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Stress Management For Clients and Their Counselors. Michele D. Aluoch , PCC River of Life Professional Counseling LLC c.2013. The Client’s Stress. Area #1- Not Feeling Listened To. Three Common Assumptions about Listening (Barker, L., & Watson, K., 2000 )

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stress management for clients and their counselors

Stress Management For Clients and Their Counselors

Michele D. Aluoch, PCC

River of Life Professional Counseling LLC

c.2013

area 1 not feeling listened to
Area #1- Not Feeling Listened To

Three Common Assumptions about Listening(Barker, L., & Watson, K., 2000)

  • Speakers control communication more than listeners.
  • We can wait to listen well when we really have to.
  • When someone starts talking people automatically listen.
realities of listening
Realities of Listening
  • Listeners control communication because they can open up communication by engaging or shut it down by tuning out.
  • Listeners use their will to tune in or out to a person.
  • The listener often is the one who puts his/her interpretation into things.
  • Listeners evaluate whether messages are important and valuable or not.
  • Listeners decide to follow through on what the speaker says or to not to that.
  • Listening is not automatic. Rarely can listeners answer more than 4 details of a conversation correctly.
  • Listening takes time and practice.
  • Listeners only remember a small portion of what has been said- 50% immediately after talk, 10% after 1 day.
listening pitfalls
Listening Pitfalls
  • Tuning Out or Halfheartedly Listening
  • Rehearsing Our Responses
  • Assuming Meanings From What the Speaker Says
  • Jumping to Conclusions
four listening preferences
Four Listening Preferences

People- Oriented

Action Oriented

Content Oriented

Time Oriented

people oriented listening
People Oriented Listening
  • Other focused
  • Demonstrates caring and warmth
  • Nonjudgmental
  • Clear verbal and nonverbals
  • Relates to where the other is coming from
  • Focuses on building relationships
  • Notices changes in other’s moods & incongruencies in them quickly
people oriented listening1
People Oriented Listening

Problems

  • Becomes overinvolved in other’s feelings
  • Too empathic and may overlook faults
  • More prone to burnout because internalizes and adopts other’s feelings
  • Sometimes considered overly expressive by others
  • Nondiscriminating in relationships- nice to everyone
  • Exs: counselors, service professionals, teachers
  • Tell stories, use illustrations.
  • Use “we” and focus on teamwork.
  • Be personal.
action oriented listeners
Action-Oriented Listeners
  • Concentrate on the task at hand
  • Frustrated with disorganized people
  • Comes across as impatient to others
  • Focuses on expectations
  • Able to redirect others towards the most important points of things
  • Identifies inconsistencies in messages where things don’t add up
action oriented listeners1
Action-Oriented Listeners

Problems

  • Impatient with people who talk too long
  • Jumps to conclusions quickly
  • Distracted by disorganization
  • Too blunt- pushes people too far too fast in conversations
  • May ask blunt questions
  • Comes across as critical
  • Minimizes the importance of the emotional/feelings in communication because they are too task and thing oriented
  • Exs: Attorneys, financial analysts
  • Keep points to 3 or less
  • Be short and to the point.
  • Speak quickly.
content oriented listeners
Content-Oriented Listeners
  • Evaluate every angle of things
  • Likes digging below the surface to dissect problems
  • Value technical information
  • Wants people to back up what they say with examples and supports
  • Values complexities
content oriented listeners1
Content-Oriented Listeners

Problems

  • Overly detailed
  • May come across as intimidating because knows so much
  • Asks pointed questions
  • Devalues info. from people who don’t know their job
  • Takes time to make decisions after studying all the angles of things
  • Exs: scientists, mathematicians, engineers
  • Provide the data.
  • Quote experts and statistics.
  • Use charts and graphs.
time oriented listeners
Time Oriented Listeners
  • Sets time boundaries for conversations
  • Gives guidelines for conversation
  • Does not want “wasted” time
  • Tells others when they are “wasting” time
time oriented listeners1
Time Oriented Listeners

