that there is a “why” underlying every sort of behaviour.

Transparency is also important. Clients are told what will happen and what to expect in advance. For example, each step of the intake and admission process, and what the treatment program will entail is explained in advance. This helps them to feel safe:

“We’re really good at trying to explain things in advance, what’s going to happen, and that’s part of that safety thing for the clients as well. They’re telling us they want to be here in a safe, sober environment to do their recovery work. They want to make sure we’re providing that to the best of our ability.” [Capri Rasmussen]

The safety of Aventa staff is also important and is addressed through a culture of caring and staff wellbeing (see below).

• Opportunities for choice, collaboration and connection – to build a sense of self efficacy, self-determination, dignity and personal control, Aventa emphasizes relational practices that help women build safe and healthy relationships with staff, peers in their program, and with their own families. This is an important part of programming that is offered.

Choices and preferences are accommodated wherever possible and safe. This includes, for example, the ability to practice one’s own religious and cultural traditions:

“We operate from that really neutral space where people are encouraged to bring their experiences or culture, whatever is helpful for them – such as accommodating Ramadan, things like that. That’s part of the consistency and compassion.” [Capri Rasmussen]

Through surveys and evaluations, clients are also asked to suggest improvements to the services that Aventa provides.

• Strengths-based, skill building and empowerment – A central aspect of Aventa’s programming is helping women realize that addiction is often a means of coping with trauma – a way of surviving. This helps to build a more positive sense of self which then supports development of new and healthier coping and grounding skills, greater competence, and more broadly, a sense of hope that they can change, and life can look different.

The walls in Aventa’s residential building are covered with inspirational quotes like these. Photos by Fraser GermAnn, Community Mental Health Action Plan.

The walls in Aventa’s residential building are covered with inspirational quotes like these. Photos by Fraser GermAnn, Community Mental Health Action Plan.

Organizational conditions and processes

Committed leadership, organizational values and a philosophy of care. Leaders at Aventa are firm believers in, and strong champions of GR-TIC. They are also strong advocates for ongoing learning and quality improvement. A philosophy of care document outlines Aventa’s views on trauma informed care and harm reduction. It talks about the “why”, not just the “what” and includes tips for practice. This leadership and philosophy of care grounds organizational decision making and resource allocations, making GR-TIC a consideration in everything that is done.

Hiring practices. Hiring decisions at Aventa are based on the philosophy: “It’s not about a specific degree; it’s about the best fit”. This is based on research showing that the ability to build a therapeutic alliance is central to success with clients. As such, Aventa looks for people who have a positive attitude, the ability to be welcoming and engaging, who have genuine compassion and unconditional regard for others, and the belief that people (and the sector) can change. These qualities or competencies are then matched with other requirements of the job (e.g., clinical skills, professional designation).

Training and ongoing professional development. Strong emphasis is placed on education for staff. Numerous training and professional development processes are in place, including the following:

• Induction training for new clinical staff.
  • Completion of components of AHS trauma-informed care modules.
  • Completion of online modules developed by Stephanie Covington re: gender-responsive trauma informed care, and clinical care.
  • Several weeks of observation and co-facilitation of process groups based on Covington’s material, and then engaging in ongoing clinical supervision with reflective practice on how they’re moving through and integrating the materials into their process groups.
• Regular training is offered in three core areas: gender-responsive trauma informed care, addiction, and group counseling. Dr. Covington or her associates have visited Aventa several times to provide training grounded in her GR-TIC research and practice.

Other foundational topics such as ethics, safety, Indigenous awareness and working with diverse communities are addressed annually. Requirements of funders and Accreditation Canada (in order to maintain accredited status) also provide a framework for training content. For example, one funder required that staff to take gender-based analysis training.

Topics of current interest or sector and community issues are also addressed. These topics are identified through conversations with staff as a collective, and individually, and through observation of current issues relating to women with trauma and addiction. Most recently, for example, staff received training related to opioid use.

A half day each month (excluding December and summer) is devoted to training. Staff also take online training. In summer 2019, Aventa staff are trying out some of the online training available through the Crisis and Trauma Resources Institute. They will evaluate these in the fall and decide whether or not to continue with these.

