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elisa-ventur-bmJAXAz6ads-unsplash.jpgIn 2022, the U.S. Surgeon General issued a report about workplace mental health and wellbeing. Many ‎of you will not be surprised to learn that in a survey of 1,500 U.S. adult workers across for profit, non-‎profit and government sectors, 76% of respondents reported at least one symptom of a mental health ‎condition, and 84% reported at least one workplace factor that had a negative impact on their mental ‎health (Office of the U.S. Surgeon General, 2022). This means that in every mental health, healthcare ‎and social service setting, clinicians must deal with the effects of workplace stress on their clients, while ‎they are also trying to manage similar problems themselves. Not surprisingly, the report cites research ‎suggesting there are five workplace attributes most predictive of whether workers refer to their ‎organization’s culture as “toxic”: disrespect, non inclusivity, and unethical, cutthroat or abusive ‎behavior (Sull et al., 2022). ‎

In caregiving environments, these toxic factors have been accumulating and spreading like a contagious ‎moral virus for decades. Indeed, my colleague and I wrote a whole book about it that was published ‎thirteen years ago, and for the most part, nothing has significantly changed for the better (Bloom & ‎Farragher, 2010). As service delivery has been seized by the mandates of capitalism, not by the ethics of ‎caregiving, it is individual caregivers and their patients who have borne the burden of unrealistic ‎economic demands that make high quality service delivery difficult or impossible (Christiansen, 2017; ‎Porter, 2013). ‎

The universality of these problems determines this to be not a health, psychiatric  or psychological ‎problem, but another public health epidemic. Then, when we broaden the notion of caregiving to ‎encompass our care for the planet and all life on Earth, the threat to the overall wellbeing of the ‎environment takes on even more meaning and relevance. The Gaia hypothesis, named after the ancient ‎Greek goddess of Earth, posits that Earth and its biological systems behave as a huge single living entity. ‎This entity has closely controlled self-regulatory negative feedback loops that keep the conditions on ‎the planet within boundaries that are favorable to life (Midgley & Lovelock, 2007). ‎

These conditions have been deteriorating for decades, and without radical change, the environment for ‎future children may be so toxic as to be unsurvivable. This is a difficult reality to face, but we all live in ‎cultures that are “traumatogenic,” that create, participate in, and permit the creation of trauma. A ‎traumatogenic culture produces trauma‚Äźorganized individuals, families, organizations, communities, ‎and governments that become stuck in time, repetitively adapting to circumstances and events that ‎have already happened, but not responding well to the present and creating a predictable, but highly ‎problematic future. I have defined a trauma‚Äźorganized system as one that is fundamentally and ‎unconsciously organized around the impact of chronic and toxic stress, even when this undermines the ‎essential mission of the system (Bloom, 2012). The more people there are in an environment with ‎unrecognized, untreated, chronic, or continuous exposure to the stressful conditions that have been ‎and continue to be a fundamental part of our environments, the more likely that parallel processes of ‎dysfunction will occur and affect everyone, top to bottom.‎

Most clinicians reading this column will be familiar with the concept of a “paradigm shift,” having ‎already experienced such a shift in reorienting your practice around the issues of trauma and adversity. ‎Paradigms are the source of systems, so a paradigm shift means transformation, revolution, or ‎metamorphosis. A paradigm represents society’s deepest set of beliefs about how the world works ‎‎(Kuhn, 1970). Scientific paradigms, like trauma theory and the adverse childhood experiences research, ‎change mental models, which represent the basic understanding we have about the rules for how the ‎world works. As a result of changes in our mental models, we then experience changes in attitudes and ‎ultimately changes in the way we behave. In the world of mental health services, these changes are still ‎evolving. In an organization, for a paradigm shift to occur, everyone needs to change by acquiring ‎knowledge and skills that lead to changes in attitudes, practice and policies.‎

If we are to address the reality of the multiple ways caregiving has been depreciated, and our cultures ‎have become toxic, we need a new mental model for thinking about our sociopolitical and economic ‎systems and their component parts, as biological systems. That means sacrificing our current thinking ‎about them as machines, a paradigm inherited from the last Industrial Revolution. Instead, we must ‎develop an understanding that every corporation, each workplace, regardless of how small, and every ‎person that works for the organization is a living being with all the basic characteristics and ‎requirements of life. We need to think of our workplaces and all our emergent systems as “biocratic.”‎

