the cost of caring how working with clients who have experienced trauma can affect you and the...

The Cost of CaringThe Cost of Caring

How working with clients who have How working with clients who have experienced trauma can affect you experienced trauma can affect you and the importance of effective self-and the importance of effective self-

care strategiescare strategies

Roger Higgins Roger Higgins C2010C2010

The Cost Of Caring The Cost Of Caring

• “Therapists cannot do this work without experiencing assaults to their usual ways of viewing themselves, the world, and other people...we do not believe anyone, however psychologically healthy, can do this work and remain unchanged.” (Pearlman and Saakvitne, 1995b: 295)

•Traumatic Stress can affect people Traumatic Stress can affect people physically, emotionally, cognitively, physically, emotionally, cognitively,

behaviourally, and spiritually.behaviourally, and spiritually.

• According to Allen (1995: 14), the most important factor, in relation to the extent to which someone is affected, is his or her subjective experience of the event - “the more you believe you are endangered, the more traumatized you will be”.

Who can be affected by STS?Who can be affected by STS?

• Anyone who works with or helps traumatized people

• their families and friends

• counsellors, psychotherapists, social workers, healthcare professionals, clergy, shelter workers, emergency workers, police officers, lawyers, teachers, researchers, journalists

Is it a disorder?Is it a disorder?

• Is it a disorder or is it a transformation in the therapist’s inner experience, which does not reflect pathology in the therapist, as it is “an occupational hazard, an inevitable effect of trauma work”? (Pearlman and Saakvitne, 1995b:151)

STS As A ProcessSTS As A Process

• Pearlman and Saakvitne (1995b) consider it to be a process, which, when working with survivors of physical and sexual abuse, can involve strong emotional reactions of anger and outrage at the cruel and inhumane ways in which people can be treated, in addition to a deep sense of loss which can follow such reactions.

STS As A ProcessSTS As A Process

• Witnessing such “traumatic loss of loved others, of dreams, of innocence, of childhood, of undiminished body and mind” (Pearlman and Saakvitne, 1995b: 32) can shatter core assumptions about the self and the way we perceive the world around us (Davis, 2000; Janoff-Bulman, 1992) and leave practitioners struggling to make sense of a world in which they may no longer feel safe or secure.

Positive AspectsPositive Aspects

• It’s easy to forget that there are also positive aspects to this work, sometimes referred to as compassion satisfaction (Stamm, 1999).

• These can include “personal growth, spiritual connection, hope and respect for human resiliency” (Kassam-Adams, 1999), and in some cases a major transformation in a therapist’s sense of identity and purpose.

• McCann and Pearlman (1990: 147) refer to “a heightened sensitivity and enhanced empathy for the suffering of victims, resulting in a deeper sense of connection with others...a deep sense of hopefulness about the capacity of human beings to endure, overcome, and even transform their traumatic experiences; and a more realistic view of the world, through the integration of the dark sides of humanity with healing images”.

How Practitioners Are AffectedHow Practitioners Are Affected

• You can’t describe it unless you’ve seen it.

• You can’t explain it unless you’ve done it.

• You can’t imagine it unless you’ve been there.

• Then it never goes away. – Bill Blessington, Retired Reporter, Chugiak,

Alaska (cited in Stamm, 1999: xix)

6 Common Themes in 6 Common Themes in Relation to STSRelation to STS

• Feelings of helplessness

• Questioning of competence

• Triggering of own issues

• Strong physical feelings

• Intrusive thoughts

• Changes in beliefs/worldview

Changes in beliefs

Intrusivethoughts

Strong physicalfeelings

Triggering of own issues

Questioning of

competence

Feelings of helplessness

Secondary

Traumatic Stress

HELPLESSNESSHELPLESSNESS

• Helplessness is a common factor in psychological trauma (Herman, 1992)

• Trauma therapists can feel a client’s despair, which can in turn lead to confusion and helplessness.

• Therapists “must also be, in effect, bystanders and helpless (although not silent) witnesses to damaging and often cruel events” (Pearlman & Saakvitne, 1995a: 155)

• ...As he began to talk and as I began to focus on him and what he was experiencing, a lot of what he was saying was ricocheting through me, because I just felt the same helplessness, that this can’t be happening. (Filomena)

• What can I do? What can I do to make this better? And it really made me feel quite helpless. (Daphne)

Think about:Think about:

• An occasion with a client when you felt helpless

• How did you manage this feeling?

• Were you able to share it with someone?

COMPETENCECOMPETENCE

• At times we can feel pushed beyond our ability to cope and Gentry, Baranowsky & Dunning (1997: 2) include ‘feelings of therapeutic impotence’ and feeling ‘de-skilled with certain clients’ among a list of symptoms, any of which ‘could be signaling the presence of compassion fatigue’.

