“Counselor Burnout and Vicarious Trauma: Taking Care of the Caregiver”

1. “Counselor Burnout and Vicarious Trauma: Taking Care of the Caregiver” Geoff Wilson, LCSW, LCADC The Offices of Paul Dalton/Lexington Counseling & Psychiatry

2. A Question??? • As a counselor, which of the following elements is absolutely essential for you to do your job well? • a) Thorough grounding in counseling methods and techniques • b) A strong sense of empathy and compassion • c) Adequate sleep • d) Regular vacations or breaks • e) All of the above

3. Stewardship • " As counselors, we're entrusted with people's stories and, at times, their lives. This is an incredible honor and a tremendous responsibility. In counseling, we create space for and honor clients' hardship and pain. To be a good steward of this privilege is to remember the sacredness of this relationship, to maintain the highest ethical practices, to act with integrity, and to honor our responsibility.” (David J Powell, Caring for Self While Caring for Others)

4. Houston, We Have a Problem! • “Counselors who neglect their own mental, physical and spiritual self-care eventually run out of ’oxygen’ and cannot effectively help their clients because all of their energy is going out to the clients and nothing is coming back in to replenish the counselors’ energy.” (Sandra Rankin, ACA)

5. Working in Addiction Treatment • Addiction counseling is another area that requires counselors to have a firm grasp of what they can and cannot do. “Counselors get tired out. They [feel like they] keep banging their heads against the wall because their client’s relapse, but that is the nature of addiction,” he says. That doesn’t mean that clients struggling with addiction can’t be helped, but relapse is often part of the process, and counselors need to be able to make peace with that.(Charles Crews, ACA)

6. Its Not Supposed to be a Two-Way Street • “Wellness is one of the critical factors in being a healthy counselor,” says Stephanie Burns, an adjunct professor of counseling at Heidelberg University in Tiffin, Ohio. “We are asked as professionals to provide a tremendous amount of empathy to our clients. We often listen to very tragic and emotionally difficult stories. We are offering this empathy to the client and offering a place to share these stories, yet our profession is not meant to be a two-way street — the client is not there to provide us empathy. So, somehow, when you do that work on a daily basis, you have to have an outlet to receive things back. Otherwise, you end up depleting yourself and you don’t have anything more to give.”

7. So You’re Having Some Stress!!!!!

8. Distress • Distress is described as the subjective emotional reaction we each experience in response to the many stressors, challenges, and demands in our lives (Barnett, Johnston, & Hillard, 2006). • How is Distress a normal part of our lives? • While distress is a normal part of life, distress left unchecked over time can lead to burnout, what Baker (2003) describes as “the terminal phase of therapist distress”.

9. Key points about distress: • Distress left unchecked may result in an impaired ability to effectively utilize and implement our knowledge, skills, and abilities. • Its development may be a gradual process and fall on a continuum. • The line between distress and impairment may only be seen in the rearview mirror. • We are all vulnerable to some form of distress-related problems with professional competence at some point(s) in our lives and careers. • Distress and problems with professional competence are not discrete entities. They fall along a continuum.(Jeffrey E. Barnett, Psy.D., ABPP)

10. Therapist Burnout • Burnout, a term first coined by Freudenberger (1975), has three components: • Emotional exhaustion, • Depersonalization (loss of one’s empathy, caring, and compassion), and • A decreased sense of accomplishment. • “You can’t pour from an empty cup.”

11. Vicarious Traumatization • When treating clients who were victims of trauma, psychotherapists may themselves be traumatized by the emotionally intense experience of engaging in this type of psychotherapy. This may result in the psychotherapist developing many of the same intrusive and debilitating symptoms for which the client was being treating (Figley, 1995; Pearlman & Saakvitne, 1995).

12. Vicarious Traumatization • Symptoms of vicarious traumatization include: • intrusive thoughts and images related to the client’s disclosures • avoidant responses • physiologic arousal • somatic complaints • distressing emotions • addictive or compulsive behaviors that may adversely impact one’s competence

13. Disengagement • Warnings Signs of Disengagement: • Lack of preparation for interviews • Drift of counselor attention during interviews • Aversion to seeing particular clients • Failure or delays in returning client phone calls • Decreased frequency/length of sessions • Unfocused, superficial content of sessions • Disrespect of clients • Adversarial relationships with clients • Depersonalization of clients (e.g., use of labels) He’s just an addict! • Precipitous, unprocessed terminations

