Welcome to the Course
Welcome to balancing Professional and Personal Lives through Self-Care. Self-care is necessary to a Home Based family Therapist's overall well-being and clinical effectiveness. Yet the question is how many therapists take time out of their hectic schedules to take care of their lives? Working in the area of psychotherapy and especially in families' homes is often challenging and draining to emotional and physical health as well as to your profession. Maintaining a balance between your professional and personal life is critical for providing ethically appropriate therapy. This module will guide you to consider ways self-care can enable you to face professional challenges without sacrificing important aspects of your personal life and relationships. The module provides frameworks, strategies and techniques to assist in striking that delicate balance.
The module explores concepts of self-care by:
- Establishing a common ground of terminology derived from varying points of view
- Developing a unified framework for exploring the concept of self-care
- Providing effective strategies and techniques to practically address self-care while developing a personal self-care strategy
- Applying your personal self-care strategy through a clinical example
Through the module the therapist will be able to
- Obtain knowledge on the scope and concept of self-care
- Identify sources of impairment and appropriate treatment options
- Maintain professional boundaries and avoid boundary violations
- Utilize self-care strategies and specific prevention techniques during therapy
- Develop an understanding of the self-care model
- Develop personal self-care program that will lead to a balanced personal and professional life
Scope of the Issue
Suppose you were to come upon a man in the woods working feverishly to saw down a tree.
"What are you doing?" you ask.
"Can't you see?" comes the impatient reply. "I'm sawing down this tree."
You exclaim, "You look exhausted! How long have you been at it?"
The man replies, "Over 5 hours, and I'm beat! This is hard work."
You inquire, "Well, why don't you take a break for a few minutes and sharpen that saw? I'm sure it would go a lot faster."
The man empathetically replies: "I don't have time to sharpen the saw. I'm too busy sawing!"
*When diagnosing our own problems, it is easier said than done
(Covey, 1989, cited in Norcross & Guy, 2007 p. 6).
In a study, Mahoney (1997) conducted a survey of 325 mental health professionals attending a conference on brief therapy in San Francisco and found therapists reporting a host of problems, such as:
- 43% irritability or emotional exhaustion
- 44% insufficient or unsatisfactory sleep
- 42% doubts about their own therapeutic effectiveness
- 38% had concerns about the size/severity of their caseload
- 38% problems in their intimate relationships
- 35% episodes of anxiety or depression
Other studies researches have consistently shown these types of distress among therapists. The top five sources of distress over this period include:
- Relationship difficulties (38–82%)
- Job stress (33–72%)
- Irritability and exhaustion (33–43%)
- Doubts about therapeutic effectiveness (42%)
Wood, Klein, Cross, Lammers, & Elliott (1985) also found that 40% of psychologists are aware of colleagues whose work is affected by the use of drugs and 60% of psychologists are aware of colleagues whose work is affected by depression or burnout.
Burnout intensity varies from temporary career boredom to full-blown meltdown. The symptoms range from empathic lapses to grouchiness to resentment to snapping at clients to indulgent self disclosure to a complete disregard for professional boundaries and ethics. Consequences include job dissatisfaction, poor job performance etc. (many of which will be discussed in the module).
- Extensive information on burnout and depression can be found in a previous self-care module, "Challenges to Therapist Self-Care With in- Home Work"
Adding self care to your personal and professional life may sound like a strange concept, however it as essential to your wellbeing and your profession. As therapists you cannot give to others from an empty place. Taking time for self-care allows you to be replenished and energized instead of irritable, angry and overwhelmed. By nurturing, love and appreciating yourself you will be able to do the same for others.
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Establishing a Common Ground
Concepts of Self-Care
What is Self-Care?
The University of Texas Dallas (UTD) student counseling center provides a practical concept of defining self care, "a way of living that incorporates behaviors that help you to be refreshed, replenish your personal motivation, and grow as a person. It's the equivalent of keeping your car filled with gas so that you are ready to "motor" when you want to go somewhere!"
Some people may consider self care as selfishness and meant for people who have little consideration for others around them. It is important to note that taking care of your needs lays in a balanced, steady place on the middle of a continuum, with intense selfishness on one end, and extreme sacrificing what you need or want for others' sake on the other end ( UTD, 2008).
Extreme Selfishness Extreme Scarificing
Self-care strengthens your resiliency, reducing your susceptibility to burnout. Self-care includes more than making healthy lifestyle choices. It includes:
- Staying true to your values
- Having healthy boundaries
- Being attuned to your needs
Self-neglect takes a toll on your health, relationships, and your effectiveness. Caring for ourselves helps keep us balanced, flexible, and happy. Being balanced helps us work at our most effective level, and the result is that clients benefit. Carroll, Gilroy, & Murra (1999) argue that self-care fits with our ethical responsibility to protect clients and can be seen as a moral imperative. By nurturing yourself you will be able to keep up strength, resolve, motivation and inner resources to continue to give to your clients.
Importance of self care
Self Care includes an understanding of yourself as an adult and a professional, being able to request and obtain support from family and friends, professional growth and maturity, having support from associates, and physical activities that replenish the body and mind. There are certain principles that therapists help their clients acquire. These include:
- Self care
But when a therapist or any professional does not practice self care they are not allowing themselves to develop the same principles they help their clients with. The paradox of therapy is to help others and not ourselves (Macci, O'Conner, Garrett, 2006).
When therapists practice self care they are more likely to avoid caring and emotional exhaustion, they are able to prolong professional longevity, are more effective with clients, create and sustain an active individually designed development method, and validate professional competence and self worth (Skovholt et al, 2001).
Therapists who do not practice self care find themselves less confident in their ability to provide their clients with the help they need. This leads them to depression and a sense of worthlessness. Practicing self care is also important to the therapist to avoid legal and ethical liabilities, avoid isolation, and being able to separate work from the therapist's family and social spheres, causing less strain and stress (Zur, 2003).