Problems

  • Impatient with time wasters as he/she see it
  • Interrupts others
  • Not good at concentrating and just hearing others in the moment
  • Rushes others by watches and clocks
  • Squelches creativity because so focused on time and clocks
  • Go under time limits if you can.
  • Avoid unnecessary exs.
  • Watch their impatience level.
top ten listening hindrances barker l watson k 2000
Top Ten Listening Hindrances(Barker, L. & Watson, K., 2000)
  • Interrupting the speaker.
  • Not looking at the person who is talking.
  • Rushing the speaker and communicating thereby that his/her message is unimportant. Not letting the speaker tell the whole thing.
  • Showing interest in things other than the conversation at hand.
  • Getting head of the speaker and finishing or concluding what he/she is saying.
top ten listening hindrances barker l watson k 20001
Top Ten Listening Hindrances(Barker, L. & Watson, K., 2000)
  • Not doing what the speaker requests.
  • Saying, “yes- BUT” which shows that the speaker doesn’t matter as much as what you want
  • Stopping the speaker by relating things to yourself.
  • Forgetting what the speaker talked about.
  • Asking too many questions about details. Not doing what the speaker requests.
nonverbal listening
Nonverbal Listening
  • Body language= up to 93%
  • Words can hide secrets whereas body language gives more clues
  • 1st 10 seconds= most important
  • Cautions: defining things by a single gesture alone without context
  • Cultural background must be considered
  • First obtain baseline behavior
  • Factors to consider:
  • Status in society fashion subculture
  • The gaze of person- direction, length of gaze
  • What eyebrows do
  • Touch- spatial relations and how touch is used
nonverbal listening1
Nonverbal Listening
  • Direct look
  • Lean slightly in
  • Smile gently
  • State the person’s name and shake hand
  • Take turns communicating
  • Angling your body toward the speaker
  • Use regular head nods
  • Reflect the speaker’s emotions
issue 2 client s expectations
Issue #2- Client’s Expectations
  • Advertisements/Marketing of Your practice
  • Insurance panels Bios.
  • Your website
  • What they thought they gave consent for
  • Their understanding of what therapy is/is not
  • What they think your title or credentials are or mean
  • What they think your certifications, licenses or certificates are for
  • How they perceive the environment physically
  • How they perceive you, office staff, colleagues, other clients
issue 3 informed consent
Issue #3- Informed Consent
  • Extent and nature of services
  • Pros and cons (counseling in general, electronic counseling, phone counseling, techniques used, setting)
  • Limitations
  • In clear, understandable, non-technical language
  • Specified provider name
  • Therapist’s responsibility to make sure the client understands (e.g. if cannot read, blind, etc.)
  • Defines role of counselor (versus mediator, court guardian, expert witness)
  • Expectations of both therapist and client behaviors
  • Risks/benefits of therapy
  • Qualifications of the therapist
  • Financial considerations and responsibilities
issue 4 assessment diagnosis
Issue #4- Assessment/Diagnosis
  • Why we as the questions we do
  • What the diagnosis mean
  • s
  • Who knows what
  • Unethical- therapist as moral agent, client no longer autonomous person coming for help
  • Ethical- based on observation of concrete, observable or clients self reported behaviors compared to “norms” and researched and studies standards
  • with respect to client perspectives and worldview
  • with full information and informed consent
  • under a specific “contract” outlining terms of the clinical relationship
issue 5 treatment p lanning
Issue #5- Treatment Planning
  • What goals the client will by into
  • Client desires
  • What client perceives to have worked/not worked so far
  • How involved client wants to get in the therapeutic process
  • How goals are measured
  • Operational definitions of measurable goals
  • How achievable goals are
  • Competing demands therapist’s hopes, clients’ hopes. Referring agency, insurance company, family/friends, employers/schools/physicians
issue 6 client s perceptions of your competency
Issue #6- Client’s Perceptions of your Competency
  • How the client defines competency
  • Board requirements regarding licensure, certifications, and disclosure statements in office
  • Client’s assumptions about your title and ability to clarify or correct these
  • Techniques used
issue 7 readiness or resistance
Issue #7- Readiness or Resistance

A) RESPONSE QUALITY RESISTANCE

  • Silence
  • Minimal talk
  • Incessant talk

B) RESPONSE CONTENT RESISTANCE

  • Intellectualizing everything to avoid discussion of emotions
  • Preoccupation with symptoms
  • Small talk
  • Rhetorical questions bout the counselors decisions on hmwk, assumptions of Dx, etc.
issue 7 readiness or resistance1
Issue #7- Readiness or Resistance

C) RESPONSE STYLE RESISTANCE

  • Discounting (yes BUT ____)
  • Limiting topics in session
  • Blaming others
  • Second guessing the counselor (“are you saying or meaning ___?”)
  • Reporting only positives
  • Seductiveness
  • Forgetting supplies or materials
  • Disclosure at last minute
  • Habitually breaking promises

D) LOGISTIC MANAGEMENT RESISTANCE

  • Poor appointment keeping
  • Payment delay or refusal
  • Personal favor asking
common defense mechanisms clark a j 1991
Common Defense Mechanisms(Clark, A.J., 1991)
  • Outside awareness initially
  • Habitual
  • Useful (in client’s perception)

Denial- rejecting responsibility

  • “I don’t have a problem.”
  • “Nobody ever told me.”
  • “I didn’t know.”

Displacement- shifting responsibility to a vulnerable substitute

  • “I couldn’t control my behavior because of that stupid overbearing teacher.”
  • “A few drinks just cause me to do things I don’t expect.”

Identification- acting like someone he/she admires

  • “I have a good heart just like my brother.”
  • “My family may have it’s flaws but we all are hard working.”
  • “I can be just as competitive as the next guy when things comes down to it.”
common defense mechanisms clark a j 19911
Common Defense Mechanisms(Clark, A.J., 1991)

Undoing- Trying to reverse an unhealthy behavior by doing something opposite

  • “I drank all weekend but when I came to my senses I realized this isn’t me so I threw all the liquor in the house down the drain.”
  • “I know I mouth off and get out of control but I am the most gentle and apologetic person afterwards.”
common defense mechanisms clark a j 19912
Common Defense Mechanisms(Clark, A.J., 1991)

Intellectualization- avoiding unpleasant feelings which are perceived as “negative” and make someone feel vulnerable

  • “Drinking on occasions is not like getting drunk, you know.”
  • “I just have a different way of getting things done than what my boss wants.”

Projection-attributing unacceptable behaviors to others that are really characteristic of self

  • “It seems like you don’t want this counseling to help me. You disagree with me.”
  • “They said I didn’t perform on my job.”
  • “If that fool would have gotten out of the way I wouldn’t have hit him in the drunk driving incident anyway.
common defense mechanisms clark a j 19913
Common Defense Mechanisms(Clark, A.J., 1991)

Rationalization-Justifying one’s behaviors

  • “Everyone lies to their parents.”
  • “All people steal some of the extra supplies on the job that aren’t being used.”
  • “Most parents get frustrated with their kids and lose control at times.”