The word “biocratic” was first used in the 1930s by Dr. Walter B. Cannon, a famous Harvard physiologist ‎who had already named the “fight-flight” response and had defined the internal physiological ‎balancing act that keeps us all alive: homeostasis.  He used the word “biocracy” to describe the ‎relationship between the physical body and the social body, emphasizing the vital importance of ‎democracy. He understood that our socially constructed systems are alive, just as the human body is ‎alive. In 1936, he wrote, “It seems to me that quite possibly there are general principles of organization ‎that may be quite as true of the body politic as they are of the body biologic.” Then in 1940, he became ‎President of the American Association for the Advancement of Science, and in his presidential address, ‎he asserted that the most efficient and stable human society would be a “biocracy in which the myriad ‎of differentiated cells would be organized into functional organs all cooperating in a dynamic ‎democracy in which any form of dictatorship would lead to degeneration and death” (p.1) (Laurence, ‎‎1940).‎

For several thousand years, humanity has been laboring under anti-democratic, top-down ‎organizational structures that are taken as the norm. Since the second half of the 20th century, we have ‎also been laboring under the delusional notion that the “market” will take care of all our problems, ‎including climate change (Orestes & Conway, 2023). Unfortunately, this neoliberal market ‎fundamentalism stands a very good chance of destroying all of us. As a result, there are few truly ‎biocratic workplaces, and therefore most people have little to no experience with practicing ‎democratically, and none approaching their organizations as living systems. ‎
Such a change requires the development of new skills that can serve as an antidote to the almost ‎universal adaptations that humanity has made to thousands of years of relentless exposure to ‎adversity and to trauma. Learning to participate in the workplace environment requires an ability to ‎process complex information along with active listening to others as key leadership skills. Conflicts ‎inevitably emerge that require the capacity to manage emotions and control impulses that disrupt the ‎group process. Working in participatory environments requires shared decision making and problem-‎solving. That means people must substitute words and reasoning for action. All of this necessitates ‎workers with sophisticated social skills that include the capacity for trustworthy behavior and ‎negotiation, combined with a willingness to compromise and make concessions that promote collective ‎action. ‎

Unfortunately, few people have grown up in democratic families or schools, much less workplaces so all ‎of this may be foreign to them, and even frightening. Creating more biocratic workplaces will depend ‎upon trustworthy supervision, coaching and leadership. One of the pioneers of social, organizational ‎and applied psychology, Kurt Lewin, pointed out long ago that, “Only through practical experience can ‎one learn that peculiar democratic combination of conduct which includes responsibility toward the ‎group, ability to recognize differences of opinion without considering the other person a criminal, and ‎readiness to accept criticism in a matter-of-fact way while offering criticism with sensitivity for the other ‎person’s feeling” (p.52)(Lewin, 1951). ‎

Biocratic organizations are living systems that model themselves after the human body, and that may ‎guide us in formulating strategies that support organizational health instead of tolerating dysfunction. ‎In service of this possibility, my colleagues and I have created a new online organizational approach, ‎only recently released during the COVID pandemic, that we call Creating Presence to assist whole ‎organizations in making the paradigm shift to becoming trauma-informed, healthier, biocratic ‎organizations (Bloom, 2023). The organizing framework builds on the scientifically grounded and ‎extensive knowledge about trauma and adversity that I now call “The Science of Suffering.” The ‎overarching purpose in Creating Presence is to provide the knowledge base and skill development for ‎collective change starting at the organizational level, and gradually impacting every member of the ‎organizational culture through the acquisition of knowledge and experience. It also builds on the ‎landmark work of organizational development theorists, Peter Senge and his colleagues, who laid out a ‎roadmap for the future workplace as Learning Organizations, before the knowledge we now have ‎about the effects of adversity and trauma were widely recognized.‎