• Another component of Aventa’s strong education plan is documentation and manuals. A philosophy of care document guides actions and practices. And, there are manuals that set out organizational practices for specific topics such as ethics, managing information, client confidentiality and so on.
• Training for non-clinical staff. Non-clinical staff also receive a general orientation to the women that Aventa serves and why, boundaries and how to support clients. Clinical staff support non-clinical staff in applying this knowledge.
• Information about “global topics” as well as community resources and educational opportunities is shared with all staff. For example, for “National Indigenous History Month” and “Indigenous Day”, all staff received an educational email about the Treaty area in which Aventa is situated, community resources and educational opportunities.

Reflective supervision. A core of ongoing practice improvement for clinical staff is clinical supervision – a form of critical reflection. Aventa and has a framework for this that includes three components:

• Each clinical staff person reports to a clinically trained program manager who does supervision with them.
• A PhD-prepared clinical supervisor provides weekly clinical supervision in a group format. Staff can bring in scenarios or case consults, or there might be discussions about interventions – and what went well, what didn’t go so well. Staff are vulnerable in this kind of process, but it is a safe space and it works, people learn from one another. As Capri Rasmussen notes,

“For every person who has a question, there’s probably three in the audience that didn’t want to ask it that can learn from it. So, we find that group is very helpful because you’re learning in the supervision whether or not you’re the person with the presenting issue. And we’re a team here. So not individuals in private practice; we want to build that team format.”

• There is also open supervision time where staff can make one-to-one appointments with the clinical supervisor.

A comfortable meeting space for staff and for clients. Photo by Fraser GermAnn, Community Mental Health Action Plan.

Organizational policies and procedures. Organizational policies and procedures are regularly reviewed to ensure congruence with GR-TIC. Policies, practices and programs that promote healthy connection to children, family members, significant others and the community are an important part of this. This is resonant with the relational base of GR-TIC for women.

Culture of caring and staff wellbeing. Aventa has a staff wellness strategy, and it is recognized that the principles of TIC are also important for staff. The impact of vicarious traumatization for staff is well understood, so supports for prevention and for post-incident are available. Strong emphasis is placed on self-care and “doing your own work” around one’s own traumatic experiences. Alongside that is building a strong and cohesive team. At the core is a culture of respect, caring about the work, caring about each other, having time for training, and having fun together. There are several “Wellness Wednesdays” each year. One of the most recent Wednesday activities was at the luge track at Calgary Olympic Park – a good bonding experience! Others have included meditation workshops and movies. These activities allow staff to get to know each other on a deeper level, strengthening the sense of team. Staff wellbeing surveys are also conducted as part of Aventa’s accreditation with Accreditation Canada.

Ongoing learning and quality improvement. Aventa has strong leadership commitment toward sustaining a culture of ongoing learning and quality improvement. Extensive work around monitoring and evaluation is done. Aventa voluntarily sought and received accreditation from Accreditation Canada in 2011. The organization has “Exemplary Status” from Accreditation Canada. This provides an external validation of the quality of the organization and the care it provides.

[See the story, “Sustaining a culture of continuous learning at the Aventa Centre of Excellence for Women with Addictions” for more information about this [insert link].

A welcoming and safe physical environment. Aventa has taken great care to design physical spaces that are safe, warm and welcoming and feel more like a home than a facility. The buildings are safe, clean, bright and pretty. There are “proper beds” covered with quilts. The walls are covered with art and inspirational quotes. The floors are easy to clean, but they are not “institutional” – they look like a floor you might have in your home. There are nooks and crannies where clients can be alone; and there are communal spaces where they can be together.

Clients have expressed their appreciation of this:

“I hear from a lot of women that talk about when you walk into this place, you feel the care, you feel the welcoming environment… and I hear all the time that Lisa, our receptionist, makes people feel safe and comfortable.” [Capri Rasmussen]

Surveys are done with staff and clients in order to identify what people like about the current environment and what else they would like: “If we could do something different, what would that look like?”. The feedback received has been used to make changes.

Gender-responsive, trauma-specific clinical care

While GR-TIC forms the ground in which all care and services are provided at Aventa, trauma-specific care is also provided by clinical therapists. While anyone can “do” trauma-informed care, trauma specific care requires training and clinical expertise.

