The Cost of Caring

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The Cost of Caring

• How working with clients who have experienced
  trauma can affect you and the importance of
  effective self-care strategies
• Roger Higgins
• C2010

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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)

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

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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

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Is it a disorder?

• Is it a disorder or is it a transformation in the
  therapists 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, 1995b151)

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STS 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.

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STS 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.

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Positive Aspects

• Its 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 therapists
  sense of identity and purpose.

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• 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.

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How Practitioners Are Affected

• You cant describe it unless youve seen it.
• You cant explain it unless youve done it.
• You cant imagine it unless youve been there.
• Then it never goes away.
• Bill Blessington, Retired Reporter, Chugiak,
  Alaska (cited in Stamm, 1999 xix)

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6 Common Themes in Relation to STS

• Feelings of helplessness
• Questioning of competence
• Triggering of own issues
• Strong physical feelings
• Intrusive thoughts
• Changes in beliefs/worldview

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HELPLESSNESS

• Helplessness is a common factor in psychological
  trauma (Herman, 1992)
• Trauma therapists can feel a clients 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)

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

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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?

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COMPETENCE

• 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.

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• 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.

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• So my anxieties were all tied up with how I would
  be in the room with the person. It wasnt 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 dont know how to deal with this. What am I
  going to do here? (Louise)

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Fear of re-traumatizing the client

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

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Regression

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

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Think about

• An occasion when you didnt feel competent to
  help your client.
• Did it highlight a specific area where you would
  like more training?
• Should counselors always feel competent?

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Counsellors 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.

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• 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 counsellors previous trauma
  history.

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• You dont 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 dont 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).

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Think 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?

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PHYSICAL 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)

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• Although physical sensations are normal reactions
  to stress, its 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).

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Think about

• Any physical feelings you have been aware of when
  working with clients
• Have these feelings given you any information
  about your clients?

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INTRUSIVE THOUGHTS

• Id 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 clients
  traumatic imagery became entangled with his own.
• I was reliving incidents Id been to, which
  hadnt affected me until this. (Bill)

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• 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 therapists own psychology.
• Pearlman, 1999 61

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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?

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BELIEFS / 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.

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• 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. Id 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 Id seen it as opportunistic
  before and suddenly its very deliberate and its
  very targeted.

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• 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.
  Its made me very aware of personal safety and
  others safety too...
• And I think in some way its taken some of the
  lightheartedness out.
• In a way it shatters the belief that really
  everythings ok...(Louise)

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• 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).

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• 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)

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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?

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Summary of How Practitioners Are 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

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Coping Mechanisms and Self-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)

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Achieving Balance Between 5 Key Areas

• Physical exercise, activity
• Psychological time for self-reflection
• Emotional comforting activities
• Spiritual experiences of awe
• Professional supervision, peer support

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PHYSICAL

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

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• 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 ones body through
  massage, dance, yoga.

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Select those which apply to you and 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

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PSYCHOLOGICAL

• 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 -

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• 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 dont 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)

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

• 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

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EMOTIONAL

• 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 Im dancing... (Bill)
• I do keep a journal when somethings bothering
  me, but sometimes a hug is all you need...just
  the touch, thats all ...(Bill)

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• 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, Ill have a nice glass
  of wine and a hot bath, although in some ways
  its a negative coping strategy. I think if
  youre using an aid, something like that to get
  you there, its a shortcut...(Daphne)

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• 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.

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

• 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

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SPIRITUAL

• 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.

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• 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.

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• 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).

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

• 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

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PROFESSIONAL

• 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.

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• Its made me think about the different types of
  support I need while I work, and this is one of
  the reasons why Ive got more than one type of
  supervision, but its made me think about who I
  want supervision with, and its 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)

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• 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 dont know whether that was just
  me or whether it was her), Not this one again?
  Cant you find something else to bring?

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Peer 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 therapists 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.

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Training

• 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)

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

• 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

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BALANCE

• But I dont think the theme of self-care is
  pushed enough on courses and supervision alone
  isnt the answer. You have to have the other
  things in place to create a balance. (Louise)
• Achieving a balance is paramount. Absolutely
  paramount. (Filomena)

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• 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.

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

• 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.

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CONCLUSION

• 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.

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• 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).