Module 5: Trauma, Violence, and Cultural Safety – Topic E Provide welcoming processes, safe spaces, and culturally safe care to persons using opioids and those with opioid use disorder.

Learning Objectives

By the end of this topic, the student should be able to:

• Explain what compassion is and describe why it is critical to providing care.
• Recognize that relapse is common, and recovery can be a lifelong process.
• Describe how the concept of confidentiality informs a safe space.
• Recognize the importance of language to create an emotional space of comfort.
• Recognize that a welcoming and safe space can include physical and emotional factors.
• Integrate cultural safety into developing a welcoming and safe space.

Key Concepts

• The use of compassion by service providers has been empirically shown to result in better outcomes for the people accessing services.
• Confidentiality is a cornerstone in all therapeutic relationships and critical to establishing trust.
• Language, both oral and written, can further stigmatize and cause harm through re-victimization.
• Welcoming physical space is important to create an environment that promotes a feeling of safety.
• Practising cultural safety to ensure people of all cultural backgrounds feel safe and respected when accessing health and social services is crucial for effective care. This involves doing personal critical self-reflection on what people bring to the workplace, understanding the influences of dominant Western/White culture on other cultures, recognizing personal biases and assumptions pertaining to other people, and reducing assumptions made about others based on those biases.

Importance of Compassion

Compassion is different from empathy, which is the ability to put oneself in the other person's place. Compassion has the additional component of having a desire to alleviate or reduce the suffering of another. Having compassion can lead to feeling empathy.

Cassell (2009) reported the following three requirements for compassion:

• understanding that the situation the other person experienced is serious,
• that their experiences were outside the individual’s control or choice, and
• that the experience is relatable: “It could happen to me.”

Compassion is not an automatic response to another’s plight; it is a response that occurs only when the situation is perceived as serious, unjust, and relatable. It requires a certain level of awareness and concern.

Relationship Between Compassion and Care

Compassion involves active listening, which relays to the other person that their narrative/story is valid and important.

Studies have shown that compassion can:

• reduce stress and anxiety,
• result in positive cognitive restructuring from trauma experiences by removing feelings of guilt and shame,
• contribute to the building of resiliency and acceptance, and
• promote connection, trust and a feeling of acceptance and safety.

Relapse Prevention

Relapse, or reoccurrence of a specific past condition such as alcohol or other drug use, is common. When it occurs, it can reveal something new about the persons’ change process.

Focusing on the successful part of the plan (“You did it for six days; what made that work?”) shifts the focus from failure, promotes problem solving, and offers encouragement.

Relapse prevention (RP) is a strategy to reduce the likelihood and severity of relapse. RP is a cognitive behavioural approach used to identify and address high-risk situations with two specific goals:

• to prevent an initial lapse and,
• if an initial lapse does occur, to prevent further relapses by developing healthy coping skills.

Because of the high likelihood of lapse or relapse after formal treatment ends, RP prepares the individual to anticipate and cope with challenging situations upon returning to their former environment.

NOTE: Recovery can be a lifelong process of personal growth. It takes commitment, work, and support to continue new behaviours and ways of thinking.

Relapse Rates in Canada

Relapse rates after opioid detoxification are known to be very high. Relapse rates after stopping opioids can range from 72 to 88 percent after 12 to 36 months. Factors contributing to relapse commonly include:

• lack of supportive social networks,
• inability to obtain safe and stable housing,
• limited access to mental health professionals for emotional support,
• barriers to obtaining and maintaining employment, and
• low socioeconomic status.

Importance of Confidentiality

One of the most important elements of creating a safe space relates to confidentiality.

NOTE: Confidentiality is different from privacy.

Privacy is the right of an individual to determine when, how, and to what extent they share information about themselves with others.

Confidentiality involves the practitioner keeping the person’s information private. It is critical because not sharing or disclosing a person’s information recognizes and respects that the information belongs to the person and encourages a relationship of trust and safety.

Confidentiality allows for the free flow of information by the individual knowing the other person is fully engaged, actively listening, and committed to not sharing the information without consent or only under certain conditions required by policy or law.

It can be frightening for someone to seek counselling or health and social services; knowing that personal information will not be shared can promote a welcoming and safe space.

Importance of Language

“It's important to understand the power of language, and the impact it can have, both positively and negatively, on someone who is struggling with a substance use disorder," said Dr. Heather Fulton. "For example, if you say 'a mother who is a struggling alcoholic' we are missing the other important part of a person's identity. If we use stigmatizing language, it could deter someone from seeking help or staying on their pathway to recovery.”

Language is a critical part of creating a nonjudgmental and safe space for people. The BC Mental Health and Substance Use Services (2017) suggests the approach outlined below.

Adapted from BC Mental Health and Substance Use Services, 2017

Importance of Physical Environment for Safety

How a physical space is structured, decorated, and organized can create a feeling of safety and calmness.