For this clinical work, Aventa uses Covington’s model known as “Women’s Integrated Treatment” (WIT). WIT is grounded in theories of addiction, trauma and women’s psychological development. WIT has been shown to result in reduced substance use, less depression and fewer trauma symptoms, including anxiety, sleep disturbances and dissociation[vi].

Specifically, two of Covington’s curricula are used: “Helping Women Recover” and, “Beyond Trauma: A Healing Journey for Women”. These are group process-based and the content is holistic. For example, the content of “Helping Women Recover” focuses on self, relationships, sexuality, and spirituality.

Outcomes

An extensive array of monitoring and evaluation strategies are employed to assess the success of programs and services. The organization produces an annual report of its findings and shares the highlights publicly on its website. From the 2017-2018 report, a sampling of reported outcomes includes:

• 488 admissions within the reporting period
• 94% reported having a better understanding of their addiction
• 97% reported that the treatment program had provided them with skills that are useful for their recovery
• 93% reported they are better able to manage their emotions
• 88% reported they are better able to manage their trauma
• 93% reported feeling better about themselves
• 97% reported having an increased sense of hope for their future

Clearly, Aventa’s programs and services are generating many beneficial outcomes for the women they serve. Thousands of women have crossed that threshold into Aventa’s embrace, worked with other women and Aventa’s staff, and have found light, love, hope, and strength. This is evidenced not only in the statistics noted above, but in testimonials shared by former clients:

“I came here broken and you helped me pick up the pieces of my life. My future looked bleak and you helped clear the fog in my head. My heart was full of sorrow, but as I leave this place, I am full of light and love. You’ve given me back my life with hope for the future.” [Cathy B., Aventa website]

“The last four and a half months have saved my life. I came to this centre broken and full of self-loathing. I truly believe this program was one of the biggest tools in not only picking up the pieces of myself and my life, but putting them back together in a way that was stronger than I could have ever imagined.” [Ashley F. Aventa website]

“When I came to Aventa I was lost, broken and alone… I was greeted with acceptance and understanding. The program helped me open up, let go and grow in a safe environment. I am leaving Aventa a strong woman, ready to take on the challenges and the future.” [Rachel F. Aventa website]

“Aventa is an awesome program for women suffering from addictions and trauma. I felt like it got more to the root of my problems and why I was drinking so I didn’t have to deal with my feelings. That was what I hadn’t dealt with in other co-ed treatment facilities.”

[“Linda” in, Aventa Outcomes and Community Impact Summary, 2017-2018 fiscal year, online.]

Aventa leaders’ advice for others who want to integrate TIC and GR-TIC into their organizations

When asked what advice they would offer to other organizations wishing to implement trauma informed care, Aventa leaders offered the following:

• TIC is an organization-wide effort – an integrative approach; it must become embedded into everything that is done: “You can’t simply read a book and send staff off to training if you want to implement TIC”. Training is not enough.

• Implementing TIC is like introducing any kind of change. This includes assessing what needs to be changed and why, and then looking at the resources that exist to help with the change.

• It might be helpful to assess existing practices. For example, the BC Centre of Excellence for Women’s Health’s Trauma Informed Practice Guide (see its Appendix 2) includes an organizational assessment tool.

• Start with training but don’t stop there.
  • Find a training/approach that works for your organization and provide that to staff.
  • Ensure there is a way to sustain this training as new staff come onboard.
  • Evaluate and adapt or refine your training approach and bring in other aspects as needed.
  • Support training with other organizational supports such as clinical supervision and supportive policies to reinforce and sustain good practices.

• Look at your policies and make them more trauma informed; monitor this over time.

• Dedicate resources (people, time, money) and supervision to ensure successful implementation of TIC.
  • Capitalize on whatever information and resources are available and free. There are several good Canadian-based toolkits, some of which are listed at the end of this story. Capitalizing on these would be helpful, as would talking with other agencies about what they’re doing. This might be as simple as having staff complete some or all six of AHS trauma modules, and then building in training each month or quarter, then building in supervision.
  • Consider developing a community of practice around TIC or create some other way of working on TIC collectively.
• Endorse and resource ongoing monitoring, learning and adaptation – Aventa has an underlying philosophy of continuous quality improvement. People here are not afraid to try new things and if something doesn’t work, try to understand why, then try again. This culture helps ensure that learning is occurring, and adaptations are made as needed to continue to improve the care and services that are provided. [See the story, “Sustaining a culture of continuous learning at the Aventa Centre of Excellence for Women with Addictions” [insert link].