When the therapist is able to be more effective and interested in their work they are more likely to build their competence and self worth. Besides the need to make the therapist healthy in mind and body, the legality and ethical liabilities take another strain on the therapist. This can affect the stature of the professional's reputation if legal or ethical practices are called out.
There are three main components to help the therapist stay physically, mentally, emotionally, and spiritually healthy:
- Self awareness, recognition
- Self regulation, managing
- Balance, finding your foundation
Self care is a lifelong issue that should be practiced especially in the helping profession but also in any job. If you are not able to help yourself you will not be effective enough to help anyone else. If the three key components are being met then you have a better chance to be more successful in your profession. Without all three components you are still in an unstable state. You have to have all three. For instance having self awareness and self regulation without finding your foundation will not balance the triangle. As a home therapist you have to be consistent in practicing self care and hit every different category; physical, mental, emotional, and spiritual, just like the three components if one is neglected the you will continue to be ineffective and unhealthy.
Strengths and Rewards of Home-Based Therapy
In recent review of literature, Macchi, O'Conner, & Petersen, (2008) discussed some of the specific strengths associated with practicing therapy within the home:
Home-based therapy is being recognized as a viable mode of therapy, specifically in instances when families are at risk for children being placed outside of the home (Jordan, Alvarado, Braley, & Williams, 2001). HBFT is a specialized therapeutic service delivery that utilizes the natural environment of a family's home and community, offers ways to overcome barriers to service provision, and creates opportunities for direct translation of therapeutic processes into a family's daily living. The therapeutic process within the home takes on a different tone and direction than the process occurring in the office. The therapist is able to observe natural interactions and use those interactions to create immediate interventions. The interactions can provide the therapist an opportunity to raise the family's awareness of an issue and engage the members in specific, change-making behaviors. The focus of home-based treatments expands to address the family as the client and the family system as the focus of intervention.
(Macchi, O'Conner, & Petersen, 2008)
However, there are also strengths and rewards in the practice of therapy in general which are significant for Home therapy. One rewarding quality of the work was documented by Radeke and Mahoney (2000) who found that therapists were enriched emotionally by their work. In addition, compared to the rapid obsolescence of technical knowledge, therapists have skills that can increase in value with age, a reality described by senior practitioners of average age 74 (Rønnestad & Skovholt, 2001).Skovholt (2001) explains some of the rewards of practicing therapy as hitting a bulls-eye of success with a client. Kramen-Kahn and Hansen (1998) identified some occupational rewards as:
- 93% promoting growth in a client
- 79% enjoyment of work
- 76% opportunity to continue to learn
- 73% challenging work
- 71% professional autonomy—independence
- 61% increased self-knowledge
- 56% variety in work and cases
- 56% personal growth
- 51% sense of emotional intimacy
- 39% being a role model and mentor
Focusing on the rewards of practice, and to your higher purpose, is a wonderful way of managing some of the hazards associated with being a Home therapist. People who cope well with stress have a sense of meaning and purpose in their lives (Nicely, 2004). It is therefore important to value what you may find important and purposeful in your life.
The quality of our life is influenced by the degree of purpose and engagement one feels at any given time. The process of increasing your sense of meaning and purpose in life involves defining "success" and making very hard choices in light of limitations to time and energy (Baker, 2003) and that include finding time for self care.
Challenges and Risks of Home-Based Therapy
In Macchi, O'Conner, and Petersen's (2008) review they identified some of the specific challenges associated with home-based family therapy.
The activity occurring within the home such as unexpected visitors, the phone ringing or the television volume can provide the therapist with information about the family's home life. These types of activities can easily become distractions for the therapist and create disruptions to the therapy process. The therapist is also able to use certain daily life activities as therapeutic moments to assist families with the alleviation of a current crisis and help them to develop skills and reinforce the empowerment necessary to address crises on their own with a different circumstance (Cherniss & Herzog, 1996).
The therapeutic relationship between the therapist and family members is an important part of the therapeutic process. The relationship within the office begins with the family accommodating to the therapist's familiarity with his/her domain of practice. In the family's home, however, that relationship begins with the therapist as the guest accommodating to the family's familiar environment. These experiences often create anxiety for the therapist. Issues of safety, perceived lack of control over the environment, and the distances traveled to get to the home produce a degree of anxiety and stress that the therapist must manage to effectively engage in the therapeutic process. Having an effective, personalized self-care plan can help the therapist manage some of the stress, and focus on the joys and rewards of practice.
However, there are challenges and risks associated with therapy in general that are also significant for Home therapy. We have identified a few of the potential hazards/challenges that the practice of therapy poses to you as well as your family. Please see Ofer Zur (2003) for more of the challenges.
Challenges and Risks: Challenges to the Therapist
- Emotional Depletion: The psychotherapy profession consists mainly of working long hours in isolation. Therapists deal primarily with people in crisis and pain. They are supposed to offer these people support, empathy, interpretation, explanation, direction, or advice. They are expected to give endlessly while expecting nothing in return, except the fee. Not surprisingly, this results in practitioners' emotional depletion, in the therapists' sense that there is nothing more they can give to themselves or to anyone else.
- Isolation: Not only do therapists work mostly in private settings, but also a growing number of laws, codes, and regulations concerning confidentiality and anonymity exacerbate the therapists' sense of loneliness and isolation. In addition, therapists work when most people are off work.
- Helplessness and Sense of Inefficiency: Unlike carpenters, gardeners, or surgeons, psychotherapists rarely see immediate, profound, or tangible results from their efforts. The work is often slow, and with difficult or charactologically impaired people, they may never see improvement. Even when therapy is effective in relieving painful symptoms and termination is successful, patients leave. With them goes the knowledge of the long-term effect the work has had on their lives. In addition, the lack of easily available scientific and measurable ways to evaluate the outcome of therapy leaves therapists wondering whether or not they are being truly effective and helpful. They may question their entire involvement with what Freud calls "the impossible profession."
