Challenging Times Require a Commitment to SelfCare by Practitioners

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Challenging Times Require a Commitment to
Self-Care by Practitioners

• Raymond F. Hanbury, PhD, ABPP
• H. Katherine ONeill, PhD
• Richard A. Heaps, PhD, ABPP
• Suzan M. Stafford, EdD
• Ester Cole, PhD
• Sunday, August 9, 2009

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Empathy Versus Strain Need for Self-Care
Raymond F. Hanbury, PhD, ABPP
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Disaster Response Network Focus on Responder
Self-Care

• Stress
• Empowerment
• Life
• Functioning
• Compassion
• Assessment
• Resiliency
• Empathy

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Types of Stress

• General Stress Eustress/ Distress
• Acute (incident specific immediate)
• Delayed (incident specific can be latent for
  about 6 months)
• Cumulative / Chronic (not incident specific)
• Critical Incident Stress
• Posttraumatic Stress

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Major Types of Stressful Events / Stressors

• Natural Disasters
• Mass Interpersonal violence
• Technological Disasters
• Disasters of Human Intention
• Large scale transportation accidents
• House or other domestic fires
• Motor vehicle accidents
• Economic factors

• Sudden traumatic loss
• Rape sexual assault
• Stranger assault
• Partner battery
• Torture
• War
• Child abuse
• Emergency worker exposure
• Medical Illness
• Military Deployment

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Working With Trauma

• Helpers sometimes mistakenly believe their
  training, role, and experience make them somehow
  immune to the effects of traumatic exposure.
• Traumatic stress response is in part an autonomic
  biological response.

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Trauma Phenomenon Reviewed in Different Ways
Click to add text

• Classical Burnout Freudenberger, 1984
• Compassion Fatigue Figley, 1995
• Vicarious Traumatization McCann
• 
  Pearlman, 1990

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Difference Between Burnout Secondary Traumatic
Stress

• Burnout is conceptualized as the gradual
  depletion of resources with the residual effect
  of inefficacy while.
• Compassion Fatigue or Vicarious Traumatic Stress
  is seen as the rapid insertion of fear associated
  with the psychological material or others
  encountered in the work setting.
• 
  (Stamm, 2002)

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Current Conceptualization of Work Related
Indirect Trauma
It is widely accepted that interaction with
victims of traumatic exposure places helpers at a
high risk of secondary exposure.
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Direct and Indirect Trauma

• Sometimes work-related trauma places one in the
  path of both direct and indirect trauma.
• Responding to humanitarian disasters, such as
  wars or terrorist attacks helpers find
  themselves dealing with these events in difficult
  living conditions.
• (Stamm,
  2002)

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Line of Duty Aspects

• Overcrowding
• Sanitation
• Poor housing
• Long hours

• Food insufficiency
• Poverty
• Absence of medical assistance

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The danger increases when helpers assumption of
immunity allows them to put themselves at
increased risk by continuing to work when they
have exhausted their personal resources.
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Sometimes helpers conceal their distress behind
masks of denial and avoidance because they think
they are failing as helpers.
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Vulnerability to Secondary Exposure

• Some work has been done on the factors that
  contribute to helpers vulnerability to secondary
  exposure, but much of it is anecdotal,
  theoretical, or retrospective survey but not
  separate secondary exposure from primary
  exposure.
• Even less is available as what supports
  resiliency in helpers.

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Empathy Empathic Strain in Trauma Work

• The capacity for sustained empathy is pivotal for
  the recovery process of the victim.
• Achieving empathy requires a nonjudgmental manner
  to the victim and the ability to project oneself
  into the phenomenological world being experienced
  by the other person. Empathy is both more
  necessary and more difficult to maintain.
  
• (Ochberg, 1993)

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Vicarious Trauma

• In the last decade it became clear that people
  can be secondarily affected by the suffering of
  others
• Empathy - vehicle whereby helpers make themselves
  open to absorption of stressful and traumatic
  events
• Vicarious Traumatization - The process of changes
  in the helper/rescuer resulting from empathic
  engagement with patients or survivors

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• Empathy is a complex concept in that the
  responders must be aware of his or her own
  partial identification with the victim in other
  words, take into account countertransference.