14. Disengagement • Another red flag for practitioners is disengaging in session with clients, West says. “It’s that feeling of sitting with a client and having them talk to you, and in your mind, you’re thinking, ‘I don’t know what this person just said.’ You realize after a period of time that you’ve been thinking about something else and you’ve missed what the client has said. Or it may be noticing that things your client is doing or saying are irritating you more than usual. You might notice that you’re putting a lot of blame on clients for not making progress instead of asking ‘What is my role? How can I help?’” explains West, who co-authored a 2016 Journal of Counseling & Development article on stress and burnout in counselor educators. (Erin M. West, The Battle Against Burnout, March 28, 2018)

15. Here Comes and Ethical Disaster!!!

16. Warning Signs for Therapist Burn-Out • I have disturbed sleep, eating, or concentration. • I isolate myself from family, friends, and colleagues. • I fail to take regularly scheduled breaks. • I enjoy my work less than in the past. • I find myself bored, disinterested, or easily irritated by clients. • I have experienced recent life stressors such as illness, personal loss, relationship difficulties, financial problems, or legal trouble. • I feel emotionally exhausted or drained after meeting with certain clients.

17. Warning Signs for Therapist Burn-Out • I find myself thinking of being elsewhere when working with clients. • I am self-medicating, overlooking personal needs, and overlooking my health. • I find my work less rewarding and gratifying than in the past. • I am feeling depressed, anxious, or agitated frequently. • I am enjoying life less than in the past. • I find myself experiencing repeated headaches and other physical complaints. • I sit staring into space for hours and can’t concentrate on my work.

18. Challenges throughout your career • Undergrad/Graduate students: The impossible situation. Practice good self-care, but do a great job on every assignment, turn them in on time, do research, see clients, make money, have a life... • Early career: Starting a practice or career and starting a family. Expectations and time pressures. • Mid career: Raising a family, finances, running a practice, seeking tenure, (divorce, remarriage, blended families?), etc. • Later career: Raising a family, caring for aging parents, retirement planning, declining health, etc.

19. Thoughts on Self-Care From A Counselor…. • “Engaging in self-care takes discipline, just like eating healthy. On Sundays, I look at my week ahead and I physically schedule time for my kick boxing classes, a few hours on my day off for my nails, a massage, or something fun just for me. I schedule time for myself and I hold myself accountable. • I also plan lunch with my girlfriends twice a month, phone calls with long distance friends, and date nights with my husband. These self-care activities and pleasures feed my soul, rejuvenate me, and are things that make me feel truly happy. When taking time for myself, I’m able to give 100 percent of myself to my clients”. (Amy Mcnamara, LMFT, Counseling Advice: Counselor Self-Care.)

20. Self-Care Assessment • Kramen-Kahn (2002) suggests the following 15 questions to determine ones’ current level of personal self-care. • Do you: • appear competent and professional? • appear warm, caring, and accepting? • regularly seek case consultation with another professional while protecting confidentiality. • at the end of a stressful day, frequently utilize self-talk to put aside thoughts of clients? • maintain a balance between work, family and play? • nurture a strong support network of family and friends? • use healthy leisure activities as a way of helping yourself relax from work? If work is your whole world, watch out! You do not have a balanced life.

21. Self-Care Assessment • often feel renewed and energized by working with clients? • develop new interests in your professional work? • perceive clients’ problems as interesting and look forward to working with clients? • maintain objectivity regarding clients’ problems? • maintain good boundaries with clients, allowing them to take full responsibility for their actions while providing support for change? • use personal psychotherapy as a means of maintaining and/or improving your functioning as a psychotherapist? • maintain a sense of humor? You can laugh with your clients. • act in accordance with legal and ethical standards?

22. Checklist for negative or maladaptive coping practices • I self-medicate with alcohol, drugs (including over the counter and prescription), and food. • I seek emotional support and nurturance from clients. • I keep taking on more and try to just work my way through things. • I try to squeeze more into the day, get more done, and measure success by how many tasks I complete and by how much I can accomplish in a day. • I isolate, avoid colleagues, and minimize the significance of stresses in my life. • I know that distress and impairment are for others and don’t take seriously the warning signs I experience. • I believe that everything will turn out fine just because I say so! (Barnett, 2008)

23. What steps can help the addiction counselor elevate his or her level of ethical practice and what strategies can be used to proactively manage areas of potential ethical vulnerability? • If I were to offer some closing advice to the aspiring counselor, it would include these key points. • Take care of yourself! Effective self-care is an essential precursor to ethical conduct; it is the physically, emotionally and spiritually depleted counselor who is most vulnerable to using clients to meet these unmet needs. • Utilize Mentors! Develop a small cadre of consultants that can provide a sounding board and objective advice on difficult ethical dilemmas. • Ask for help! Seek formal consultation when you are in a zone of vulnerability and when there appears to be an exception to the normal ethical prescriptions.