- Grandiosity and Omnipotence: Patients often put therapists on pedestals. They may idealize the therapists, ascribing to them super-human abilities to see, understand, and heal. In the private setting of psychotherapy, these projections may repeat themselves every fifty minutes. Combined with a lack of critical feedback from objective sources, this may encourage in clinicians the development of what Ernest Jones labeled "the God Syndrome."
- Depression, Sadness and Vicarious Traumatization: Working constantly with people in pain, who feel suicidal, or are grieving over the loss of loved ones, or those severely traumatized, often takes a heavy toll on practitioners. The psychotherapist can be infected with a patient's sadness; a condition Jung called "psychic poisoning." The term "vicarious traumatization" has been introduced in recent years and has become even more popular after the events of September 11, 2001. Vicarious traumatization refers to the cumulative effect upon the trauma therapist of working with survivors of traumatic life events. It is a process in which the therapist's experience is negatively affected through empathic engagement with clients' trauma material.
- Conflicting Clinical, Ethical, and Legal Considerations: The rapidly growing number of state laws, combined with the continual updating of ethical guidelines, leave clinicians in a quandary. The question of how to act when conflicting mandates are present (for example whether to act in the best interest of the patient, to follow the ethical guidelines, or obey the laws) may be difficult to decide. Regardless of the final decision, therapists are bound to feel stressed, compromised, and frustrated.
- Split Personality-Public vs. Private: Traditional therapy emphasizes a rigid separation of the therapist's professional and personal life. With some types of people this differentiation is crucial for therapeutic and safety reasons. However, the preoccupation with such separation has led therapists to live isolated and limited lives and to exclude a sizable part of their community and their public lives from their experience.
Challenges and Risks: Challenges to New Professionals
Be that as it may, these challenges are always inherent during the practice of therapy. However, professionals new to the field have their own unique set of stressors to contend with on their way to becoming expert practitioners. Skovholt & Ronnestad (2003) identified seven stressors specific to novice counselors and therapists. We are presenting four stressors. We will delve deeper into these stressors later and provide you tools to overcome them.
- Acute Performance Anxiety and Fear: Beginning therapists of many professions and theoretical orientations from a variety of countries feel overwhelmed early in their careers (Orlinsky & Rønnestad, 2001). They lack the professional confidence that buffers the experience of anxiety when difficulties are encountered. The anxiety of self-consciousness, which leads to focusing on oneself, makes it more difficult to attend to the complex work tasks. Counselor and therapist anxiety impacts the quality of the work because attention cannot be directed toward optimally relating to the client. The individual's attention is directed toward reducing the external visible effects (e.g., trembling and wet hands, unsteady voice) and lowering the internal anxiety so one can think effectively. One novice in our research study said, "At times I was so busy thinking about the instructions given in class and textbooks, I barely heard the client" (Skovholt & Rønnestad, 1995, p. 27). In addition to pervasive performance anxiety, the novice may experience specific fears such as being speechless, with no idea what to say in reaction to a specific client's concern. Together, anxiety and fear about the unknown are like a one-two punch and can seriously heighten the stress level for the novice.
- Porous or Rigid Emotional Boundaries: Although the novice is often helped in training and supervision to develop clarity regarding appropriate physical boundaries (i.e., to touch or not to touch), issues of boundaries can also be understood in a broader sense. How counselors and therapists regulate their emotions when relating to a client is a core challenge. To function optimally, counselors and therapists need the ability to experience, understand, regulate, and express emotions at a level that facilitates the counseling/therapy process. When encountering challenges and emotional or cognitive overload, the practitioner naturally attempts to process the intense data. There seems to be three styles of reacting to the intense data: premature closure, insufficient closure, and functional closure (Rønnestad, 1996). It is difficult for the beginning counselor/therapist to regulate and express emotions. To do this strategically means that the counselor/ therapist is able to do the Cycle of Caring: empathic attachment, then active involvement, then felt separation over and over again in an optimal way with client after client (Skovholt, 2001). This is an advanced set of skills and very demanding for the beginner.
- The Fragile and Incomplete Practitionerself: In our research, we found that, at the affect level, the beginning counselor or therapist who is not yet familiar with the new professional role, feels both enthusiasm and insecurity (Skovholt & Rønnestad, 1995). Creating a practitionerself, a term similar to that of Ellwein, Grace, and Comfort (1990), involves vigorous internal construction work, as well as the external effort of trying on new clothes and new ways of being in the world. Like an adolescent, the fragile and incomplete practitionerself shifts through a series of moods: enthusiasm, insecurity, elation, fear, relief, frustration, delight, despair, pride, and shame. The novice self is fragile and, therefore, highly reactive to negative feedback. Metaphorically expressed, there is not much muscle, and the immunology system is stressed.
- Glamorized Expectation: Without full awareness, the novice often is more hopeful about the impact of his or her efforts than is warranted. This over optimism coexists with apprehension about one's skill level, and they connect in the goal of magnificent change. If the work is impactful, the novice will likely feel like a successful practitioner. The novice may reason: If I am able enough, skilled enough, warm enough, intelligent enough, powerful enough, knowledgeable enough, caring enough, present enough—then the other will improve. In time, the novice develops much clearer, more realistic, more precise, and less glamorous expectations. No longer is one able to cure the other quickly and easily. Rather, human change is seen as a complex, often slow process in which the practitioner plays only a part. This realism helps to reduce practitioner stress. But it takes time to get to a place where "realistic" replaces "idealistic." Only later will the novice really comprehend how many factors, such as readiness by the other, as extensively studied by Prochaska (1999), play such an important role in client success and that the client often accounts for much of the variance in counseling/therapy outcome (Lambert, 1989).
