Written by: Center for Care Innovations

We’re talking about the 4 R’s framework which covers the different phases of the pandemic: readiness, response, recovery, and renewal.

Our hope is that this scaffolding can help health centers and other safety net organizations navigate the crisis. This episode features a conversation between Drs. Irene Sung and Ken Epstein, two coaches for CCI’s Resilient Beginnings Network.

Listen and subscribe to our podcast on Apple PodcastsSpotify, and elsewhereBelow is a transcript of the episode, edited for readability.

CCI: I’m Alexis Wielunski, I’m a Program Manager at the Center for Care Innovations. Today, we’re talking about the 4Rs Framework which covers the different phases of the pandemic: Readiness, response, recovery and renewal. Our hope is that this scaffolding can help health centers and other safety net organizations navigate the crisis. I’m here with Dr. Irene Sung and Dr. Ken Epstein, two of our coaches for the Resilient Beginnings Network, a partnership between the Center for Care Innovations, Genentech Corporate Giving and 15 Bay Area safety Net Health Systems. The Resilient Beginnings Network is a learning program dedicated to advancing pediatric care delivery models that are trauma and resilience-informed. And today was my son’s second day back in the classroom in over a year, and he just got back from school.

IRENE SUNG: Alexis that’s wonderful. This is exactly what we’re talking about. We’re talking about moving back into renewal which is definitely one of the pandemic cases. I am Irene Sung, I am a Child and Adolescent Psychiatrist by training, and recently retired from San Francisco’s Department of Public Health where I’ve held multiple roles both as a child psychiatry clinician and up into leadership positions including overseeing behavioral health services.

KEN EPSTEIN: Alexis, congratulations about your return to school, I can’t imagine emotions of having your child back in school. I’m Ken Epstein, I’m a social worker, I had the honor and opportunity to work with Irene for almost three decades.   I have worked in both the nonprofit and public sector as a clinician leader and clinical faculty

CCI: Thank you both for being here. I’m really looking forward to this conversation. We recently marked the one-year anniversary of the COVID-19 pandemic. So in that context, tell us more about the four R’s and why are they important?

KEN EPSTEIN: So, let me just start by saying, when last March came and soon after, I remember a lot of folks, Irene, saying that we all were experiencing this common adversity. That we all now for the first time, we’re experiencing something the same. And I want to start by saying that this year has been a year like no other. And for many people, this year has been a year like every other. As a white man, as a person with privilege, I have experienced adversity. And at the same time, for those people with less privileged black and brown folks, this year has represented a year of both, a year like no other and a year where the inequities that are experienced by folks that are at the margins or disenfranchised have been shown by COVID and all of the other events of this year. When Irene and I got together last March, we were operating under the idea that we really needed to think about what are the phases of a pandemic, and we looked to and across the country and there was the Missouri Model of Pandemic Response which had readiness, response and recovery. And then we found the school model, which is about school violence that had renewal. I think today’s talk Irene is really to talk about our work and our transformation around thinking about the 4R’s.

IRENE SUNG: So I appreciate that Ken, because I do think that everyone at the very beginning was saying, “Oh, we’re all in the same boat.” That was the concept and as we were talking with different organizations, really shifted that from… “We’re all in the same storm but we’re in very different boats.” And that’s really important to remember of it. Some of us have very big cruise liners to weather the storm and then some have little dinghies and so it’s just important to remember. The four stages of the pandemic… And if you Google it, you’ll see multiple stages. And we really were focusing on what are the emotional stages of the pandemic to help understand because as people were traveling through, people were moving so fast and things were getting so chaotic and then what we found helpful is to build some cohesion around understanding what people were experiencing as a way for them to move forward.

So the four stages if we go through them one by one, would be what you described: readiness, response, recovery and renewal. Readiness is what we all understand. We at some level or another get ready for something. In California, I think everyone knows how to get ready for an earthquake. Everyone has heard duck and cover, for example. Some schools have prepared for school shootings and have created some readiness aspects to just be ready to respond. I don’t know how ready we were for global pandemic, but we understand the concept of readiness.

When the pandemic hit and became more spread, people moved into response mode. And response, they had to move very quickly. And you saw health care organizations move very quickly. Electronic health records are up so that staff could provide telehealth from home. Moving to online care. Insurance companies and other organizations are allowing for online care to be provided to their members. There’s so many things that happened during response very quickly. And I think that that response was amazing, it was quick, but also created a lot of stress for staff.