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Helpers Also Suffer

• Stresses associated w/ clinical work work
  setting(s)
• Limited decision making power control over
  aspects of work
• Poor interpersonal/ institutional support
• Heavy case-loads
• Managed care demands
• Professional isolation
• Work-Family conflict (lack of work-family
  balance)
• Work with difficult clients (e.g., chronic
  illness, suicidal)
• Financial/business pressures in independent
  practice

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Helpers Also Suffer

• Impairment
• Deleterious impact of distress/ demands on
  professional competence
• Decline in quality of professional functioning to
  the point where the psychologist is unable to
  deliver competent patient care - patient may be
  harmed or services may be ineffective (Coster
  Schwebel, 1997 Laliotis Grayson, 1985)
• Problems with professional competence proposed
  to replace the term impairment (e.g., Elman,
  2007)
• Rates of impairment among psychologists
• Current 5 to15 / Lifetime 60
• About 1/3 of psychologists report knowing an
  impaired colleague or identify themselves as
  currently or formerly impaired (e.g., Floyd et
  al., 1998)

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Helpers Also Suffer What increases
psychologists risk?

• Motivations for becoming a psychologist
• Some enter profession with known physical or
  psychological vulnerabilities
• Family of origin issues Childhood trauma or
  abuse reported in 33 - 66 of female mental
  health professionals
• The Challenging and intense nature of our work
  and our therapeutic relationships may increase
  the risk for stress, distress, and impairment
• Role identification
• Professional/ clinical responsibility for clients
• Empathic engagement as helping professionals

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• Potential Consequences of Ignoring Occupational
  Stress

• To psychologists, including
• Depression
• Social/professional isolation
• Job dissatisfaction
• Suicide
• Chemical abuse or dependence
• Relationship conflicts (divorce)
• Other addictions
• Unprofessional behaviors
• Ethical violations
• Stress-related illnesses

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Potential Consequences of Ignoring Occupational
Stress

• To Clients, including
• Malpractice
• Suicide
• Boundary violations
• Loss of faith in therapy
• Symptom exacerbation
• Guilt
• Iatrogenic symptoms
• Despair

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Potential Consequences of Ignoring Occupational
Stress

• To the Profession of Psychology, including
• Loss of credibility
• Lawsuits
• Attrition
• Negative media attention
• Cynicism
• Disillusionment

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Stressors in Our Practices

• Somatic Distress
• Isolation/Loneliness
• Transitional/Role stress
• Family crisis
• Serious mental illness
• Psychiatric emergencies
• Catastrophic crisis
• Economic stress

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Differences by Setting/Practice

• OFFICE
• Long term
• Calm atmosphere
• Quiet
• Individual/family
• Aloneness
• Business
• Long hours
• Scheduled times
• Structured interactions
• Solo or small group

• FIELD
• Short duration
• Intense exposure
• Noisy, chaos
• Mass numbers
• Groups / organizations
• Pro bono / volunteer
• Long days or weeks
• Unscheduled
• Sense of urgency
• Collaboration with teams

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Similarities by Setting/Practice

• OFFICE
• Assessments
• Connect with patients
• Competence
• Training
• Ethics
• Danger
• Need for Wellness
• Cultural awareness
• Work with tragedy
• Be in control
• Evidence based approach

• FIELD
• Assessments
• Connect with survivors
• Competence
• Training
• Ethics
• Danger
• Need for Wellness
• Cultural awareness
• Work with tragedy/ trauma
• Be in control
• Evidence based approach

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Wellness and Self-Care Moral Ethical
Imperatives
APA Ethics Code Principle A - Psychologists
strive to be aware of the possible effect of
our own physical and mental health on our
ability to help those with whom we work. (APA,
2002, p. 3) - Awareness is an important first
step towards wellness Pursuit of Wellness -
Wellness is the enduring quality in ones
professional functioning over time and in the
face of professional and personal stressors
(Coster Schwebel, 1997) Self-Care - Self-care
practices are necessary to maintain optimal
wellness in the face of occupational and personal
stress - If you dont practice self-care, you
risk harming clients - Moral Imperative
(Carroll et al., 1999) - Ethical Imperative
(Baker, 2007 Barnett et al., 2007)
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Maintaining Empathy Self-Care

• Adequate education and training
• Experience in the field and office in treating
  survivors
• Proper supervision
• Collegial peer support
• Personality traits

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MENTAL HEALTH PROFESSIONALS
We May Also Be Victims!!!
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Vicarious Traumatization Recommendations for
Prevention and Intervention
H. Katherine ONeill, PhD NDSU Dept. of
Psychology and Knowlton, ONeill,
Associates Fargo, ND
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Definition

• Vicarious traumatization has been defined as a
  change in therapists inner experience resulting
  from empathic engagement with a clients material
• (Pearlman Saakvitne, 1995)