• Coster and Schwebel (1997) believe ‘feelings of failure’ can be an early sign of distress for therapists.

• E is more affected by issues of competence than traumatic material. She describes working with a client who never really explained what the traumatic incident had been and realises her anxieties were about “how to deal with it in the room and his feelings in the room”.

• So my anxieties were all tied up with how I would be in the room with the person. It wasn’t so much about the nature of their experience or the details of their experience, but whether I was up to the task of holding the situation for them. (E)

• I don’t know how to deal with this. What am I going to do here? (Louise)

Fear of re-traumatizing the Fear of re-traumatizing the clientclient

• And I got this awful feeling that perhaps I was somehow re-abusing him, or re-traumatizing him in some way and I guess that’s all part of how it affected me. Am I doing more harm here? Am I not taking the right way with him? (Louise)

RegressionRegression

• Two counselors interviewed had clients who regressed back to childhood states, which in itself was challenging, but there was additional anxiety about the client’s ability to function safely after returning.

Think about:Think about:

• An occasion when you didn’t feel competent to help your client.

• Did it highlight a specific area where you would like more training?

• Should counselors always feel competent?

Counsellor’s Own IssuesCounsellor’s Own Issues

• All but one of the counsellors interviewed found that some aspects of the material they heard triggered difficult memories and powerful emotions, even when they felt the original trauma had been resolved, which underlines the importance of being aware of your own issues before entering the counseling room.

• Although it is generally believed that therapists who have experienced some form of trauma are more vulnerable to secondary traumatic stress, Schauben and Frazier (1995) found that the number of secondary trauma symptoms reported by counsellors increased in direct proportion to the number of clients being treated and was not connected to a counsellor’s previous trauma history.

• “You don’t have to have been abused but it helps to have experienced that sense of loss and to appreciate how much it affects somebody, and perhaps you don’t realise that until the first time you come across it.” (Louise)

• A therapist who has worked through his or her own healing process has a distinct advantage in understanding the client and being able to model healing (Munroe et al, 1995: 214-5).

ThinkThink about:about:

• A time when your own issues were triggered

• Was it helpful in any way?

• Were you able to discuss it with a supervisor or colleague?

PHYSICAL FEELINGSPHYSICAL FEELINGS

• Counsellors described strong physical sensations, often in relation to powerful emotional reactions.

• I felt very, very sad. I suppose really almost bereaved. That feeling like lead in your stomach when something dreadful has happened...I just wanted everyone to go away. (Julie)

• Although physical sensations are normal reactions to stress, it’s important to be aware of these reactions in order to monitor our stress levels (Menninger, 1999) and the extent to which our arousal has been heightened (Catherall, 2000).

• “Our bodies hold many of the painful feelings stirred by trauma work” (Saakvitne at al, 2000).

ThinkThink about:about:

• Any physical feelings you have been aware of when working with clients

• Have these feelings given you any information about your clients?

INTRUSIVE THOUGHTSINTRUSIVE THOUGHTS

• I’d go to bed and switch off from the everyday things and then this would come back... (Louise)

• One counselor interviewed, who worked in the emergency services, found that his client’s traumatic imagery became entangled with his own.

• I was reliving incidents I’d been to, which hadn’t affected me until this. (Bill)

• “Through their work with survivors, therapists may also experience intrusive imagery, often images of those scenes that survivor clients have described vividly which connect in some way with the therapist’s own psychology.”–Pearlman, 1999: 61

Think About:Think About:

• Have you experienced any intrusive imagery or unwanted thoughts?

• If so, were you able to find a way of managing these thoughts or images?

BELIEFS / WORLDVIEWBELIEFS / WORLDVIEW

• Counsellors found themselves looking at the world in a different way, especially in relation to issues of trust and safety.

• Louise experienced this after counselling a male survivor of sexual abuse.

• For quite a while when I saw anybody in a similar situation to the situation the abuser was in, I found myself thinking, “Oh God, you know, is that him?” He could be doing this to a child. So if I saw a little boy with maybe his father or an adult in the park, I would be quite ultra sensitive to it. I’d be wondering when you see men buying sweets for kids, are they grooming them? When you see a child crying, is that his real dad?...So it affected my worldview, to some extent...I think I’d seen it as opportunistic before and suddenly it’s very deliberate and it’s very targeted.

• Filomena feels she has changed as a consequence of counselling traumatized people.

• It changes you in some way, though not necessarily in a bad way. It adds another layer. It’s made me very aware of personal safety and others’ safety too...

• And I think in some way it’s taken some of the lightheartedness out.