Reaction formation- Exaggerating claims of highly moral actions and attitudes

  • “I would never get tempted to do anything like that.”
  • “I organized the community fair against that kind of behavior.”
common defense mechanisms clark a j 19914
Common Defense Mechanisms(Clark, A.J., 1991)

Regression-returning to an earlier stage of maturation and development

  • “I had these kids young. It is my time to live . What’s wrong with dressing in their clothes and going to clubs. I missed out.”

Repression-Resisting discussing or approaching topics or barring self or others from certain topics

  • “I don’t recall anything like that.”
  • “I don’t ever remember disobeying my parents.”
dealing with defense mechanisms
Dealing With Defense Mechanisms

Relationship stage

  • Identify specific defenses for that client
  • Generally will be the same ones they use with you
  • Use advanced empathy to understand and help them understand why they habitually relied on them
  • Sentence completion exercises help

Integration stage

  • Distortions are confronted
  • Lack of congruency is brought to the client’s attention

Accomplishment stage

  • Productive actions and alternatives are highlighted
  • Client is encouraged to act differently as he or she would like to be
  • Alternative behaviors are maintained
  • A strengths-based approach is used
issue 8 perceptions of process v ariables
Issue #8- Perceptions of Process Variables
  • Still critical foundations for success
  • Empathy
  • Non possessive warmth
  • Genuineness
  • Whose are these? (Counselor Versus Client?)
  • Hypothesis #1: Good counselors enhance treatment when they have high levels of these variables.
  • Hypothesis #2: Clients determine the levels of variables. Good clients elicit high variables but poor clients elicit low variables.
  • NON-POSESSIVE WARMTH- mutual function
  • EMPATHY/GENUINENESS- under control of the therapist
client s perceptions of what predicts therapeutic alliance duff c t bedi r p 2010
Client’s Perceptions of What Predicts Therapeutic Alliance (Duff, C.T., & Bedi, R.P., 2010)
  • Therapeutic alliance=most robust predictor of outcome than techniques
  • Three critical factors: making encouraging statements, making positive comments about the client, greeting the client with a smile
  • Others listed:
  • Asked me questions
  • Identified and reflected back feelings
  • Was honest
  • Validated my experience
  • Made eye contact with me
  • Referred to details discussed in previous sessions
  • Sat still and did not fidget
  • Sat facing me
  • Told me about similar experiences he/she had
  • Let me decide what to talk about
  • Kept the administration outside of our sessions
mattering to others rayle a d 2006
Mattering To Others (Rayle, A.D., 2006)
  • Internal need to feel significant:
  • A) general mattering
  • B) interpersonal mattering
  • Why do I exist? What difference do I make?
  • Do others notice me?
  • Are my interactions with others different because of me?
  • Do I have the social supports I desire?

*** Counselors can have a significant role in shaping mattering.***

issue 9 successful intervention
Issue #9- Successful Intervention
  • Elements of Helpful Counseling Interventions(Miller, G., 1997)
  • Promote empathy, encouragement, and positive approach to addressing problems
  • Assist clients in attending to previous unattended areas
  • Shifts clients from a problem focus to a solution focus
  • Plants the seed that there will be a time where the issue does not have to have a negative hold on the client (Getting the client to imagine not having the problem anymore)
  • Shift from constructing problems/analysis to constructing solutions
  • Reinforcing how the client manages to get by
  • Emphasis on increasing the frequency of healthy behaviors
issue 10 confidentiality privacy
Issue #10- Confidentiality/Privacy
  • Has to do with private information being protected through reasonable expectation that it will not be further disclosed except for the purpose for which it was provided

Areas Protected:

  • Whether or not a person has been a client
  • The frequency and intervals of appointments
  • Types of treatment or services received
  • Reasons for treatment
  • Specific words, behaviors or observations during treatment
  • Client diagnosis
  • Course and prognosis of treatment
  • Summaries and recommendations
confidentiality privacy
Confidentiality/Privacy
  • Requires informed consent- specifying what consenting to, with discussion to client about advantages and disadvantages and potential limitations of disclosure
  • Should be in your policies and procedures about confidentiality, possible breaks of confidentiality and how this is should be handled
  • Should be in writing and signed by all parties
confidentiality privacy1
Confidentiality/Privacy
  • Information cannot be disclosed in court proceedings unless both: 1) a subpeona has been issued 2) a court order has disclosure. Then court must find that the need for information outweighs the public policy for confidentiality (42 CFR 2.61-2.65 and 45 CFR 164,512 (e) (1) (ii)
  • By law confidentiality continues even after the death of the patient, death of the therapist or sale of the practice to others
  • “When in doubt don’t give it out.”
issue 11 therapist openness disclosure
Issue #11- Therapist Openness/Disclosure

Reasons to Disclose

  • Fostering therapeutic alliance
  • Modeling freedom for clients to disclose
  • Reducing client’s sense of being alone in his/her problems
  • Increasing sense of realness in the counselor
  • Sidney Jourard’s idea of “dyadic effect”: “disclosure begets disclosure”- people are more likely to be open with interviewers who themselves are open than with interviewers who express little or nothing of themselves”

Reasons against Disclosure

  • Shifting focus off the client
  • Using counseling time
  • Role confusion
therapist openness disclosure
Therapist Openness/Disclosure

What May Be Disclosed:

  • Professional identity/credentials
  • Educational background
  • Professional experiences
  • Professional Successes or failures
  • Counselor Cognitions and emotions related to the client life Experiences
  • Personal Feelings
  • Personal Life Successes or Failures
  • Personal Values
  • Personal Beliefs
  • Personal Attitudes on Topics
  • To Be individualized to each client
three dimensions of self disclosure jeffrey a austin t 2007
Three Dimensions of Self Disclosure(Jeffrey, A., & Austin, T., 2007)
  • The amount of disclosure
  • The intimacy of information shared
  • The duration of disclosure
  • Within each there are the issues of where the disclosure is positive or negative, personal or demographic, similar or dissimilar, past or present.
what clients said was helpful disclosure
What Clients Said Was Helpful Disclosure
  • Acceptance and Encouraging
  • Ensuring Attention
  • Body Language
  • Silence (Listening)
  • Open and Closed Ended Questions
  • Reflection of the Content of Sessions
  • Disclosure of Feelings
  • Reflection of Feelings
  • Self Disclosure
  • Confrontation
  • Key- developing an understanding of what each operationally means to a given client
how clients judged if disclosure was helpful
How Clients Judged if Disclosure Was Helpful
  • It built my confidence.
  • It helped me share more.
  • I felt relieved afterward.
  • I had more respect for the therapist and/or the clinical relationship.
frequency of reasons to self disclose simone d h mccarthy p skay c l 1998 p 179
Frequency of Reasons to Self Disclose(Simone, D.H., McCarthy, P., & Skay, C.L., 1998, p.179)
  • Promote feelings of universality-85
  • Encourage client and instill hope- 81
  • Model coping strategies- 71
  • Build rapport and foster alliance-68
  • Increase awareness of alternative views- 67
  • Provide reality testing-38
  • Decrease client anxiety-37
  • Prevent client idealization of counselor-36
  • Increase self disclosure through modeling/reinforcement-31
  • Increase counselor authenticity-29
  • Decrease client resistance-8
  • Dilute transference near termination-7
  • Challenge the client-4
  • Decrease general transference-3
  • Prevent transference with clients who have poor reality testing-3
  • Provide counselor satisfaction-1
  • Decrease counselor anxiety-0
frequency of reasons not to self disclose simone d h mccarthy skay c l 1998 p 179
Frequency of Reasons Not to Self Disclose(Simone, D.H., McCarthy, ., & Skay, C.L., 1998, p.179)
  • Avoid blurring boundaries- 107
  • Stay focused on the client-99
  • Prevent concern about counselor welfare-67
  • Prevent merging-54
  • Prevent premature closure-45
  • Avoid information overload and confusion-40
  • Prevent client feeling burdened by counselor problems-39
  • Avoid interfering with transference-28
  • Prevent client demoralization by counselor success/failure-25
  • Avoid giving client information to manipulate counselor-20
  • Avoid counselor discomfort-14
  • Prevent client questioning counselor’s ability to help-11
  • Avoid questions about counselor’s mental helath-9
  • Prevent client communicating information about counselor-4
  • Avoid losing credibility as an expert-3
questions to consider regarding disclosure
Questions to Consider Regarding Disclosure
  • Have I paused to evaluate this potential disclose beforehand?
  • Why am I disclosing?
  • How will this help the client’s goals in counseling?
  • Are there conditions which necessitate this disclosure? If so, what?
  • Are there other ways of approaching the client’s issue that may be as effective as disclosure?
  • Is there any potential harm or danger to the client from this potential disclosure?
  • Does the client have the ego strength for this disclosure?
  • Will this disclosure blur professional boundaries?
  • How will this disclosure help the client emotionally (instilling hope, moving toward counseling goals, feeling less alone)?
  • Could the client end up feeling demoralized by my disclosure?
  • Will this disclosure help with reality check?
  • Possibly test out a lower level disclosure first (e.. an obvious topic the client may be wondering about) versus a more detailed deliberate disclosure
self disclosure with children teens capobianco j farber b a 2005 gaines r 2003
Self Disclosure With Children/Teens(Capobianco, J., & Farber, B.A., 2005 & Gaines, R., 2003)
  • Children/teens require a higher degree of self disclosure.
  • Children may elicit and require a higher level of therapist disclosure
  • All information on you is a type of disclosure for a child/adolescent (mannerisms, dress, décor, word you use/don’t allow, etc.)
  • Children/teens generally less rigid than adults.
  • Find the meaning for the child (what is the symbolism behind it?)
  • Keep in mind age, maturity level, culture, an individual variables unique to this child/teen.
  • Our reactions to the child’s behaviors disclose something to (e.g. how we handle misbehaviors, how to set boundaries, how we handle parent/child interactions, play allowed
issue 11 cultural sensitivity
Issue #11: Cultural Sensitivity
  • Counseling is culture infused so the working alliance must be culture infused when necessary
  • The worldview, orientation, race, ethnicity, identity factors, abilities, religion, socioeconomic status, language, music, hobbies, traditions, beliefs, etc.
  • Three areas of competency:
  • Domain I: Self: active awareness of personal assumptions, values, and biases
  • Domain II: Cultural awareness: Other- Understanding the worldview of the client
  • Domain III: Culturally Sensitive Working Alliance: (respect, goal formation, collaboration throughout)
discursive empathy sinclair s l monk g 2005
Discursive Empathy(Sinclair, S.L. & Monk, G., 2005)
  • Also called “discursive” empathy