It is our hope that the description of novice struggles here will help ease the difficult novice voyage. After all, a productive and meaningful career in counseling and therapy can be just ahead.
Some or all of these stressors may act together and prevent self-care activities from occurring in helping professionals, thereby leading to burnout, compassion fatigue, and other similar impairments.
Challenges and Risks: Therapist Impairment
Typically, the progression of inevitable life events and experiences, challenges and risks associated with therapy (discussed in previous sections) which the therapist may or may not be aware of often lead to therapist impairment.
Sherman and Thelen (1998) defined impairment as '"the interference in the ability to practice therapy, which may be sparked by a variety of factors and results in a decline in therapeutic effectiveness." Macchi, O'Conner and Garrett (2007) also define impairment as "a deficiency of a therapist's competence in at least one of three areas:
- Knowledge, training, experience
- Theoretical orientation
- Therapist personal characteristics"
Some common behavioral patterns that signify impairment for therapists includes:
- Social isolation
- Loss of energy
- Feelings of failure
- Somatic complaints
- Lowered self-esteem
- Decreased exercise
- Neglecting meal breaks
- Putting clients' needs first
(Carroll, 1999; Margison, 1997).
While these behaviors are very helpful indicators that something is going wrong, by their very nature they are easy to miss, at the same time they are impairments which when not dealt with may lead to poor clinical judgment, increased risk of ethical breaches, boundary violations, and inappropriate emotional involvement in clients (Nicely 2008).
Therapist impairment can adversely affect clients well being, impede therapy outcome and endanger your professional role as a home therapist (Macchi, O'Conner & Garret, 2008) It is also possible that sometimes the sense of stigma, embarrassment, loss of status and client loss, may prevent you from getting help for your impairment. For instance sometimes you may feel judged, ostracized by your colleagues who learn of your impairments (Nicely 2008). To avoid the hazards of practicing beyond your area of competence, you should improve your treatment skills; refuse to accept certain clients for whom you are not well prepared to treat; know personal danger schedules and monitor your own mental health.
Forming a Unified Framework
Model of Self-Care Behavior
The Model of Self-Care Behavior (Eckstein, 2001) and Compassion Stress and Fatigue Model (Figley, 1997 in Figley, 2002) provide a general explanation of stress, the role of supportive relationships in self-care as well as limiting compassion stress and effectively managing case loads by compassion fatigue. The model of self-care provides preventative techniques for your overall well being whilst the Compassion and Fatigue Model provides techniques for mitigating fatigue to enhance your wellbeing as a therapist. The value of having both models complement each other is important to enhance a healthy health care behavior as well as prevent /reduce the adverse effects of compassion fatigue. Thus, creating a balance for both your professional and personal wellbeing.
The Model of Self Care Behavior (Eckstein, 2001)
The Model of Self-Care was developed as part of "the F.A.M.I.L.Y. Approach to self-care"; a model developed to create:
- A healthy balance
- Identify basic human needs
- Problem solving skills to meet those needs while balancing current strengths and weaknesses with self care behaviors.
Although the model focuses on health factors with one's self-care, it is an applicable and invaluable resource for home therapists' self care practices.
Unrealistic expectations can increase your stress which in turn plays a major role in undermining your profession. Utilizing the model of self care will help you make meaning of supportive relationships, and social support in identifying sources of stress and resistance to self care.
The focus of the model is on the need for integration and balance in five different aspects of self. These include, physical, mental, spiritual, emotional and social. By recording behaviors in each of the dimensions, you can create a healthy balance with your health care behavior and will be informed on what supports the different parts of yourself working together with a sense of joy and harmony. Note that some of the behaviors may be repeated in different dimensions.
Model of Compassion Stress and Fatigue
Figley first published an etiological model in 1995 (subsequently revised) that offers a way to prevent and mitigate compassion fatigue in those that are most susceptible to it (Figley, 2002). The model assumes that empathy and emotional energy are the driving force behind effectively working with the suffering. However, being compassionate and empathic involves costs to the therapist. Following are ten variables that, together, form a causal model that predicts compassion fatigue. The model not only shows what causes compassion fatigue, but also what is required to prevent and treat it (Figley, 2002).
- Empathic Ability is the aptitude of the therapist for noticing the pain of others. The model suggests that without empathy there will be little to no compassion stress and no compassion fatigue. However, without empathy there will be little to no empathic response to suffering clients.
- Empathic Concern is the motivation to respond to people in need. The ability to be empathic is meaningless unless there is motivation to help others who require a therapist's services.
- Exposure to the Client is experiencing the emotional energy of the suffering clients through direct exposure. The costs of direct exposure to the suffering of others is high for the therapist.
- Empathic Response is the extent to which the therapist makes an effort to reduce the suffering of the sufferer through empathic understanding. The therapist might experience hurt, fear, anger, or other emotions experienced by the client, which obviously has inherent benefits and costs.
- Compassion Stress is the residue of emotional energy from the empathic response to the client and is the on-going demand for action to relieve the suffering of the client. With sufficient intensity, it can have a negative impact on the immune system and life in general.
- Sense of Achievement lowers or prevents compassion stress. It is the extent to which the therapist is satisfied with his/her efforts to help the client.
- Disengagement is the other factor that lowers or prevents compassion stress. It is the extent to which the psychotherapist can distance himself or herself from the ongoing misery of the client between sessions. A therapist's ability to disengage demands a conscious, rational effort to "let go" of emotions associated with the sessions
If compassion stress is allowed to build, the therapist is a greater risk of compassion fatigue. Three other factors play a role in increasing compassion fatigue.
- Prolonged Exposure is the ongoing sense of responsibility for the care of the suffering, over a protracted period of time. The longer the period of time between breaks from being a professional service provider the better-at least a day of appointments and as much as a week's vacation.