• In a way it shatters the belief that really everything’s ok...(Louise)

• At times counsellors interviewed found their beliefs that people are basically good and the world is a safe place were challenged and there is a danger that we can become cynical and consequently lose our sense of hope and connection, which is vital for the success of this type of work (Saakvitne et al, 2000).

• “Engaging the power of trauma will change us, and it has the power to harm us when we engage it in such close quarters. But, engaging it can bring us to the edge of the human condition and offer us opportunities to move beyond the common distractions of life, which frees us to deal with the unspeakable which is happening in our very experience.” (Stamm, 1999: xvi)

Think About:Think About:

• Have you noticed any changes, however subtle, in your beliefs about the world?

• Do issues of safety concern you more that they used to?

Summary of How Practitioners Summary of How Practitioners Are AffectedAre Affected

• Feelings of helplessness

• Questioning of competence

• Triggering of own issues

• Physical feelings

• Unwanted and intrusive thoughts

• Changes in beliefs / worldview, often in a negative way

Coping Mechanisms and Coping Mechanisms and Self-Care StrategiesSelf-Care Strategies

• All therapists should establish and maintain a balance between their professional and personal lives, but for trauma therapists, this is imperative...Frequently overworked and over-traumatized themselves, these therapists may traumatize their families by their chronic unavailability and emotional withdrawal, perhaps in much the same way that victims sometimes traumatize those around them. (Cerney, 1995: 140)

Achieving Balance Achieving Balance Between 5 Key AreasBetween 5 Key Areas

• Physical: exercise, activity

• Psychological: time for self-reflection

• Emotional: comforting activities

• Spiritual: experiences of awe

• Professional: supervision, peer support

Professional

Spiritual Emotional

Psychological

Physical

Balance is the Key

PHYSICALPHYSICAL

• In terms of getting back some equilibrium, walking and gardening are very much for me the times when I’m physically on my own. They’re very much grounding experiences for me, making sense of stuff and getting things back into perspective, getting peace again. (Louise)

• “Everyone needs an outlet for pent-up emotions of anger, frustration, hostility, and discouragement. Toward that end, physical exertion can help divert aggressive energy; it is a safe way to express powerful emotions.” (Menninger, 1999: 6)

• Pearlman (1999: 54) recommends “being physically active through exercise, dance, or hard physical work; reconnecting with one’s body through massage, dance, yoga”.

Select those which apply to you Select those which apply to you and include anything else you doand include anything else you do

• Exercise - walking, going to the gym

• Activity - gardening, dancing

• Eating regularly

• Eating healthily

• Sleep patterns

• Taking time off when sick

• Time to be sexual with yourself / partner

PSYCHOLOGICALPSYCHOLOGICAL

• This area covers time for self-reflection and processing, which is an essential component of effective self-care.

• Sometimes we may use negative coping strategies like avoidance.

• One counselor used a cognitive approach to establish a clear boundary -

• After a while I disciplined myself, to some extent, not to carry him around with me. I gave myself some processing time after each session and I gave him longer than I normally do. Then I quite firmly put it out of my mind and said, “Now, you don’t deal with it again ‘til next week,” which sometimes is quite hard, but I think actually, I needed to do that to get that distance and to get that impartiality, that balance back again, before the next session.” (Louise)


• Creating time for self-reflection

• Keeping a journal

• Being mindful - yoga, meditation

• Reading books for pleasure

• Learning something new

• Doing something different

• Saying no occasionally

• Listening to your intuition

EMOTIONALEMOTIONAL

• This area includes comforting activities, such as spending time with family and friends, listening to music and having fun!

• I love listening to music. I can wind down listening to music...I can get lost in that and pretend I’m dancing... (Bill)

• I do keep a journal when something’s bothering me, but sometimes a hug is all you need...just the touch, that’s all ...(Bill)

• One counselor was aware that her method of relaxation could be viewed as a negative coping strategy.

– A glass of wine can work wonders too. If nothing else reaches those places, I’ll have a nice glass of wine and a hot bath, although in some ways it’s a negative coping strategy. I think if you’re using an aid, something like that to get you there, it’s a shortcut...(Daphne)

• Several counselors underlined the importance of a support network, where “you just access different bits on different days for different purposes, but they all feed each into other” (Filomena).

• Friends, who may or not be therapists, can provide invaluable support and reassurance in times of crisis.

• Yassen (1995: 188) believes “connections with other people are restorative” and that “social supports are a central component of the prevention of personal and professional Secondary Traumatic Stress Disorder”.