Not only 1) perceiving the client’s view

  • Or 2) communicating this to the client
  • But also … 3). incorporating the culture framework and backdrop
  • 4). while keeping our separateness
  • Involves “deconstruction”- exploring assumptions and what they are made up of to reinforce or challenge them

What this achieves:

  • 1. clarifies the client’s position and values
  • 2. helps the clients become more reflexive
  • Increases client’s ability for choice, freedom and self-development
  • “no study found that showed that empathy is harmful”
issue 12 doing confrontation
Issue #12: Doing Confrontation
  • Open, Honest identification of self defeating thoughts or behaviors
        • identify the cycle
        • help client increase awareness of thoughts and behaviors which keep the unhealthy cycle going

Functions

  • bringing contradictions to light
  • helping develop congruency
  • admit personal needs
  • keys:
  • timing
  • genuineness and empathy of counselor
  • foundations of rapport and trust built
issue 12 doing confrontation1
Issue #12: Doing Confrontation

Types of Confrontation

  • body language and words do not match up
  • two verbal comments do not match up
  • words and long term behaviors are incongruent
  • one person’s behaviors influence the system negatively
issue 1 therapist expectations
Issue #1: Therapist Expectations

What I Expect of The Mental Health Field

What I Believe Is Expected of Me In My Job Setting

My Company ShouldMy Company Actually

the interpersonal cycle of burnout geurts s schaufeli w dejonge j 1998
The Interpersonal Cycle of Burnout( Geurts, S.,Schaufeli, W., & DeJonge, J., 1998)
  • Cognitive thoughts regarding injustice
  • Social comparison
  • Communication with colleagues
  • Reactions to ambiguous criteria for success

EQUITY

EXPECTED CONTRIBUTIONS

EXPECTED BENEFITS

  • Sense of negative norms in the setting
  • Discrepancies between investments and outcomes
  • Availability of positive alternatives
  • Discrepancies between “shoulds” and actualities
issues in job satisfaction graduate school instruction expectations
Issues In Job SatisfactionGraduate School Instruction/Expectations
  • Client loads
  • Ability to help others
  • Ability to have freedom to schedule and build practice in own personal style
  • Time frame for building a caseload
  • Role models witnessed- grad school, practicum, internship, mentors, TV, coursework, volunteering, etc.
  • Dealing with uncontrollable variables
  • The practice versus the business
  • Enthusiasm to help versus practical mgmt. of tasks involved
  • The many facets of counseling: Community, private practice, teaching, administration, assessment, crisis work, consultation
issues in burnout institutional goals
Issues in Burnout: Institutional Goals
  • QUESTION: DOES EVERYONE EXPERIENCE IT?
  • 10 year life span
  • 60%-90% depression rates in mental health professionals
  • Is the pay worth the “emotional” cost?
  • Mission of the organization versus personal mission- partnership?
  • Administrative tasks, counseling tasks, associated tasks
  • Proportion of job/home/personal life expected from this setting
  • How is this job affecting my home? Interpersonal? Other life?
issues in burnout institutional goals1
Issues in Burnout: Institutional Goals

HealthyUnhealthy

Strong commitment of employees Weak commitment of counselors

Strong availability/support from staff Isolation, weak involvement of staff

Co-worker relationships- encouraged Minimal opportunities for rel.

Support supervision Low collegial support

Specific, concrete expectations Ambiguous/changing expectations

Freedom for some autonomy Discouraging new ideas/creativity

Reasonable deadlines Excessive unrealistic time pressure

Some staff retention High turnover of staff

Sense of purpose/fulfillment Doubt as to meaning/purpose

Clients who want help Mandated clients

Realistic specific goals Goals which cannot be achieved

Solid clinical identity Need to be liked by clients

Facilitator, counselor Responsible for change

Separation self/client Self tied to client outcomes

Setbacks are one part Setbacks as personal

what agencies can do to support wellness
What Agencies Can Do to Support Wellness
  • Educate your staff and supervisors on the concepts of impairment, vicarious traumatization, compassion fatigue and wellness.
  • Develop or sponsor wellness programs (such as in-service trainings and day-long staff retreats)
  • Provide clinical supervision (not just task supervision)
  • Encourage peer supervision
  • Maintain manageable caseloads
  • Encourage/require vacations
  • Do not reward "workaholism"
  • Encourage diversity of tasks and new areas of interest/practice
  • Establish and encourage EAPs
issue 2 time schedule
Issue #2- Time Schedule
  • Balancing counseling tasks with non-counseling tasks (setting, time mgmt., how this fits in with initial goals for entering field

Proposals

  • Blocking time for tasks
  • Scheduling certain days for certain functions

Exercise:

  • Ordering the clients in your schedule- cards
issue 3 client vs therapist goals
Issue #3- Client Vs. Therapist Goals
  • Specific
  • Measureable
  • Achievable
  • Broken down into manageable parts
  • Concrete, behavioral
  • Evidence based
  • Tailored to the specific client
  • Try camera check method to make goals concrete and behavioral. Tends to help produce operational definitions.
client vs therapist goals
Client Vs. Therapist Goals
  • Problems are rarely so well defined and linear:

if only ___, then ___.

  • Many interactional variables occur at the same time.
  • Any given person only has a portion of the information.
  • Sometimes the most important variables are not always revealed.
  • Timing of decisions may be as important as the “rightness or wrongness” of decisions.
  • Decisions are interdependent- one decision affects others.
  • Goals in decision making may sometimes be contradictory.
  • Plan for correction and modification.
exercises what s wrong with these goals
Exercises: What’s Wrong With These Goals?