- Traumatic Recollections are memories that trigger the symptoms of PTSD and associated reactions, such as depression and anxiety.
- Life Disruption is the unexpected changes in schedule, routine, and managing life responsibilities that demand attention (illnesses, changes in lifestyle, social status, or professional or personal responsibilities). When combined with the other seven factors, these normally tolerable disruptions can increase the chances of the therapist developing compassion fatigue.
We believe that the knowledge of this model will help in preventing and mitigating compassion fatigue for the therapist.
Using Strategies and Techniques
Arledge and Wolfson (2001) explain how to better relate to burnout or compassion fatigue as, "change in the clinician's internal experience that results from responsibility for and empathetic engagement with traumatized consumers (91)." Regardless of any profession that deals strictly with trauma, the practice of self-care is vital. The recurrent turnover rate of helping professionals could have strong parallels to the lack of self-care practices. The best way to help the clients succeed is if the professional is in the best state of mind and body. Arledge and Wolfson agree that for this to be accomplished the helper and organizations that these helpers work for and with "understand, recognize, and address signs of stress (p. 91)."
Impact of trauma work (ITW) is a term used when working with trauma patients. This term is used to describe burnout, compassion fatigue, and vicarious tramatization in a more positive light. These other terms give off a pessimistic implication about the client and helper. Dealing with ITW can change the way a clinician thinks, lives, and helps. This can often lead to the helper discarding any beliefs, morals, or value systems to which they used to live by.
Arledge and Wolfson also state that a "sense of personal safety can be distorted (p. 92)." The lack of safety can make the clinician stray away from the therapeutic tasks to which they are to help the clients. They can turn their sessions into negative conversations about how the world is bad and everyone is out to get them. Or it can turn the other way, it can become a situation where the helper desensitizes themselves to apparent dangers which leads them to have a failed sense of awareness, which can lead them to stop helping the client be prepared in unsafe situations.
Another way ITW can affect the helping professional is through the upheaval of their religious/spiritual beliefs. This can lead the professional to lack the ability to "heal, transition, and triumph," these practices are no longer a comfort. In the case of Sara, exhaustion was her biggest battle. Sara was tested by a client named Anne who was very aggressive and manipulative. In the sessions with Anne, Sara was confronted with so many emotions but felt she had to suppress them so she could be able to go forward helping Anne. Anne's aggressive behavior was taking its toll on Sarah and she started to experience exhaustion. Arledge and Wolfson explained that, "a clinician's ability to stay grounded in a strong sense of self, even in the face of strong feelings, is weakened when his or her inner resources are depleted. Changes can occur in the clinician's ability to tolerate, maintain a positive sense of self, and maintain an inner sense of connection (p. 93).""
This is exactly what happened to Sara when working with Anne. Her resources were fading and her work was struggling because of the impact of exhaustion. This can also lead the helper down a self medicating path of substance abuse, which is not a practice of self-care.
All of these factors prohibit the clinician from being completely successful with the goals of their client. So by understanding and respecting the apprehensions of the client the helper is better able to assist. In the situation where the professional is the survivor of trauma the helper can bring in a certain amount of skill and education. But with this it can lead to some negative dilemmas when helping the client. If the helper has not fully dealt with their trauma they can revert to their emotions and reactions from their situation. They can also want the client to cope with their trauma in the same way the clinician did and if the client does not, the helper can have feelings of anger. So before the professional trauma survivor can help any clients they need to practice self-care and deal with their own thoughts and feelings.
Solutions for the helping professional are going to come from a personal, social, and work environment.
First, the helping professional themselves have to be able to come to terms and be aware of how stress is affecting them through trauma. Without the awareness themselves they will not be able to seek out the help they need. From a social perspective, it helps if the helper's family or friends can help them understand and recognize that there is a problem and help them on a way to a path of help.
Second, from the work environment, the agencies these professionals work for should have programs set up to help the individual and the other co-workers around them. The individual also needs to be able to practice self-care, take care of themselves mentally, physically, emotionally, and spiritually. Without some kind of balance the helping professional cannot be successful with their clients on their mission to a healthier path.
Clinician Care: Expectations and Growth
Expectations and Growth in Regards to the Clinician and the Clients
According to Kestnbaum (1984) therapist's unrealistic expectations of their client's growth and progress will interfere with therapy and lead to burnout because the therapist will often blame him/herself. This section highlights some of these expectations as discussed by Kestnbaum (1984). Refer to article for detailed explanation.
Burnout cannot be viewed as a causal linear model, as has been done with much of the research regarding this topic. Rather, burnout needs to be viewed as an interaction between factors. For example, imperfect training or extremely difficult clients will not cause burnout by themselves, but an interaction between these two can cause burnout.
From time to time, all therapists, especially beginners, hold unrealistic and clinically unfounded goals, attitudes, and daydreams about what ought to be taking place in the therapy session. These expectations will greatly affect their perceptions and feelings. The dissonance between these unrealistic expectations and the actual or perceived results will lead from frustration and anxiety to disappointment, blame, and eventually burnout. Therefore, burnout can be self-made, based on perceived rather than actual failure.
There is no absolute level of truth in formulating therapeutic expectations. But therapists often possess expectations that are not well thought-out, not based on clinically observed data, or based on the needs and wishes of the therapist. Positive change is in the eye of the beholder. The recognition of growth and progress may not be as simple as it may seem. Each therapist differs in their views on defining growth and progress and how much is occurring. These differences in perspectives will certainly affect how each views his/her effectiveness and ability, and ultimately, job satisfaction.