Photo by Fraser GermAnn, Community Mental Health Action Plan.

Intrigued? Encouraged? Want to make similar changes in your practice or organization? See Shared Wisdom for a smorgasbord of ideas for how you can make it happen.

Resources

The Aventa Centre of Excellence for Women with Addictions has an informative website that is well worth exploring.

Trauma-informed care

Alberta Health Services. Trauma informed care modules. https://www.albertahealthservices.ca/info/page15526.aspx

Alberta Health Services. Why Welcoming is Important handout: https://www.albertahealthservices.ca/assets/info/amh/if-amh-ecc-why-welcoming-is-important-qrs.pdf

Arthur, E., Seymour, A., Dartnall, M., Beltgens, P., Poole, N., Smylie, D., … Schmidt, R. (2013). Trauma-informed practice guide. Vancouver, B.C: BC Provincial Mental Health and Substance Use Planning Council.

Barnett Brown, V. 2018. Through a trauma lens. Transforming health and behavioral health systems. New York: Routledge.

Bloom, S. & Farragher, B. 2013 Restoring sanctuary. A new operating system for trauma-informed systems of care. New York: Oxford University Press.

Canadian Centre on Substance Abuse Trauma Informed Care

http://www.ccsa.ca/Resource%20Library/CCSA-Trauma-informed-Care-Toolkit-2014-en.pdf

Harris, M., & Fallot, R. D. (2001). Envisioning a trauma-informed service-system: A vital paradigm shift. New Directions in Mental Health Services, 89, 3-22.

Manitoba Trauma Information and Education Centre (MTIEC). 2013. Trauma-informed: The trauma toolkit (2nd ed.). Winnipeg, MB: Author.

Manitoba Trauma Information and Education Centre: http://trauma-informed.ca

Poole, N., & Greaves, L. (Eds.). 2012. Becoming trauma informed. Toronto, ON: CAMH.

SAMHSA. 2013. TIP 57 Trauma-informed care in behavioral health systems. Author.

Gender-responsive trauma informed care

BC Centre of Excellence for Women’s Health. Online. Trauma, Gender, Sex Informed Approaches to Substance Use videos: http://bccewh.bc.ca/featured-projects/traumagendersubstance-use-project-2/tgs-videos/

Canadian Women’s Foundation. Online. The facts about gender-based violence.

Covington, S. (2012). Curricula to support trauma-informed practice with women. In N. Poole & L. Greaves (Eds.) Moving the addiction and mental health system towards being more trauma-informed. Toronto: Centre for Addiction and Mental Health (CAMH).

Covington, S. (2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, SARC Supplement 5, 377-385.

Covington Curriculum: https://www.stephaniecovington.com/books-and-curricula.php

Schmidt, R., Poole, N., Greaves, L., & Hemsing, N. (2018). New Terrain. Tools to integrate trauma and gender informed responses to substance use practice and policy. Vancouver: BC Centre of Excellence for Women’s Health.

Endnotes

[i] Schmidt, R., Poole, N., Greaves, L., & Hemsing, N. (2018). New Terrain. Tools to integrate trauma and gender informed responses to substance use practice and policy. Vancouver: BC Centre of Excellence for Women’s Health.

[ii] Covington, S. (2012). Curricula to support trauma-informed practice with women. In N. Poole & L. Greaves (Eds.) Moving the addiction and mental health system towards being more trauma-informed. Toronto: Centre for Addiction and Mental Health (CAMH).

[iii] Aventa Centre of Excellence for Women with Addictions.(2018). Annual report 2017-2018. Author, pg. 11. Note also that Stephanie Covington also has a curriculum for men who have experienced trauma.

[iv] Covington, S. (2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, SARC Supplement 5, 377-385.

[v] It is also an exemplar of an organization that has embraced the power of ongoing learning and improvement to optimize services and outcomes. See the story, “Sustaining a culture of continuous learning at the Aventa Centre of Excellence for Women with Addictions” [insert link].

[vi] Covington, S., Burke, C., Keaton, S., & Norcott, C. (2008). Evaluation of a trauma-informed and gender-responsive intervention for women in drug treatment. Journal of Psychoactive Drugs, Suppl 5; 387-398.