Poor GoalsImproved Goals

To improve client’s

sense of self confidence.

To help the client have

greater self satisfaction.

To improve communication

skills.

exercises what s wrong with these goals1
Exercises: What’s Wrong With These Goals?

Poor GoalsImproved Goals

For parent and child to

fight less.

To feel less depressed.

For things not to get to the

client as much as they do.

issue 4 not paying attention to stress burnout as it occurs
Issue #4- Not Paying Attention To Stress/Burnout As It Occurs

Emotional Exhaustion

  • “I feel drained by this work.”
  • “ I feel used up by the end of the workday.”
  • “ I am fatigued when I get up in the morning and have to face another day on the job.”
  • “Working with people all day drains me.”
  • “I feel like I’m at the end of my rope.”
  • “I have no energy left after I counseling people.”
not paying attention to stress burnout as it occurs
Not Paying Attention To Stress/Burnout As It Occurs

Sense that one can no longer give as much of oneself

to clients professionally

“I feel like this job takes too much out of me.”

“This job is more tiring and less pleasurable than it used to be.”

Increasingly cynical attitudes about the counseling field

“I can see why my clients are fed up with the system.”

Negative/critical self evaluations

“I don’t feel like I am making as much of a difference in people’s lives as I ‘should’ be or I would like to be making.”

factors in burnout
Factors in Burnout
  • Cognitive Expectations:

Self

Setting

Clients

  • Time spent in field
  • Types of cases
  • Personal “controllability” over caseload, scheduling, etc.
  • Degree of balance in life in general
irrational beliefs of burnout prone therapists deutsch 1984
Irrational Beliefs of Burnout Prone Therapists(Deutsch, 1984)
  • “I should always work at my peak level of enthusiasm and competence.”
  • “I should be able to cope with any client emergency.”
  • “ I should be able to help every client.”
  • “Client lack of progress is my fault.”
  • “I should always be available when clients need me.”
  • “I should be able to work with all types of clients.”
  • “I should be on call always.”
irrational beliefs of burnout prone therapists deutsch 19841
Irrational Beliefs of Burnout Prone Therapists(Deutsch, 1984)
  • “Client needs come before my own needs.”
  • “I am responsible for my client’s behaviors.”
  • “I have power to help, control, or fix a client.”
  • It’s selfish to put myself first.
  • There’s no time for self care.
  • I can’t do this on my own.
the cognitive behavioral cycle
The Cognitive- Behavioral Cycle
  • Feelings
  • Thoughts/Beliefs
  • Intensified Feelings
  • Goals
  • Behaviors/Actions
  • NOTE: personal patterns as a therapist of these

Toxic Thoughts

  • SHOULDS
  • IF ONLY _____ THEN _____
  • ABSOLUTES: ALWAYS/NEVER
      • STRONG/WEAK
      • GOOD/BAD
  • HAVE TO
  • GOAL OF DOING “ENOUGH”

Toxic Actions

  • Just keep trying harder/doing more
  • Give up/withdraw
cognitive debating strategies
Cognitive Debating Strategies
  • Is this a fact or just an opinion?
  • Is there any other way of looking at this?
  • According to whom?
  • Is this belief life giving or death producing?
  • If this belief is not helpful to me how can I continue telling myself this?
healthier self messages
Healthier Self Messages

I would like to do my best with this effort, but I do

not have to be perfect.

I\'m still a good person even when I make a mistake.

I can do something well and appreciate it, without it being perfect.

I will be happier and perform better if I try to work at a realistic level, rather than demanding perfection of myself.

It is impossible for anyone to function perfectly all the time.

Signs of burnout are not my fault as a “weak” person.

issue 5 balancing competing responsibilities
Issue #5: Balancing Competing Responsibilities
  • To assess clients
  • To diagnose clients
  • To provide relevant treatment for DSM IV disorders
  • To do insurance paperwork
  • Billing
  • Case notes
  • Up to date education/CEUs
  • Consultation with colleagues
  • Awareness of and adherence to agency policies
issue 6 dealing with problem spots
Issue #6: Dealing With Problem Spots

Struggles of Counselors

  • Admitting that they have any problems
  • Admitting that they need outside help
  • Setting boundaries regarding time in session and fees
  • Marketing for services
  • Knowledge of and skill development in business relations
  • Negotiating on client’s behalf
caseload versus workload
Caseload Versus Workload

Caseload= highly related to burnout

      • Highly intense clients
      • Mandatory referred clients
      • Types of clients
      • Variations of diagnoses

Workload- the actual amount of time spent in client contact and work related functions

Mediator variables

  • Support systems
  • (e.g. community mental health center example)
  • Self perception of level of effectiveness
issue 7 maintaining counselor wellness
Issue #7: Maintaining Counselor Wellness