Now recovery is a point where you start to get to a place of evenness, like you responded, and then you will recover a little bit, build some schedule for yourself, build some sort of way of doing your work, some sort of workflow that actually creates some sense of like… “Okay, I can do this and I can sustain this.” And then the last piece of renewal, is being able to look back at what you’ve learned through the process and understand what worked and what didn’t. So, things were not perfect before we went into response mode, but there are things that work that we want to hold on to.And then there are some things that we’ve learned that maybe we also want to hold on to or we want to create in the phase of renewal so we can get to a better place for ourselves, for our patients. So that is the cycle that we are talking about and we are helping people understand so that they can have some cohesion when they think back in like, “What did I just experience?”

KEN EPSTEIN: Irene you started by saying we took these ideas from places that saw these as a substance or common areas where readiness could be… “Do you have protocols and procedures? And do you have in place a way to deploy them off? And do you have in place as it turned out the ability to test or vaccinate?” There are a number of ways in which disaster response people would look at readiness. Recovery might be your ability to mobilize quickly, to be able to move quickly and it’s a very top-down approach and response would be that. And recovery would be practical sense… “Are we getting back to quote unquote normal?” And renewal, what do we want to keep. From a psychological perspective, Irene, which is where you started, renewal is a little bit different. I was thinking as you were talking.

I remember on March 6 being in the airport and I remember at that point, Wuhan had happened and there had been an outbreak in Washington State and there was an outbreak in New York. And I remember seeing people in the airport with masks. And I was thinking, “Why are they wearing masks? I don’t know why they’re wearing masks.” Well, it turns out that the people that were wearing masks were ready. They had experiences or understood the pandemic psychologically. I was not ready psychologically to wear a mask. Now we know that it’s been a debate across the country around masks and when you think about it, we didn’t get our country psychologically ready to wear masks because many people were provoked about being on one side or the other of it.

Was I psychologically ready? The answer would be no. I was not. It was a shock. I’d never been in a pandemic before. And if you’re a leader or you’re physician or you’re a nurse, the question is, you probably or might have been ready from a protocol perspective but were you ready from a psychological perspective? And what we learned is, we were not. And we did not think about that. And if you think about response, were we ready psychologically for what it would take to give up and lose the things we had to give up and lose to respond? Not seeing people, not being able to go to funerals, not being able to go to weddings, not being able to go to work. The things we had to lose and the collective grief we experienced as a nation and as a people which was increased dosage wise by based on inequities, that collective grief that rose in the response level was unaddressed.

And so as people were responding protocol-wise, they weren’t addressing the collective grief. And you begin to see the generation of rage and all sorts of feelings that come out that Irene and I have been navigating with healthcare professionals across the state and the country. And then you think about the recovery phase. Well, the recovery phase from protocol would be, “I got back to work, I’m not deployed anymore.” Recovery is also about, how do I heal from the wounds of what happened during this time? How do I attend to the staff that are alienated and disassociated? How do I tend to the folks that have been dealing with their kids and their family and their homes? And then the renewal phase is, well, I learned some things about myself, and my resilience, and my work, and what we’ve done that are amazing. And can we keep it? Will somebody support it? I’ve learned that I can actually work from home and be at work or I can work differently. And can I keep it?So when you think about those phases structurally, you think about them as practical. When you think about them psychologically, we begin to think about the workforce. And we need to attend to our workforce around these phases. Otherwise, we will and we’re already experiencing the kind of burnout, and trauma, and crisis in our workforce that we’re seeing in nurses leaving their jobs, people feeling extraordinary stress, teachers not wanting to go back to work and so on and so on. Because we need to attend to the psychological impact of this crisis.

IRENE SUNG: You made me think Ken, also about the importance of the phases and understanding it’s not going to necessarily be linear, you don’t move from one to the other, you can move back and forth. And one of your staff can be in one phase and you could be in another phase and to make sure you keep that in mind as you have the conversation because you can’t rush renewal. You can’t just move into… “Okay, what have we learned? Are we going to do something great?” without attending what Ken said, to where folks are in a process. And so to really be mindful of that especially as leaders, to not just push it forward, to actually step back and pay very close attention to what’s going on for your staff.

CCI: So the phases of the pandemic are readiness, response, recovery, renewal. Why is it so hard for organizations to move past the second R? Why is it hard to get past the response phase?