Even if some agreement on definitions of growth and progress are assumed, there still remain difficulties in getting the therapist to recognize these milestones when they occur. The ability to identify client growth and progress is not intuitive but is rather learned through skill and experience. The therapist that consistently holds unrealistically high expectations for client growth will consistently feel that his/her clients do not make satisfactory progress. Such a therapist will be unaware of or will dismiss small steps of growth. This leads to the blaming of the clients or self, either of which will pave the way to chronic disappointment and eventually a sense of failure. The therapist will believe that he/she is unable to help their clients, which will prevent professional satisfaction and lead to burnout.
For all kinds of burnout, there are a number of strategies that you can utilize to reduce the harmful effects. It is critical to maintain consistency between expectations for therapeutic growth and actual diagnostic findings. As a home therapist it is also useful to consider progress in development in trust, clarity of focus, and other non-tactile building blocks just as important as the more concrete accomplishments.
Clinician Care: Maintaining Boundaries
Maintaining Therapist-Client Boundaries: Minimizing the Risk of Dual Relationships
Within home-based therapy, unintentionally creating a dual-relationship with your clients is a possibility; particularly for therapists living in a rural area and serving clients in that same area. Many ethical decisions you make are governed by internal values, principles, or obligations and legal statutes, professional codes of conduct, and regulating boards (Schank & Skovholt, 1997). If you are working in a small community, it may be your ethical responsibility to serve an individual you already know because of the lack of other services available (Schank & Skovholt, 1997). If you are working in a more urban area, this risk of serving someone you already know is decreased and can often be avoided. As a home-based therapist, there are some precautions you can take to avoid problematic dual-relationships that can be used for both rural and urban scenarios.
It is important to remember that a dual relationship is not always a problem as long as the client's welfare is not compromised (Schank & Skovholt, 1997). A dilemma that you may face is deciding whom to see as a client when evaluating boundary issues. Some dilemmas that you may face as a therapist is the reality of overlapping social, business and professional relationships, and the overlapping of relationships of clients and members of your family (Schank & Skovholt, 1997). In Schank & Skovholt's (1997) study of rural and small community psychologists, the participants used three different criteria to help him/her make decisions on whom to see as clients: a). the decision was made on the basis of the psychologist's own comfort level of whether he/she could successfully manage the dual relationship, b). some psychologists involved the prospective client in the decision-making process, and c). some clinicians assessed the type and severity of the clients' presenting problem to determine if they could manage the dual relationship.
Schank & Skovholt (1997) have provided some ways to minimize the risk of dual-relationships within your therapeutic career.
- Always be aware of your profession's and state's specific ethical codes and regulations regarding client contact and dual relationships.
- Provide your clients with clear expectations and boundaries whenever possible. This also can strengthen the therapeutic relationship and is especially important if you will most likely come in contact with your clients in public. Remember to always obtain informed consent, stick to the alloted therapy time, protect client confidentiality, and document, document, document!
- As a home-based therapist, it is especially important that you remember to consult with other professionals and/or supervisors to discuss cases that you may be concerned involve a dual relationship. Colleagues can often provide you insight into dilemmas you are blind to.
- Maintaining self-care and a life outside of your work will decrease the risk of conflictual dual relationships. By always being aware of client-therapist boundaries, you will be taking care of yourself both professionally and personally.
Clinician Care: Ethical Codes and Regulations
We have compiled a few of the main ethical codes and regulations of each clinical profession regarding responsibilities to clients. Please refer to your appropriate professional handbook of ethical codes and regulations to review more ethical considerations regarding therapist responsibilities.
American Association for Marriage and Family Therapy (2001):
- 1.3 "Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists, therefore, make every effort to avoid conditions and multiple relationships with clients that could impair professional judgment or increase the risk of exploitation. Such relationships include, but are not limited to, business or close personal relationships with a client or the client's immediate family. When the risk of impairment or exploitation exists due to conditions or multiple roles, therapists take appropriate precautions."
American Counseling Associations (2005):
- A.5.d."When a counselor–client nonprofessional interaction with a client or former client may be potentially beneficial to the client or former client, the counselor must document in case records, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. Such interactions should be initiated with appropriate client consent. Where unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, due to the nonprofessional interaction, the counselor must show evidence of an attempt to remedy such harm."
American Psychological Association (2002):
- 3.05 "A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical."
- (b)" If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code."
National Association of Social Workers (1999):
- 1.06"(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client. (c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries"
Self-Care Techniques: Model of Self-Care
A. Model of self-care -Carroll, Gilroy, & Murra (1999)
Carroll, Gilroy, & Murra (1999) proposed a four part model of self-care techniques:
- Intrapersonal work
- Professional development
- Recreational activities and interpersonal support
Utilizing specific techniques in each area of the model provides for a self-care plan that is both comprehensive and rejuvenating.
- Intrapersonal Work: The focus of this part of the model is on increasing your self-awareness. Some specific techniques you might utilize could be participating in activities that increase your sense of spirituality, noticing how your values are reflected in your work and your life, scheduling time to reflect on your self-care plans, understanding where you are developmentally as an adult or as a practitioner, doing personal journaling, or participating in your own therapy.
Developing a practice that exercises your mind and soul is vital but depends on how you define that. Whether it is a routine of prayer, meditation, attending services, that build up your spirit and faith with likeminded others, exploration of yourself that helps you to identify your values and priorities, reading wisdom literature and discussions with others that deepen your knowledge of yourself and the universe, finding a way to contribute to the well being of others (UTD, 2008).
- Professional Development: This part of the model is to continue to develop and renew as a clinician. Some specific techniques you might utilize could be attending case consultations, completing your continuing education units in classes that are interesting or altogether different from anything you've tried before, serving in your local association, connecting or serving in your local community, or developing your own continuing education courses (Nicely, 2004)
- Physical and Recreational Activities: The focus of this part of the model is to have some fun with activities that are not related to your work. This may include an exercise program, vacations and travel, hobbies or other activities, taking time off for no specific purpose, reading, etc. Moving your body, whether in some structured sport or exercise, or just dancing around, stretching, walking over to the park to feed the ducks. Give it something good to eat, that doesn't come in a bag or box from a drive through. Cook it yourself-take time for yourself, not just whatever is the fastest thing. Get a massage or something to wear that has great texture and color. Go to the doctor when you are sick (UTD, 2008).