24. Common Forms of Self-Care • Use of Humor • Relaxing activities such as Yoga, meditation, prayer • Taking Vacations • Exercise • Scheduling Breaks • Engaging in Positive Self-talk • Use of listservs/professional affiliations

25. Integrating Self-Care • To integrate self-care into your daily life, recommend • Make adequate time for yourself. Schedule breaks throughout the day. • Do things you enjoy. Engage in hobbies. • Take care of yourself physically and spiritually. • Take care of the relationships in your life. • Say NO! • Don’t isolate yourself. • Keep in mind that self-care is a good thing.

26. Integrating Self-Care • Watch out for warning signs, such as violating boundaries, self-medicating, wishing patients would not show up, finding it difficult to focus on the task at hand, boredom, fatigue, and/or missing appointments. • Watch out for distress, burnout, and competence problems in your colleagues. • Conduct periodic distress and competence self-assessments and seek help when it is needed. • Focus on prevention. • Make time for self-care! • Seek out personal psychotherapy. • Use colleague assistance programs. • Participate in peer support groups. • Accept that you’re human, in need of assistance, and a work in progress. • Don’t try to be perfect, to have it all, or to do it all. Know your limits and be realistic.(Barnett and Sarnel (2003)

27. A Good First Step….. • A good first step for counselors who realize that they’re in the throes of burnout is to acknowledge it and to talk about it with a trusted colleague, such as a supervisor.

28. Harder to be Engaging if we are Crispy!! • Research has shown that the strength of the therapeutic relationship between the counselor and the client is the most important predictor of successful outcomes.

29. Two Professionals Reflecting……. • Bill White: Do you have a bucket list of things you hope to yet achieve in the field? • Dr. David Powell: Finally, I realize that none of this has ever been about me. I’m at the age now where people are saying nice things about my career, and I value that; however, Bob Stuckey once said to me, “No matter how famous you become, no matter how many letters are after your name, no matter how much money you earn, never lose sight of the fact that you’re in the field to help the alcoholic and the drug abuser. The minute you lose sight of that, you ought to be selling hamburgers.” That’s the issue: it is not about any of us. It is to keep our eye on the prize, which is what drove most of us into this field in the first place. And the prize is the person who’s in recovery and seeing them grow.

30. Helpful Resources!!

31. References • American Psychological Association. (2010). Ethical principles of psychologist and code of conduct. Retrieved from http://www.apa.org/ethics • Baker, E. K. (2003). Caring for Ourselves: A Therapist’s Guide to Personal and Professional Well-Being. Washington, DC: American Psychological Association. • Barnett, J. E. (2008). Impaired professionals: Distress, professional impairment, self-care, and psychological wellness. In M. Herson & A. M. Gross (Eds.), Handbook of clinical psychology (Volume One) (pp. 857-884). New York: John Wiley & sons. • Barnett, J. E., Johnston, L. C., & Hillard, D. (2006). Psychotherapist wellness as an ethical imperative. In L. VandeCreek & J. B. Allen (Eds.), Innovations in Clinical Practice: Focus on Health and Wellness, (257-271). Sarasota, FL: Professional Resources Press. • Barnett, J. E., & Sarnel, D. (2003). No time for self-care? Retrieved October 26, 2014 from http://www.division42.org/StEC/articles/transition/no_time.html. • Case, P. W. (2001). Spiritual coping and well-functioning among psychologists. Journal of Psychology & Theology, 29(1), 29-41. • Elman, N. S., & Forrest, L. (2007). From trainee impairment to professional competence problems: Seeking new terminology that facilitates effective action. Professional Psychology: Research and Practice, 38, 501–509. • Figley, C. R. (1995). Compassion fatigue: Secondary traumatic stress from treating the traumatized. New York: Bruner/Mazel. • Freudenberger, H. J. (1975). The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research, and Practice, 12, 73-82. • Guy, J. D., Poelstra, P. L., & Stark, M. J. (1989). Professional distress and therapeutic effectiveness: National survey of psychologists practicing psychotherapy. Professional Psychology: Research and Practice, 20(1), 48-50. • Kramen-Kahn, B. (2002). Do you “walk your talk”? The Maryland Psychologist, 44(3), 12. • Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist: Counter-transference and vicarious traumatization in psychotherapy with incest survivors. New York: Norton. • Pipes, R. B., Holstein, J. E., & Aguirre, M. G. (2005). Examining the personal-professional distinction: Ethics codes and the difficulty of drawing a boundary. American Psychologist, 60, 325-334. • Pope, K. S., & Tabachnick, B. G. (1994). Therapists as patients: A national survey of psychologists’ experiences, problems, and beliefs. Professional Psychology: Research and Practice, 25(3), 247-258. • Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (1987). Ethics of practice: The beliefs and behaviors of psychologists as therapists. American Psychologist, 42, 993-1006.