IRENE SUNG: Well, I think one piece is things keep happening. So first, I was talking with an organization who’s up in the North Bay and they say it’s kind of one thing after another. And so there’s the pandemic and then the Black Lives [Matter] and racial reckoning, and George Floyd and that, and then the wildfires that they have to deal with. And then the election, and then the insurrection, and now the anti-Asian violence. So it’s constantly being bombarded with things that keep happening that you have to keep responding to. Some of it is not logistic responses, it’s just psychological response, another thing to have to deal with.

And then they’re the good things, but there’s still things that respond to like the vaccines, the healthcare organizations, they have to figure out how we’re going to roll this out. And how do we do it equitably? So I think that is one thing that is making it harder for them to feel they can take a moment to recover.

KEN EPSTEIN: I so appreciate that story Irene about the ongoing stress. And I was thinking as she was saying that story that the truth is, we may not do something about it. But if things were radioactive, we would understand as a country that that radiation is bad. And if there was lead in our water, or in our houses, we would understand that would be dangerous for our health. What Irene is talking about is, the stress that is related to an unending amount of traumas that have happened in this country in the last year, that have escalated as I said in the beginning, and already existing trauma of inequity in our country and structural and historical racism. So I think the question is, why it’s hard to move from response to recovery, it’s hard to listen to the pain. It’s very hard for people to reflect in reactive spaces. They often say our organizations are reactive places. And yet change only takes place in reflective spaces.

So unless we find reflective spaces and reactive places, we won’t find the place or the ability to listen to the pain. There’s a book written by Terry Gross that she said, “All I needed to do was ask.” I think it’s something like that or, All I Did Was Ask.” I often feel like that way after I work with an organization that I have one prompt, and I say something like, “How are you holding up? Or what’s on your mind?” And an hour and a half later, people are telling their story. They’re beginning to be heard. And why are they doing that? They’re doing that because we need to keep in mind in general, trauma destroys relationships. We’ve been all about self-care. And self-care is important, am all into self-care. But the idea of self-care, is that I’m going to go out and do something by myself. And I found if I’m not doing it in some way, I should be shamed or blamed. And if I’m doing it, I’m actually getting better. But the truth is, that’s important but not essential. What’s essential is that we collaborate, that we’re in it together, that we’re coming up with solutions that are inclusive and together. So the recovery phase is complicated because the recovery phase is about recovering from the psychological sequelae, of being in a collective trauma. And we need to address that with all of our knowledge, that trauma happens in the context of relationships and it’s healed in the context of relationships.

IRENE SUNG: I think to even just this morning Ken, we were working with an organization, there is this phase of allowing people to tell their story, it’s just so important. There’s just so much relief in it. And it makes me realize how little space there is for just telling someone how it is you’re doing and how it is that you’re feeling, how it is that you’re holding up through this process. And it seems surprising, but it’s true. We just say, “How are you doing?” And the response is fine or good, and that’s it. But if you actually allow people the space, there’s a lot of healing that can happen just in that. So you don’t have to be a professional to actually ask them how they’re holding up. This connection can happen day to day with all your co-workers, with all your loved ones, it can happen and that’s going to add to moving away from response and recovery.

KEN EPSTEIN: And one thing I just wanted to add Irene, I’m so glad you said that thing because I don’t know about you, but I can’t tell you how many times as a leader, somebody said, “Oh, you’re such a clinician.” Or, “I can’t do that, that sounds like therapy.” And here’s two things about that. One is therapy works. And so the point is that, it’s good to think about how we heal in the context of relationships. So we all should learn it. If we wanted to learn first aid around the cut, we’d want to put a Band-Aid on it. If we want to learn a first aid around healing, we should put a relationship around it. And so in that sense, everybody should learn it. Should be a skill for everybody. And I think Irene you said it straight up, it doesn’t take a degree to ask you how you’re holding up, sit forward and listen, and tell somebody, “Thanks for being comfortable enough to share that with me.” Because people say, “Wow! Did you just see their shoulders go down?” So it’s so important.So I still appreciate that in terms of the skill set is one in which does not have to be embedded in a therapist or a psychiatrist or a social worker, but one on which all of our professionals should be helped to ask those questions. And it’s the core of recovery.

CCI:So I’m wondering how do we get from where we are now, into this place of recovery and renewal? Are there specific practices, trauma-informed practices, or things that leaders could be doing at a more organizational level to help move through those phases?