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Signs and Symptoms

• SYMPTOMS
• Re-experiencing (intrusive thoughts)
• Avoidance (avoidance of person and/or of hearing
  about traumatic experiences)
• Hypervigilance (arousal, anxiety, physical
  symptoms)
• Note similarity to PTSD symptoms, except these
  are not due to direct trauma exposure

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Prevention Strategies

• AWARENESS
• An empathic listener will automatically form
  images of trauma
• Fight or flight reaction is natural response to
  such images

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Prevention Strategies

• MANAGE PHYSIOLOGICAL AROUSAL
• Quick and easy relaxation methods
• Diaphragmatic breathing
• Grounding exercises
• Take a break

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Prevention Strategies
CONNECTIONS WITH OTHERS

• Share reactions with a trusted co-worker
• Find someone who will let you talk about your
  experiences without judging or trying to fix it
• Stay connected to family and friends

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Prevention Strategies

• SELF-CARE
• Engage in aerobic physical activity
• Take time for relaxation and recreation
• Pursue hobbies

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Prevention Strategies

• SELF VALIDATION
• Avoid over-reliance on client outcomes and
  supervisor praise as indicators of success
• Recognize own abilities and competencies, despite
  pressures of work environment
• The best I can do is all that I can do
• (Gentry, 2004)

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Prevention Strategies

• SPIRITUAL PRACTICES
• Put things into perspective
• Being part of a larger plan
• Connection with a benevolent presence

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Prevention Strategies

• ADEQUATE TRAINING
• Knowledge base
• Scope of competence
• RESOURCES
• Means of communication
• Backup person
• Materials needed for effective work

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Intervention Strategies

• PRIMARY TRAUMA SYMPTOMS
• Post-traumatic symptoms from direct exposure to
  traumatic situation
• History of unresolved trauma
• Address these first

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Intervention Strategies

• EMOTIONAL PROCESSING
• Process thoughts and feelings
• Release reactions to stressful situations and
  vicarious traumatic exposure in a systematic way
• Learn more about this strategy from our next
  speaker

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Intervention Strategies

• RECONNECT WITH MISSION
• Act intentionally, in accordance with your
  personal mission
• Regain your sense of integrity
• Remember, your best is all you can do!
• (Gentry, 2004)

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Intervention Strategies

• SELF CARE
• Become a good self-manager
• Engage in activities that bring joy and
  fulfillment outside of work
• Learn to self-validate, rather than rely on
  feedback from others

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Transforming Vicarious Traumatization

• POST-TRAUMATIC GROWTH
• Study of psychotherapists who work with trauma
• 100 reported transient secondary trauma symptoms
  (intrusive thoughts, arousal, negative emotions)
• 100 reported personal and professional growth
• Arnold, Calhoun, Tedeschi, Cann (2005)

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Transforming Vicarious Traumatization

• FOCUS ON BENEFITS
• Personal and professional growth
• Challenge, stimulation, intensity of work
• Satisfaction and accomplishment
• Collaboration and teamwork
• Appreciation from those being helped

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Journaling for Self-Care in Disaster Response
Richard A. Heaps, PhD, ABPP Counseling Ctr.
Counseling Psychology Dept, Brigham Young
University Kristina Withers Hansen,
EdS Counseling Psychology Dept Counseling
Ctr., Brigham Young University
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(No Transcript)
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The Problem
Traumatic Environments
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Unimaginable Trauma
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Exhausting Challenges
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Chaos
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Human Suffering
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Desperate Expectations
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Living Conditions
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Exposure Can Lead To

• Intrusive, obsessive thoughts
• Anxiety
• Work/social impairments
• Sleep disturbances

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IN DRN PSYCHOLOGISTSSECONDARY OR VICARIOUS
TRAUMATIZATION
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Self-Care
A Solution
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Example One solution - Journaling
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Personal Experiences

• Journaling for Self-Care

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Understanding and Interpersonal Connection
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Reinforcing Resilience
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• Avoiding Avoidance
• (Healing from Traumatic Experiences)

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Sleep Aid Managing Intrusive Thoughts and
Feelings
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Insight for Problem-Solving
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Emotional Outlet Controversial Issues
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Thinking In a Safe Place
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Research The Benefits of Journaling

• Health
• Emotional-Psychological
• Therapeutic Process

see paper and references
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Enhancing Benefits
Include Emotional and Cognitive expression (Feel
and Make Sense of Events)
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Psychologists Are People Too
(Same benefits from Journaling)
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How to Journal