- Interpersonal Support: The focus of this part of the model is to maintain healthy relationships that support your wellbeing. Maintaining a healthy relationship with your partner, family, and friends can serve you well in difficult times. You might spend time with family and make time for good friends, including close relationships with peers who support you and your work. Be accepting, kind, easy to forgive yourself. Get enough people in your life, that you can laugh with, share a meal with, talk to when an occasion comes up, who respect you and don't expect you to do all the work of keeping up the friendship or relationship. Do a variety of things for fun and stimulation, some that you can do with others, and some to do alone. Some times when you are having trouble coming up with an idea, remember things you liked when you were a child, but have long ago given up, like painting, drawing, getting out the hammer and nailing or constructing something (UTD, 2008).
Self-Care Techniques: Prevention Techniques
B. Prevention Techniques to apply during therapy
Friedman, R. (1985) in "Making family therapy easier for the therapist: Burnout prevention" Presented a position on the relation among the degree of responsibility undertaken by the family therapist, the outcome of the therapy and burnout. Some specific techniques for reducing the strain on the therapist while maintaining effective treatment were also outlined. A few of the techniques will be discussed:
- Awareness that responsibility to change is on the family Friedman (1985) established that family therapists be aware that the major responsibility for positive outcomes rests with the family and not the therapist. Although as a home therapist you are responsible for providing a setting for growth and change, you are not responsible for rescuing the family from pain and suffering (Exceptions being: extreme situations like suicide , child abuse, spousal abuse etc). While dedication to your work and interest in your clients needs are important aspects of your work, it is also essential to know that "exaggerated ego needs, unrealistic self-expectations, and excessive energy output can lead to burnout" (p.550).
- Role definitions (client vs. therapist) As a home therapist be cautious in order not to assume the role of "all-knowing" or "all powerful" expert. In fact withstanding the tendency for the family deify you will go a long way to emphasize the families responsibility in the process and make your work easier. Remember, you are not "rescuing the family from pain and suffering". In as much as it is tempting to answer all questions and give advice freely, doing so will make the family take a passive stand and avoid responsibility of change. For example, questions asked by parents about the reasons for a child's behavior can be redirected to the child. That way the child is held accountable for the specific behavior, and the family is involved to take responsibility in the process. Note however that in cases like crisis intervention where your expertise is necessary for constructive crisis resolution, your role as an expert is very important.
- Expressing feelings It is not uncommon to feel irritated, annoyed, baffled, confused, overwhelmed, anxious or discounted during therapy session. When such feelings occur it is important to share it in an open, nonhostile way in order to relieve the pressure on you and to be more objective. After all you are a real person who also has real problems and real feelings. Letting the family be aware of your feelings is a polite and appropriate way of allowing the family to cope with your feelings and clarifying interactions between you and the family and making issues such as transference and countertransference explicit.
- Humor Utilizing humor during therapy is an important way of easing the strain of situation where there is heightened tension which may otherwise not be clinically productive. This enhances spontaneous interaction. For example the use of cartoons where clinical point is made in a humorous context is an effective way of reducing stress. However this technique must be used judiciously and wisely.
- Flexibility Flexibility in therapy schedule is also an important way to relieve stress and burnout. Sometimes mere anticipation of appointments may be stressful for you as a therapist. However adding a little bit of flexibility in your schedule may go a long way to have a positive effect on treatment. After all this should not be a ritual. Involve the family in scheduling for the next visit. This way the family is given the opportunity to influence the therapy arrangements as well as take responsibility in the process.
Developing a Personal Self-Care Plan
C. Developing a personal self-care plan-Prochaska's Transtheoretical Model of Change
A Self-Care Plan
Having an effective, personalized self-care plan can help you stay present to the joys and rewards of practice. Given the specific hazards associated with the profession and the ethical obligations to protect the public, Porter (1995 as cited in Nicely, 2004) argues that three primary functions are served by having an effective self-care program:
- Protection of the therapist by reducing occupational hazards such as burnout
- Enhancement of therapy by modeling healthy behavior
- Protection of the client by reducing risks of ethical violations
A comprehensive self-care plan covers several conceptual levels: a broad direction that acknowledges your deeply held values and personal mission, self-care strategies that provide broad guidance across situations, and specific self-care techniques that you use every day.
Your self-care plan should begin with reflection on your personal values and keep you connected to your purpose. These values guide your life and your work, and culminate a personal mission statement. For example, the values of freedom, vitality, authenticity, and growth might coincide with a personal mission statement "to practice psychotherapy with compassion, dignity, and skill in order to promote growth in clients." Some of the strategies, derived from Prochaska's Transtheoretical Model of Change, you might consider are:
- Self-awareness: increasing information about yourself through consciousness raising activities that facilitate the development of insight, spiritual growth, etc.
- Counter-conditioning: consider ways of being different from the ways therapists are conditioned to be in the world. For example, consider a "My Greatest Moments in Therapy" journal to complement the common standard of focusing exclusively on solving client problems and treatment difficulties. Consider exercise to counter the effects of sitting most of the day.
- Self-liberation: make the choice to change and take personal responsibility for the self-care program you want. Acknowledge and accept the burden to replenish yourself both professionally and personally.
- Appreciate the rewards: refocus on the rewards associated with clinical work that bring you life and vitality. Look for ways to create a greater sense of freedom and independence in your work.