KEN EPSTEIN:I want to just give a cautionary tale and then next step. And the cautionary tale is that, we’re a people that are looking for simple tools, and step by step processes, and ABC’s. And this sort of an expectation that everybody is going to go through this process the same way. And I just want to be very clear that there are so many responses to what’s happening. And if we begin to punish someone’s response because it doesn’t fit the organizational tool that we’ve developed, we’re going to be our own worst enemy. And I worry about that. I worry that you’ll go to the airport, and there’ll be the 10 steps to recovery, the six steps to… You’ll see a series of books about: I succeeded because I did these five things, there’ll be a formula for this. And I really worry about simple solutions to complex problems.So even in answering your question, I want to humbly say, I wish I could answer your question with a simple formula because I don’t think you can solve complex trauma, this kind of collective trauma, this kind of collective grief, with simple solutions that will come up with simple answers. So that’s my caveat to answering your question

IRENE SUNG: I’m going to jump in before you move on because I want to second that, and to say there are tools, but these tools should be used in the context of your own humanity. So if you are someone who is in a leadership role in particular, to make sure that you spend time reflecting and spend time in really deep observation of what’s going on with your staff, and making a decision to be trauma-informed in your actions. So this is the piece that you can’t script it. You’ve got to be you, and you’ve got to be careful not to react, but to make sure you’re reflecting and observing what’s going on around you. And if you’re not sure, don’t move to do until you actually check it out and you connect with people to make sure that you’re not moving too fast.

KEN EPSTEIN:I do think there’s plenty that organizations and teams can do. And many of them are doing it already. Many organizations are reaching out and have been incredibly creative during this time and all along. There are three things that I’ve heard from people over and over again, as I’ve gone around. One is people are exhausted, physically and emotionally exhausted. The second is, they’re overwhelmed. Because their lives have changed so dramatically, and their jobs have changed so dramatically. And the third is, they’re confused and scared about what’s happening and what’s going to happen and what will happen.

But I want to talk about three R’s and three C’s.Three R’s besides, we talked about four R’s in readiness, response, recovery, and renewal. If you have a workforce that’s exhausted, dysregulated, and overwhelmed, you actually want to figure out how to build in rest, you want to figure out how to build in recalibration, and you want to figure out how to build regulation. What I mean by those three things… And I’ll talk about some practices that you can do it, what I mean is that, telling somebody they can go on vacation, or they need a vacation, and then giving them more work does not create rest. So structurally, organizations need to think about how to build them.

I actually know Alexis that your organization recently gave you two days off, for example, right? Because they knew that people were getting vaccines. And they knew that there would be side effects. And I thought that was really just incredible foresight of an organization. Organizations are doing things like that, many are not. And so I get a vaccine, I have an aftereffect, I’m still working, and there is no recognition that we’re trying to do that at the same time. So understanding that we need rest, and we need time off, the second thing is we need to recalibrate. Because if we’re going to experience rest, we need to think about those three jobs we took over in March, the four people that weren’t hired, and ways in which we’re deployed or still deployed, we need to think about what is a job at now, 13 months later, and how are we going to do that in a sustainable way? Because the job I had in March is not sustainable.

Examples, just many of us… I mean, last week sadly, I spent 19 hours on Zoom between Monday and Tuesday. That’s my own choice but the problem is that the workforce is doing that over and over and over again. There aren’t breaks between Zoom. So I saw that UCSF put out a memo last week, that all meetings should be 50 minutes, and there should be a 10-minute break between the meetings so that people actually have a time to recalibrate, to rest and not go because now more than ever as we’re not commuting, we’re not resting. There was a way in which even if I walked to Irene’s office, it was a two-minute walk, but I had a two-minute walk to Irene’s office. Now I want to talk with Irene, we’re zooming at 9:00 at night and 10:00 I’m going to bed. So it’s just the world has shifted because we have this access to each other, so we have to take that into consideration and recalibrate.

And then we need to regulate, we need to build… Then what I mean by regulation is that trauma causes dysregulation, dysregulation causes symptoms like my breathing, my tightness in my neck, biting my lip I get an embodiment of trauma and it makes me not well. And so we have to help our organization regulate which means that we have to do things that help people organizationally calm down. So I’ll give you the three C way of doing that. The first one is connection. There are actual things you can do about connection even on Zoom. There are people doing creative things like random coffee check-ins on Zoom, if we’re on Zoom. Somehow we have to create the water cooler. We have to recreate walking by in the hall. You can’t do it the same way. Some people are having outdoor meetings if they’re allowed to have it.