Defining Counselor Wellness

Both an outcome and a process

Involves several dimensions

physical
Physical
  • Sleeping
  • Eating healthy
  • Alertness/being aware and attentive to clients
  • Ability to physically accomplish the tasks of counseling
  • Regular schedule of meals
  • Sufficient liquid intake
  • Awareness of hunger and thirst
  • Limiting sugar intake
  • Routine physical exams
  • Self monitoring personal physical needs
  • Creating a warm environment: music, flowers, pictures
  • Breaks (with non-counseling content)
emotional
Emotional
  • Skills in helping clients identify and process their feelings and issues
  • Balancing insight, awareness and action
  • Allowing for balance between social time and time alone
  • Professional training/competency
  • Caseload evaluation
  • Vacations/breaks
  • Daily recognition of small victories in spite of challenge
  • Flexible thinking
  • Revisiting successful client files
  • Re-evaluating personal growth throughout time in practice
  • Journal of successes and victories
  • Accountability with colleagues- to help affirm strengths
  • Involvement in interests or projects outside themselves
  • Limited the number of one way relationships
behaviors of healthy self care
Behaviors of Healthy Self Care
  • Look at own unresolved issues with clients or supervisee’s clients
  • Have a network of other supervising counselors to speak with
  • Set aside time for healthy lifestyle behaviors: eating, sleeping, exercising
  • Allow space from the clinical setting
  • Permit self to not be a caretaker and caregiver for everyone (e.g. see “Letting Go” Poem)
  • Take time off when necessary
  • Reconceptualize being a supervisor not as one with all the answers (promotes burnout) but a more experienced facilitator
  • Keep a clear contract (modify if necessary) in writing what job roles and tasks are
  • Charge an appropriate fee
  • Keep your own professional development up to date
  • Keep an idea about expectations ahead of time so there is some structure for supervision sessions
  • Have an idea ahead of time about how you will let go of stress at the end of the work day
includes life tasks of wellness myers j e sweeney t j witmer j m 2000
Includes Life Tasks Of Wellness(Myers, J.E, Sweeney, T.J., & Witmer, J.M., 2000)

Spirituality

  • a sense of where I am in the universe
  • personal and private beliefs about self, others, and the world
  • hope and optimism
  • a sense of meaning and purpose
self direction
Self Direction
  • mindfulness and intentionality toward achieving personal goals
  • higher levels of perceived self control
  • acceptance of the whole self (shortcomings and strengths)
  • realistic beliefs- reduction in irrational thoughts, absolutes, and polarized thinking, or magnifying one aspect of situations
  • emotional awareness and regulation
  • developing creative problem solving
  • goal setting and plans for a personal and cultural identity
work and leisure
Work and Leisure
  • satisfaction at challenges of task completion and quality of work
  • a sense of competency
  • balancing work and relaxation (doing versus being)
work and leisure1
Work and Leisure
  • Leisure (Iwasaki, Y., 2003)

2 Coping Models:

  • The Deterioration Model- the presence of stressors reduces levels of resources that could have a negative effect on well being, all about conserving resources and protecting their loss
  • The Counteractive Model- Stressors elevate proactive resources which enhance well being
leisure kleiber d a hutchinson s l williams r 2002
Leisure(Kleiber, D.A., Hutchinson, S.L., & Williams, R., 2002)

Four Functions of Leisure

1) Serves as a distraction away from negative life events- temporary suspension from them (Pallative coping & Leisure mood enhancement)

2) Generating optimism about the future- cognitive reappraisal, consideration of possible perspectives

3) Reconstruction of one’s life story- back to “normal”

4) To assist with personal transformation- writing the story and planning for different endings

friendship
Friendship
  • relational connection with others
  • asking for help when needed
  • extending outreach to others
slide85
Love
  • building trust in ability to give and receive from others
  • stability in close relationships
  • knowing someone really cares for you
  • Goal of Counseling= to develop a personal wellness plan
concept of counselor stamina osborn c 2004
Concept of Counselor Stamina(Osborn, C., 2004)

Stamina- strength to withstand and hold up under pressure

Seven Principles of Counselor Stamina:

  • Selectivity- intentional choosing what one will and will not do
    • tasks
    • populations served
    • number of cases
    • limiting “specialty” areas
    • reasonable goals/objectives
concept of counselor stamina osborn c 20041
Concept of Counselor Stamina(Osborn, C., 2004)

2.Temporal selectivity- time consciousness

  • sessions
  • planning days
  • juggling tasks
  • work/personal
  • spacing of sessions
concept of counselor stamina osborn c 20042
Concept of Counselor Stamina(Osborn, C., 2004)

3. Accountability- partnering with credible colleagues

  • Standard of care
  • Ethics
  • Current practice

4. Measurement/management- conserving and budgeting resources

    • Role clarifications
    • Supportive, positive capable personnel choices
concept of counselor stamina osborn c 20043
Concept of Counselor Stamina(Osborn, C., 2004)

5. Inquisitiveness- fascination with people and their journey in life

  • “mutual puzzling”
  • Desire for ongoing learning

6. Negotiation-flexibility

  • Diagnosis within context
  • Cultural and personal sensitivity
  • Re-evaluation of “counselor as expert”
concept of counselor stamina osborn c 20044
Concept of Counselor Stamina(Osborn, C., 2004)

7. Acknowledgement of agency

  • Focus on personally meaningful goals
resiliency
Resiliency

Resiliency

Hardiness- mediates effects of stress

  • Feeling in control
  • Commitment to the work
  • Change is a challenge
resiliency1
Resiliency
  • “More than education, more than experience, more than training, a person’s resilience will determine who succeeds and who fails.”
  • Adaptation under adversity
  • The ability to recover from psychological harm
  • Not being defined by earlier negative experience
  • To jump, to spring back, to rebound
  • Survival, adaptation, recovery, risk assessment
resilience models
Resilience Models
  • Dispositional/Trait Models
  • Protective Factors
  • Risk Factors
  • Protective and Risk Factors combined
personality qualities of resilient people
Personality Qualities of Resilient People
  • Acceptance of reality
  • Strongly held values
  • Sense that life is meaningful
  • Optimism without distortion
  • Hope
  • The ability to make do with whatever is set before them
  • Cognitive flexibility
  • Balance between expressing and concealing emotion and between positive and negative emotion
dispositional resilience rossi n e bisconti t l bergeman c s 2007
Dispositional Resilience(Rossi, N.E., Bisconti, T.L., & Bergeman, C.S., 2007)
  • Is resilience a personality trait?