• Time to relax

• Time with loved ones

• Having a support network

• Accepting small breakthroughs and victories

• Laughing

• Crying

• Being playful

• Engaging in social action, campaigning

SPIRITUALSPIRITUAL• This area covers beliefs, worldview, finding

meaning, cherishing hope, experiences of awe, creativity, and activities which replenish or feed the counsellor.

• Beliefs, ranging from religious faith to humanistic philosophy, play a crucial role in motivating therapists and in helping them to find meaning in their lives as they listen to stories of unbearable pain, suffering and cruelty.

• Pearlman and Saakvitne (1995a) believe therapists suffer spiritual damage as a result of vicarious traumatization and that, as a consequence of this, “it is essential to develop and nurture spiritual lives outside of our work”.

• Each counsellor values experiences of awe, which can be a simple appreciation of the beauty of nature, but which help the counsellor to feel more grounded and balanced.

• Counsellors also find that there are positive aspects to this difficult work, where “those who voluntarily engage empathically with survivors to help them resolve the aftermath of psychological trauma open themselves to a deep personal transformation. This transformation includes personal growth, a deeper connection with both individuals and the human experience, and a greater awareness of all aspects of life” (Pearlman 1999: 51).


• Having experiences of awe

• Being creative - writing, drawing, gardening

• Cherishing hope

• Having beliefs which give meaning

• Being inspired

• Going for walks in the countryside

• Sharing your spirituality with others

• Praying / meditating

PROFESSIONALPROFESSIONAL

• This area includes supervision, peer support and training.

• All the counsellors found supervision, either individual, group, or both, essential, but it made some counsellors more selective in their choice of supervisor.

• Some also believed it was more beneficial if the supervisor for this type of work was of a similar theoretical orientation.

• It’s made me think about the different types of support I need while I work, and this is one of the reasons why I’ve got more than one type of supervision, but it’s made me think about who I want supervision with, and it’s made me put another layer in place, as well as the stuff that ticks boxes, that we have to do.

• I now look for more experience in the people I work with, and a different level of experience, wider experience, more experience of very difficult situations, rather than just the norm. (Filomena)

• Etherington (2000: 146) raises the problem of denial amongst colleagues, where “there is a wish to deny the centrality of the harm caused by abuse”.

• This may be why Louise felt her supervisor gave mixed messages, because, although she offered support, “running through that, somehow, there was this (and I don’t know whether that was just me or whether it was her), “Not this one again? Can’t you find something else to bring?”

Peer SupportPeer Support

• Peer support was also valued and according to Catherall (1999: 81), “one of the primary sources of support for therapists is the professional peer group.

• The therapist’s professional peer group has the power to dilute the impact of STS, to normalize the disturbing reactions, and to help the therapist maintain the therapeutic connection with clients despite his or her personal upheaval”.

TrainingTraining• None of the counsellors felt that their training

had prepared them for the negative effects of STS or had introduced them to effective coping strategies and mechanisms for managing it.

• However, all believed that training courses have an important role to play in this area.

• “We have a duty to educate those entering the field to anticipate how the work will affect them and to prepare them to address these effects.” Zimering, Munroe, & Gulliver (2003: 3)


• Having adequate and regular supervision

• Peer support where you can be open and honest

• Peer support which will challenge you

• Setting adequate boundaries

• Feeling comfortable in your workplace

• Having time for lunch

• Setting achievable goals

BALANCEBALANCE

• But I don’t think the theme of self-care is pushed enough on courses and supervision alone isn’t the answer. You have to have the other things in place to create a balance. (Louise)

• Achieving a balance is paramount. Absolutely paramount. (Filomena)

• Yassen (1995: 186) refers to the concept of ‘life balance’, which “emphasizes the value of striving for an overall balance of work, outside interests, social contacts, personal time, and recreation. Life balance includes a commitment to life and life-enhancing activities”.

• It appears to be the key component in managing the secondary stress which inevitably accompanies work with people who have been traumatized.


• Finding a balance between the 5 areas: physical; psychological; emotional; spiritual; professional.

• Finding a balance between work and play

• Identifying areas which are out of balance in your life, either professionally or personally.

• Developing plans to re-balance those areas.

CONCLUSIONCONCLUSION

• We need to be aware of the cost of caring.

• Self-care has to be a continual, evolving process for any therapist helping clients who have experienced trauma.

• Therapists need to discover the combination of elements from each of the self-care areas, which can meet their individual needs, and which may differ considerably from therapist to therapist, in terms of specific activities, beliefs, or interests.

• When each of these area is represented in a balance way, “while we will certainly not eliminate trauma nor likely eliminate the hatred, evil, or violence that feeds it, we may learn to transform our encounters with these things into opportunities for growth for ourselves and for those whom we seek to heal” (Stamm, 1999: xviii).

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