A personal self-care plan is integral to effectively coping with the unique hazards associated with your profession. A comprehensive plan, as outlined in this module, can tie specific rejuvenating activities to your higher purpose and personal values. Approaching your work from a deep sense of meaning, expressed in your core values, keeps you in touch with the unique joys and rewards of practicing psychotherapy.
Eckstein (2001) provided simple and practical measures in integrating a plan of action as: Identify self-care behaviors in each of the five dimensions (physical, mental, spiritual, emotional and social) of yourself. For example if you identify "more energy" is important in improving your health and self care, then what behaviors can you consider in the five dimensions to create more energy? Then choose one behavior that can have the most positive effect on "more energy": for example exercise. Now think about the first action to take with that behavior (eg. Walking three to four times a week). The next step is to find support with this plan (eg. Walk with a friend every Saturday). Remember to keep this simple and "doable" and identify your warning signs to getting out of balance such as skipping exercise for example.
After all the concepts of self-care, assessing your strengths and weaknesses, identifying sources of social support and some of the techniques for self-care, what will you like to do in creating a plan of action with your self-care?
What have you identified as most important in improving your health?
Eckstein (2001) provided simple and practical measures in integrating a plan of action as:
Identify self-care behaviors in each of the five dimensions
For example if you identify "more energy" is important in improving your health and self care, then what behaviors can you consider in the five dimensions to create more energy? Then choose one behavior that can have the most positive effect on "more energy": for example: exercise. Now think about the first action to take with that behavior (e.g. Walking three to four times a week). The next step is to find support with this plan (e.g. Walk with a friend every Saturday). Remember to keep this simple and "doable" and identify your warning signs to getting out of balance such as skipping exercise for example.
Applying the Framework
For three years, Sara, a case manager in a mental health agency, worked with Anne, a thirty-five year old single white female diagnosed with major depressive disorder with psychotic features and a history of anorexia. They met twice each week and spent most of the time discussing the intensely painful feelings Anne experienced (rage, disappointment, and abandonment), her difficulties managing family relationships, and her plans for coping with these issues without self-injuring.
These sessions were emotionally draining for Sara, who, through supervision, developed a number of strategies to let go of the impact of the negativity and rage expressed by Anne. These strategies worked well until Anne's rage became focused on Sara over several months and she became increasingly agitated and psychotic. Anne now sought daily contact with Sara, requiring Sara to drop whatever she was doing to attend to her. Despite her demands for extra support and assistance, Anne insisted she was not getting "sick" and refused to consider a medication change or hospitalization. Anne became rageful and verbally abusive toward Sara on an increasing personal level, cursing her and calling her names on a number of occasions. Sara began feeling defensive and angry, yet felt she needed to hide those feelings and instead be all the more patient and consistent in her work with Anne. Sara found her patience and energy for her other clients waning and she had trouble sleeping well: she was dreaming about conflict with Anne. She felt too tired to see friends. After helping Anne finally agree to be hospitalized and consider a change in medication to help her restabilize, Sara had to confront her personal sense of exhaustion and evaluate the toll that working with Anne, in the way in which she was, was having her own health.
(Arledge & Wolfson, 2001)
Applying the Sara Vignette
In the case of Sara, exhaustion was her biggest battle. Sara was tested by her client Anne, who was very aggressive and manipulative. She is experiencing traumatic stress reaction often termed compassion fatigue (Figley, 2002). In the sessions with Anne, Sara was confronted with so many emotions but felt she had to suppress them so she could be able to go forward helping Anne. Anne's aggressive behavior was taking its toll on Sarah and she started to experience exhaustion. Arledge and Wolfson explained that, "a clinician's ability to stay grounded in a strong sense of self, even in the face of strong feelings, is weakened when his or her inner resources are depleted. Changes can occur in the clinician's ability to tolerate, maintain a positive sense of self, and maintain an inner sense of connection (p. 93)." This is exactly what happened to Sara when working with Anne. Her resources were fading and her work was struggling because of the impact of exhaustion. This can also lead the helper down a self medicating path of substance abuse, which is not a practice of self-care.
Utilizing the model of compassion fatigue can help to predict onset of compassion fatigue as well as prevent and mitigate this fatigue. It is evident that Sara sympathized with Anne and was concerned about her depressive condition. Hence Sara found the need to help her with her expertise. Being exposed to Anne, Sara experienced an emotional energy of Anne's suffering and empathized with her. In her demand to relieve the suffering of Anne, Sara suppressed her emotions. Hence she responded to Anne's call of wanting to see her on a daily basis which contributed to compassion stress. Being aware of her situation would have helped Sara to prevent this kind of stress.
It is obvious that Sara was not satisfied with her efforts to help Anne. Having a sense of achievement, Sara would have made a conscious effort to rationalize where her responsibilities ends and to distance herself from Anne's misery. Thus being disengaged from the thoughts, feelings, and sensations associated with the sessions with Anne, Sara would have recognized the need for self-care.
Sara's prolonged exposure to Anne and daily contacts also heightened Sara's stress. Sara felt that she was responsible for the care of Anne and so responded to her call to daily contacts and saw her for several months. In this case taking a longer time between breaks from Anne would have helped in giving a pause to being compassionate and over empathetic. It would also have been important for Sara to have sort social support.
Utilizing the model of self-care (Eckstein, 2001) will help Sara make meaning of supportive relationships, and social support in identifying sources of stress which will enhance her overall well being. By identifying and recording behaviors in each of the dimensions (physical, mental, spiritual, emotional and social), she will be informed on where she was lacking and can create a healthy balance. Balancing the five different aspects of self is crucial.
Refusing to seek help often keeps you off the balance and in the case of Sara she had to deal with the personal exhaustion and stress. This may have serious repercussions in both her personal and professional life. Perhaps if she had sought help and practiced self-care, she would have been satisfied with her achievement. It is really the issue of balance-having a passion for the profession and at the same time being protective of your well being.
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