The other connection activity is checking in. Because if every meeting started with something, not a 50-minute check-in, but a mindfulness check-in or something that gets people in the room, in the Zoom, in the place, even if you’re working on site that gets you regulated so that before we start talking about the budget cuts in the new memos, and all the things that are going on, we’re trying to bring people in the room so they’re off their emails, off their tax, and with us. It’s very important to be in this space. Other connection activities could be acknowledgments, gratitude practices. We did a gratitude practice today with a group and you could just feel the whole tension of the group shift. Irene and I did this. It was the last six minutes of the meeting, it was a very… I’d say intense meeting, lots of feelings. And then the gratitude practice you could see people saying gratitude to each other, or their mom with a team, and they’re regulated. And so they can go on to the next thing.

Do not send your work staff out after a meeting, or supervision, or an activity, just regulated. Doctors can do it with each other, and nurses can do with each other. So that’s the connection activity. And there are many others you can do, acknowledgement practices, you can have people’s start each day having a theme. There are lots of creative ideas and many of them we have on our website.

The second one is coherence. Now coherence is really about there being spaces to reflect. As you heard me say before, we live in reactive places, we need to create reflective spaces. This means that in our organization during our workday, not after, not as homework, not on the weekends, not in the middle of night when I’m waking up, but in our organization, we need to figure out places and spaces where people can have reflective practice. They can talk about what’s going on for them and not be told that it’s not going on or they don’t have time for that. Because now the more we reflect, the more we can reintegrate and become part of and become more coherent. And the more we reflect, we can make sense out of the chaos. So it could be a 20-minute check-in about what’s on your mind, It could be a 10-minute conversation, it could be an email, asking somebody how they’re doing, or it could be as Irene said, “Tell me a story.” Let me hear or remembering that somebody’s kid went to school to stay, or that they missed their child’s graduation or wedding. Those are all things that build coherence to the chaos. And our workforce and our organizations have to honor that and create space for those stories to live and breathe and be honored.

And the third one is collaboration. And there are many specific strategies you can use around collaboration. A collaboration embedded in collaboration is inclusiveness. And remember that we have been in a very top-down environment. The new mandate, the new deployment, you have to get here, you can only get vaccinated if you’re this age. Each day we’re looking for the new rules. Inclusiveness is finding those places, those spaces where when you have a meeting you can invite people’s opinions and listen to those opinions, repeat them back and allow for voice and choice to be part of our lives again. Because once we’ve removed voice and choice, we’ve actually removed our feeling of being included in and now we’re excluded, and now it’s us versus them, and our anger generates into a much…

And another area of collaboration is being able to engage in people’s pain, and understanding it and responding to it. So many strategies around collaboration, or even concrete strategies around collaboration, is like asking if they have to return to work, asking people how they want their worksite to look, giving them some sense of ownership or agency about coming back into the office. Just those kinds of things makes me feel more part of the process, as opposed to just going back to it as if nothing has ever happened. So those are some of the practices, there are many concrete practices that organizations can use.

CCI: So with our just last couple of minutes left, is there anything else that you had wanted to say in this conversation?

IRENE SUNG: I think the only thing that I would add is that this actually does take some courage, to be able to sit with people’s pain and not… That’s what I’ve heard some leaders say like, “I kind of don’t want to ask that question, because I don’t know if I’m prepared to hear the answer.” I don’t know what to do with it. And so I just want to reiterate what Ken said, is just to thank you for letting me know. Thank you for sharing. That in of itself can be healing, without having to… Again, you don’t have to have any special words or strategies to take away the pain because I don’t think we can expect that we think we can take away someone’s pain. You’re there with them and you’re not going to run away from it.

KEN EPSTEIN:I believe with everything that we’ve talked about, as difficult as this year has been, as difficult as it is to understand and then address the inequities created by white supremacy and our institutional ways of creating bias, I have so much hope for the generation coming up, and the kinds of conversations that are taking place and the integrity and curiosity of leaders these days to try to do something different. There’s hunger among healthcare professionals for more than the simple answer. And it’s really the first time in my career I’ve seen this level of interest and desire to change really structural issues, and how our organizations are organized, constructed and are implemented.

And so in every crisis, there is an opportunity and I do think there is an enormous opportunity for us to seize this moment and follow the workforces lead and really build new organizational structures that are more humane, more attentive, and less inhumane. So I feel very hopeful from what I see and hear as we move forward.



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