Tips for health and social service providers to create a safe and welcoming space:

• Create a space that feels open and has sufficient light – preferably natural, if possible; otherwise, soft lighting through lamps versus stark florescent lights.
• Be mindful of the textures used in the room; research shows that when natural wood surfaces like floors and walls exceed 45 percent of a room's surface, they can actually induce a feeling of stress.
• To support a need for control, space should include chairs that can be moved or are large enough to let people shift to one side or the other and adjust the distance between themselves and the health and social service provider.
• Chairs with backs at shoulder height can facilitate a feeling of protection.
• To promote a sense of personal safety, you can place a plant behind the chair and position chairs so clients can see the door.
• Place small tables next to chairs to enhance a person' sense of "territory" by giving them a place to put personal items.
• Encourage clients to sit where they think they might be comfortable; for individuals who have trauma or abuse in their past, a clear exit is important in order to relax and feel safe.
• Include cultural artwork and display welcoming signs specific to diverse groups (i.e., LGBTQQIAAP) can help to make people feel accepted, respected, and safe.

Importance of Cultural Safety and Cultural Humility in Creating Safety

Culture is lived and ever-changing. It is a relational experience shaped by a person’s history; their past experiences; social, professional, and gendered location; and their perceptions of how they are viewed by others in society.

Different cultural groups conceptualize health differently, people’s culture shape:

• health behaviours and lifestyle,
• health beliefs, and
• response to health directives

Therefore, it is important to consider culture when providing health care.

NOTE: Being aware of culture and difference does not mean focusing on learning about the culture of the other. Rather, health and social service providers need to engage relationally to understand the person accessing services.

Cultural safety is about recognizing and working to counteract the everyday impacts of social inequities on peoples’ lives.

The following are some key features of cultural safety:

• It shifts the provider’s attention away from cultural differences as the source of the problem to the culture of systems of care, where inequities are sometimes perpetuated.
• It places responsibility on the provider to create culturally safe interactions and environments.
• It draws attention to the power imbalance between the person coming to services and the provider; the provider needs to recognize and minimize this imbalance. One way of doing this is recognizing and working with the person’s agenda and strengths.
• It expects the provider to actively counteract racism, stigma, and other forms of discrimination by questioning stereotypes and acknowledging the impacts of structural violence within the work environment.

Cultural humility is a provider’s awareness of their own limitations as a provider regarding what they can actually know about the culture of another person. Because culture is a lived, dynamic experience, it can only truly be known by the person themselves.

The goal of employing cultural safety and humility is to avoid cultural stereotyping and understand the influence of culture on a person’s identity so that culturally appropriate and culturally safe interventions can be applied.

By understanding and engaging in the cultural context of a client, a health and social service provider can ensure better client satisfaction and adherence, and therefore improved health outcomes.

Addressing their own intrinsic biases will help health and social service providers avoid applying negative stereotypes to their clients.

NOTE: Cultural safety is inextricably linked with trauma- and violence-informed care. Drawing on both approaches in tandem will help to ensure that clients receive appropriate services in ways that are emotionally safe and respectful and reduce harms.

Questions

Are confidentiality and privacy are closely related concepts and can be used interchangeably?

a. Yes, these terms mean the same thing.

b. The terms are closely linked so it’s fine to use them interchangeably.

c. No, these terms are different.

d. It depends upon the context.

Correct! Confidentiality relates to the free sharing of information knowing it cannot be shared without consent; privacy is the right to control how much information is shared. Both are important to create a safe space.

Incorrect. The correct answer is c. Confidentiality relates to the free sharing of information knowing it cannot be shared without consent; privacy is the right to control how much information is shared. Both are important to create a safe space.

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Does relapse only happen in substance use treatment? (Select all that apply.)

a. Yes, it is specific to substance use disorders.

b. No, it is part of all chronic conditions.

c. It depends upon the individual, not the disease.

d. Yes, but only to individuals who use methadone.

Check

Please select an answer.

Correct! The stage of lapse and relapse is part of all chronic conditions where behaviour is a component of recovery. Individual differences regarding etiology and cause for the substance use means that relapse does not occur for all individuals, but for 40 to 60 percent of people, this stage will occur.

Incorrect. The correct answers were b, and c. The stage of lapse and relapse is part of all chronic conditions where behaviour is a component of recovery. Individual differences regarding etiology and cause for the substance use means that relapse does not occur for all individuals, but for 40 to 60 percent of people, this stage will occur.

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Evaluate: Although compassion is nice to receive, there is no empirical evidence that it results in better outcomes for people.

a. True

b. False

c. Depends on the context

d. A personal preference

Correct! Studies have shown how the act of compassion reduces anxiety and stress in others, which improves their outcomes.

Incorrect. The correct answer is b. Studies have shown how the act of compassion reduces anxiety and stress in others, which improves their outcomes.

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Which of the following is NOT one of the three components of compassion?

a. The situation the person experienced is serious.

b. Such experiences were outside of the individual’s control.

c. The same experience could happen to you.

d. You have been educated in compassion.

Correct! Compassion cannot be taught but is an innate ability that can be enhanced and practised.

Incorrect. The correct answer is d. Compassion cannot be taught but is an innate ability that can be enhanced and practised.

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True or false: One of the best ways to understand a person’s cultural identity is to do a cultural inventory.

a. True

b. False

Correct! The best way to connect with a person’s cultural identity is to connect with a person relationally—respectfully, without judgment, to listen. We have an opportunity to create a cultural moment with people in every interaction.

Incorrect. The correct answer is b. The best way to connect with a person’s cultural identity is to connect with a person relationally—respectfully, without judgment, to listen. We have an opportunity to create a cultural moment with people in every interaction.

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References