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ELIZABETH GARONE
Contributor to Health Progress

Dr. Arpan Waghray

Arpan Waghray, MD, is the chief medical officer for Providence St. Joseph Health Behavioral Medicine and the co-chair of the organization's Behavioral Health Leadership Council. He is also the executive medical director for behavioral medicine at Swedish Health Services and chief medical officer for Well Being Trust. Much of his current work focuses on how Providence can best take care of its employees given the unprecedented stresses caused by the COVID-19 pandemic. Health Progress recently talked with Waghray about the resources that Providence has developed to offer emotional, mental and spiritual support to employees and the methods they utilized to create these tools to respond to the needs of their workforce.

When people hear the term "caregiver," they often think of doctors and nurses. However, when you speak about "taking care of the caregivers," who does this include?

We are talking about the mental health and well-being of all 120,000 Providence employees and affiliated providers. When we say caregivers, we mean everyone who works as a part of the Providence family: those who are non-clinical, who work in the kitchen or for environmental services, surgeons, ICU doctors, the nursing staff and everyone else. We want to make sure that we are focusing on every single person, because they might have different needs and we want to make sure that we are meeting them appropriately.

How did mental health services change for these 120,000 people when the pandemic hit?

When the pandemic hit and one of our ministries in the state of Washington admitted the first patient who was COVID-19 positive, our senior executives, including Providence president and CEO, Rod Hochman, MD, very quickly identified what our workforce was going to be experiencing, the trauma that would come along with it and what they were already seeing. It was very important that leadership identified this as something imperative early on and brought the mental health, well-being and resilience of employees into the bigger discussions already occurring around many COVID huddle topics.

You speak a lot about "seamless access to care." How did you make this happen, and why is it so important, especially now?

In March of 2020, when we were in the midst of the chaos of everything happening, one of the mandates that we had was to very strategically focus on the approach that allows any of our employees to have seamless access to care based on their needs and preferences.

Some people might want to speak with a spiritual health provider, such as a chaplain, as opposed to speaking with a behavioral health provider. Someone else might want self-help resources, and another individual might want to speak with a therapist. The question became: How do we make sure that we do this in a way that helps everyone and is easy for them?

The first thing we did was we partnered with the Providence Digital Innovation Group and created an accessible and easy-to-use online stress meter on Providence's website (www.providence.org/stress). Essentially, you ask people how they are feeling that day, how they are doing and they begin by clicking on an image that rates their stress. Based on where they click, appropriate resources pop up and guide them. For example, when they click on the mild stress range, self-help resources and other similar tools appear.

How did Providence employees respond to this?

The stress meter proved extremely successful and has already been used more than 30,000 times. We found early on that many people who are in the "mild" stress range preferred self-help tools, so we partnered with UC Berkeley's
CredibleMind group, which has compiled a resource repository. For example, you could say, "I want help with anxiety during a pandemic, and my preferred medium of learning is a podcast." You put those filters in, and it gives the best options recommended from experts in the field.

We found in the early months of the pandemic — and unfortunately, we are seeing it again now — that the most common search topic for self-help was "compassion fatigue." So, we guided people to resources for this. We also added other resources like computerized cognitive behavioral therapy (CBT), which we found was something that allowed people working long shifts, such as residents, to use on their own time.

What is computerized cognitive behavioral therapy?

Computerized cognitive behavioral therapy is just like the CBT therapy you would get in an office with a therapist. There are multiple weekly modules that are taught with videos and worksheets that people can use on their own time. They also take self-assessment tests to gauge their progress and have the option to use a coach if they like. Essentially, it offers the same level of therapy that you would get with a therapist, but you can get it through a computerized module on your own time.

What about those employees who aren't asking for help but clearly still need it?

This was a very big concern of ours. We recognized that for most people in health care, help-seeking behavior doesn't come naturally. They are used to being on the front line, and there's a stigma there — a sense that it might be selfish to ask for help — so they continue to suffer in silence.

So, while we are meeting the needs of the small subset of people who are raising their hands and asking for help, how do we lean in and support all those who might not be seeking help and support them in ways that will be beneficial and really take that to the next level?

One way we did this was to support our core leaders. They have the toughest job in the world: they have to manage up, manage down and manage sideways. They are human, so they are going to be stressed dealing with all that is going on. How do we really support them in a way that can enable them to do better and to give them practical tools to support their teams?

During the pandemic, we focused on a few areas that were very high stress and started a pilot program called "No One Cares Alone." We reached out to core leaders in high-impact areas: medicine, medical staff, nursing staff, environmental services, respiratory therapists, security and the like. These are different groups that are having different stresses. Wellness consultants would meet with the core leader to gain an understanding on how they were doing while also understanding how their team was doing and what their stressors were. Questions included in these conversations included "What matters to you?," "What matters to your team?" and "What are the pebbles in your shoes?"

When you're in a crisis, it can be really hard to navigate. How do we train our workforce to become the most mental health literate company in the world, so we can all truly look out for each other and have real conversations? How do we train people to have a conversation when someone looks like they are withdrawn or struggling and really connect with and support them?