• Use comfortable materials
• Define your audience
• Use concrete descriptions
• What happened?
• Write freely and honestly
• Say what you really think and feel
• What does your experience mean to you?
• Be truthful

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How Local Associations Can Promote Self-Care
Suzan M. Stafford, EdD
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Articles in Newsletters and E-Grams

• Defining, evaluating, and offering ways to
  promote self care
• Cultivating resilience and how it applies to self
  care
• Positive peer partnering and how it works

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Promoting Self-Care in Professional Psychology

• Culture change in psychology - Normalizing
  discussion of occupational stress, distress,
  temptations, via training programs and in
  Psychological Associations
• Training/Teaching/CE about self-care, trauma,
  boundary management
• Self-care as part of supervision
• Peer consultation
• Early (self) assessment and intervention
• Early (self) referral before actionable
  violations have occurred

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Resilience and Self-Care

• Maintaining physical health
• Developing insight into ones emotions and
  reactions
• Learning new skills
• Education and experience
• Community and family support
• Strengthening self-esteem
• Spirituality

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Positive Peer Partnering For Psychologists

• This concept encourages psychologists to engage
  in a collaborative, informal connection with 1 or
  2 colleagues to help
• Maintaining mind/body wellness
• Reducing levels of stress, especially when
  working with critical incidents/DMH
• Collaborating due diligence regarding our
  client services ethical responsibilities
• Practicing Prevention to assure healthiness
  with respect to self, others clients

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Positive Peer Partnering For Psychologists

• Consider identifying and then checking in with
  one or two colleagues about developing such an
  informal arrangement
• Be flexible, creative, develop guidelines
  together that will help to structure and honor
  healthy mind and body care for you and your
  professional efforts
• Consider how often to connect, what setting,
  perhaps during a walk, lunch, stretch class, yoga
  class, sharing joyful moments over tea, or just a
  telephone check-in

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Informal Peer Supervision Groups

• Choose a group of colleagues/friends with similar
  interests
• Allows more comfort than with someone assigned to
  you
• Allows self-assessment in safe environment
• Prevents sense of being alone with ones concerns

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Present CE Workshops

• Half day/day long workshops on self-care
• Workshops on resilience
• Yearly Association conference to include stress,
  trauma, self-care, or resilience workshops
• Utilize resources from APA and others

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Colleague Assistance Programs

• APAs Advisory Committee on Colleague Assistance
  (ACCA)
• Recognize and investigate occupational
  vulnerabilities and need for assistance
• Promote development of state colleague assistance
  programs

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Purposes and Goals of Colleague Assistance
Programs (CAPs)

• CAPs intended to benefit/protect both the public
  the profession
• Educate psychologists on how to prevent
  ameliorate the effects of stress through
  self-care
• Provide treatment and support services for those
  who self-refer or are referred by others
  (including licensing boards)
• The most effective and efficient CAPs result from
  collaboration between psychology associations and
  licensing boards

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CAPs in SPTAs

• Half of associations have never had or no longer
  have CAPs
• A large decrease was seen in the last decade
• The most common reason for discontinuing a
  program was lack of use

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Barriers to CAPs

• Focus on substance abuse or impairment
• Stigma, shame
• Fear of censure or discipline
• Denial of need for assistance
• Lack of models for intervention

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How Associations Can Help

• Develop a CAP for your Association
• Work with Licensing Board and Ethics Committee to
  develop the CAP
• Work with Licensing Board and Ethics Committee to
  utilize the CAP first instead of taking negative
  actions
• Allow the CAP confidentiality within state laws
• Publicize the CAP

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Disaster Response Network Helping Disaster
Responders

• Emphasis on training
• Being ready before, during and after the event
• Utilizing support systems
• Offering information before response
• Checking in after response
• Availability of ongoing support

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Thank you to ACCA members

• Diane Bridgeman, PhD
• Raymond F. Hanbury, PhD, ABPP
• H. Katherine (Kit) ONeill, PhD
• Martha F. Simpson, PhD
• From their presentation at the 2009 APA State
  Leadership Conference Helping Others While
  Helping Ourselves During Challenging Times

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Thank You!

• Raymond F. Hanbury, PhD, ABPP rhanbury_at_verizon.ne
  t,
• H. Katherine ONeill, PhD Kit.oneill_at_ndsu.edu
• Richard A. Heaps, PhD, ABPP richard_heaps_at_byu.edu
  
• Suzan M. Stafford, EdD suzanms_at_verizon.net
• Ester Cole, PhD ester.cole_at_sympatico.ca