We use the word P.R.E.S.E.N.C.E. as an acronym for interlinked trauma-informed concepts and values ‎that are meant to consistently inform and anchor all personal, interpersonal and organizational ‎processes: P = PARTNERSHIP AND POWER – Promoting shared decision-making; R = REVERENCE AND ‎RESTORATION – Promoting respect and healing from the past; E = EMOTIONAL WISDOM AND EMPATHY ‎‎– Promoting deep understanding and compassion; S = SAFETY AND SOCIAL RESPONSIBILITY – ‎Promoting safety, self-awareness and teamwork; E = EMBODIMENT AND ENACTMENT – Promoting ‎insight and empowered behavior; N = NATURE AND NURTURE – Promoting proactive rather than ‎reactive behavior; C = CULTURE AND COMPLEXITY - Promoting diversity and avoiding oversimplification; ‎E = EMERGENCE AND EVOLUTION – Promoting healthy growth rather than repetition. ‎

We have also created an instrument to measure change, OPTIC: Organizational Presence of Trauma-‎Informed Change, that is administered during the assessment period, and at intervals along the way. In ‎the implementation process of Adoption, Installation, Initial Implementation and Full Operation, each ‎value is actualized through the acquisition of individual and organizational knowledge, practices and ‎skills that are tailored to specific needs of the organization, and the role of the individual within the ‎organization, and lasts for at least eighteen months so that the learning can begin becoming deeply ‎embedded in workplace practice without significantly interfering with workplace function, and because ‎it is more than just “training” – it is about redevelopment (Brownson et al., 2017). By the end of the ‎process, we expect that the organization will have decided on policy changes that need to be ‎implemented to make the change permanent. The process is too new for anything, anecdotal and ‎qualitative data so far, but the results are promising.‎

About the Author

Dr. Sandra L. Bloom is a Board-Certified psychiatrist, and Associate Professor, Health Management ‎and Policy at the Dornsife School of Public Health, Drexel University. Dr. Bloom is recognized nationally ‎and internationally as the founder of the Sanctuary Model and is the Past President of the ‎International Society for Traumatic Stress Studies. For more information, please see: www.creatingpresence.net and www.sandrabloom.com.


Bloom, S. L. (2012). Trauma-Organized Systems. In C. R. Figley (Ed.), Encyclopedia of Trauma (pp. 741-743). Sage.

Bloom, S. L. (2023). A Biocratic Paradigm: Exploring the Complexity of Trauma-Informed Leadership and Creating Presence&trade. Behavioral Sciences, 13(5), 355. https://www.mdpi.com/2076-328X/13/5/355

Bloom, S. L., & Farragher, B. (2010). Destroying sanctuary: The crisis in human service delivery systems. Oxford University Press.

Brownson, R. C., Colditz, G. A., & Proctor, E. K. (2017). Dissemination and Implementation Research in Health : Translating Science to Practice (Edition 2). Oxford University Press. https://doi.org/10.1093/oso/9780190683214.001.0001

Christiansen, I. (2017). Commodification of healthcare and its consequences. World Review of Political Economy, 8(1), 82-103. http://ezproxy2.library.drexel.edu/login?url=https://www.proquest.com/scholarly-journals/commodification-healthcare-consequences/docview/1907287204/se-2?accountid=10559


Kuhn, T. (1970). The Structure of Scientific Revolutions, 2nd ed. University of Chicago Press.

Laurence, C. (1940, December 28). Human body held best "democracy"; A Society Modeled After Its Organization Urged by Dr. Cannon Before Scientists. New York Times.

Lewin, K. (1951). Field Theory in Social Science: Selected Theoretical Papers. Harper & Brothers.

Midgley, M., & Lovelock, J. (2007). Earthy Realism: The Meaning of Gaia. Andrews UK Ltd.

Office of the U.S. Surgeon General. (2022). The U.S. Surgeon General’s Framework for Workplace Mental Health & Well-Being.

Orestes, N., & Conway, E. M. (2023). The Big Myth: How American Business Taught Us to Loathe Government and Love the Free Market. Bloomsbury.

Porter, S. (2013). Capitalism, the state and health care in the age of austerity: a Marxist analysis. Nursing Philosophy, 14(1), 5-16. https://doi.org/https://doi.org/10.1111/j.1466-769X.2012.00556.x

Sull, D., Sull, C., Cipolli, W., & Brighenti, C. (2022). Why Every Leader Needs to Worry About Toxic Culture. MIT Sloan Management Review, 63(3), 1-8. http://ezproxy2.library.drexel.edu/login?url=https://www.proquest.com/scholarly-journals/why-every-leader-needs-worry-about-toxic-culture/docview/2655624549/se-2?accountid=10559