As the pandemic has dragged on, what have you learned from some of the original approaches and how have they evolved?

This outreach under "No One Cares Alone" was very successful early in the pandemic. But we realized that there were limitations in what we were doing. As we have moved forward, the program has evolved. We've created a core team that now includes chaplains, behavioral health providers and consultants because there were complimentary skill sets that were missing in the first iteration. When you bring these together, it is so much more powerful because there are certain skills that chaplains, for example, can bring, such as being present and supportive listening.

We hope to continue to improve on this over time, to be more targeted and focused to better understand how we are driving real change. Sometimes, the wellness consultant might not be in a position to solve the issue — it might be staffing or something else. So we want to have a pathway to communicate that, to find a way that we can organize that information and then share that with our workforce council and other leaders who can make those decisions.

The pandemic has been tough on everyone but especially employees. In some extreme cases, it has meant people taking their own lives. How is Providence responding to that?

During this difficult year, we unfortunately lost some of our caregivers to suicide, and this has been very painful. This was across the board. We lost physicians, nurse techs and nurses across all regions, and this was very distressing for us. For us, it was a call to action.

We started doing more research and delved into the following question: What is the best science that we can bring today to prevent deaths by suicide and promote mental health among our workforce? This is where we did some work with the Institute for Healthcare Improvement. We are continuing to partner with other groups as well, like the American Hospital Association and the American Foundation for Suicide Prevention. We know we can't do this alone. Together, we are stronger. The Catholic Health Association's Well-Being Task Force, which I serve on, has also been very helpful. All of us are struggling, and we're all in this together.

We're literally writing the textbook while the disease is unfolding. It's not simply recycling wellness offerings from the past but rather learning what health systems across the country are doing in the midst of the pandemic, what people are doing and what are the best practices. Bringing that together allowed us to understand what the psychological equivalent of personal protective equipment (PPE) is. Everyone is careful to put on their PPE when they are caring for patients, but what about when it comes to their mental health?

Can you talk about Providence's partnership with the American Foundation for Suicide Prevention?

As part of our work with the American Foundation for Suicide Prevention, we are using a program started at the University of California San Diego. Many years ago, they unfortunately lost many of their providers to suicide and as a result, they implemented this program that led to a significant decrease in the number of deaths by suicide.¹ That program is something that we have been deploying in our system at Providence. The first part provides education and a destigmatization campaign through which we normalize help-seeking behavior among our health care workforce. This is done by creating a lot of different educational content around mental health in the context of work life, relationships and family. We are also making sure that trusted leaders talk about why their mental health is important and what they are doing to take care of themselves — in other words, we normalize it. We have been blessed that our CEO is so passionate about this. He even made a video and said why this is important for him, which really helps. From July to October of 2021, we had about 48,000 views of mental health content.

What is really exciting to me is despite all the stress that people are going through, the most viewed video was around the following question: How do I help my peers? Even with the pandemic, helping others is still where our caregivers are focused and the core of who they are.

We're all used to getting an annual dental or medical physical exam, so we have added the equivalent with a mental health checkup that's conducted anonymously and confidentially in partnership with the American Foundation for Suicide Prevention. It takes about five minutes, and people can log on and do it confidentially. It covers areas like depression, anxiety, PTSD and suicidality. If you have a high level of suicidal risk or emotional distress, you are in a certain tier, and every one of these assessments is reviewed anonymously on the back end by our therapists. We have trained therapists going through these, providing the employee with compassionate personalized feedback and offering help if wanted. So there is engagement back and forth within the platform. Every single person is communicated with, responded to by a therapist and receives a personalized response within 24 hours. We connect people who are in a crisis or higher level of emotional distress to other services as well.

What about organizations without as many resources dedicated to mental health? What do you recommend they do?

One of the lowest hanging fruits is connecting employees to whatever resources are available in an intelligently curated way, putting it into something like the stress meter, for example. It doesn't take a lot of effort and could be done in a straightforward, meaningful way.

I think that is foundational because it's hard for people to raise their hands and ask for help. The worst thing we can do is when they ask for help, that we're not available or not able to help them. We all need to double down and make a commitment that somebody is there.

Also important is normalizing help-seeking behavior. So truly destigmatizing, sharing informational content and frankly talking about it is vital to accomplishing that. Everyone, including the top leaders, needs to be able to openly talk about why their mental health matters. When they do that, it gives people permission to be vulnerable and comfortable to share and talk about it. If there's nothing else you can do, just show up for one another. We're all human and we can connect with each other.

ELIZABETH GARONE is a freelance writer who has covered a wide range of health, business and human interest topics. Her writing has appeared in The Wall Street Journal, The Washington Post, BusinessWeek and The Mercury News, among other publications.

NOTE

1. Christine Moutier et al., "The Suicide Prevention and Depression Awareness Program at the University of California, San Diego School of Medicine," Academic Medicine 87, no. 3 (March 2012): 320-26, https://doi.org/10.1097/ACM.0b013e31824451ad.