1)Commitment (involvement with people)

2) Control (influence over outcomes rather than powerlessness)

3) Challenge (learning from experience)

Those who support this view claim that virtues can be cultivated if innate inclination: self discipline, compassion, friendship, work, perseverance, honesty, loyalty, truth, selflessness (Hall, S.E., 2006)

  • Stress cultivates dispositional resilience (more effective coping strategies, support seeking)
hope theory grewal p k porter j e 2007
Hope Theory (Grewal, P.K., & Porter, J.E., 2007)

Two components:

1) Agency- belief that goals can be met, goals are manageable and achievable

2) Pathways- Actual behavioral plans of implementing goals

  • May need to be taught:
    • Recalling past successes
    • Naming and reconceptualizing goals
    • Accountability for actions and follow through
four categories of hopeful goals cheavens j s feldman d b woodward j t snyder c r 2006
Four Categories of Hopeful Goals(Cheavens, J.S., Feldman, D.B., Woodward, J.T., Snyder, C.R., 2006)
  • Approach goals- moving toward a desired outcome
  • Forstalling negative outcomes- deterring unwanted consequences
  • Maintenance goals- sustaining the status quo
  • Enhancement goals- augmenting positive outcomes
reasonable hope weingarten k 2010
Reasonable HopeWeingarten, K., 2010

1. Relational- community of others

2. A Practice- not in isolation, not just one goal

3. Maintains that the future is open, uncertain, and influenceable- realistic but full of possibilities

4. Seeks Goals and Pathways to Achieving Them- willing to do trial and error and modify as needed

5. Accomodates doubt, contradictions, and despair- life can be messy

  • Can also be vicarious
post traumatic growth rolli l savicki v spain e 2010
Post Traumatic Growth(Rolli, L., Savicki, V., Spain, E., 2010)

Emotions, Mood, and Affect

  • Emotions- short-term focused, intense, adaptive
  • Mood- long term pervasive, less intense, and continuous
  • Affect- involves both emotion and moods
  • Cultivating positive affect in the face of trauma is an essential ingredient for posttraumatic growth
    • Broadening of focus
    • Finding resources
    • Defending against the effects of stress
    • Can co-exist with negative emotions but act as diversion and balance
narratives of resilience hauser s t allen j p
Narratives Of Resilience Hauser, S.T., & Allen, J.P.
  • Reconstructing the story as able to be modified
  • Promote internal locus of control and manageable client goals
  • Seeing things working out
  • Envisioning the stress and trauma being disrupted
  • Creating a long term vision
protective factors
Protective Factors
  • Personal- intelligence, emotion regulation, temperament, coping strategies, locus of control, attention, genetic influences, absence of antisocial behaviors, history of academic success, help skills, ego control, flexible, positive appraisals
  • Family-stable caregivers, basic needs met, atmosphere of love and nurturance, security, positive parenting strategies, parental monitoring
  • Community-neighborhood quality, community organizations, quality schools and businesses
risk factors
Risk Factors
  • Personal- disabilities, emotional instability, mental health diagnosis (self or close love one), uneven temperament, poor or no coping strategies, avoidance, withdrawal, external locus of control, family history of negative genetic influences, antisocial behaviors, academic challenges, low self efficacy, inflexible, negative appraisals
  • Family-unstable caregivers, basic needs unmet, atmosphere of inconsistency, harsh or negative parenting strategies, parental monitoring
  • Community-dangerous or unsafe neighborhood quality, no or few community organizations, poor schools and businesses, limited resources
issue 8 empathy without loss of self
Issue #8: Empathy Without Loss of Self
  • Hearing the client’s account without putting self into it
  • Feeling parallel emotions but actively reminding self that in a session and someone else’s story
  • Helping the client going through the issue(s)
  • Can share with client in words the client relates to the feeling elicited by the incident but in such a way that it does not become the clinician’s story
  • Awareness of signs of overload- muscle tension, fatigue, which clients you can’t handle at a certain tie, lack of boundaries, poor eating/sleeping habits, disorganization
  • Balance between relating to what the client reports yet being detached enough
empathy without loss of self
Empathy Without Loss of Self

The Most Important Factor: Social Support Systems

Personal life/family/friends

Community involvement

Colleagues

What social supports do that helps:

Facilitating compassion

Focusing on similar elements among all people-

normalizing feelings

Reducing self blame

Facilitating realistic self acceptance

exercise planning for wellness
EXERCISE: PLANNING FOR WELLNESS

Word Associations:

  • Health-
  • Healing-
  • Replenish/renewal-
  • Escape-
  • Coping-
  • Fulfillment-
  • Satisfaction-
issue 9 developing a balanced life
Issue#9: Developing a Balanced Life

Leisure

  • Leisure directly related to ability to cope
  • True leisure related to sense of self spiritually
  • True leisure related to healthy connectedness
  • True leisure promotes balance

“I can let things happen in the moment.”

“I try to see the beauty in everything.”

“Playfulness is not necessarily unproductive or wasteful.”

“I can periodically revisit how I am feeling and what I need.”

“Meanings of my personal and career goals are allowed to change with age and life stage.”

Examples:

Arts, cooking, music, meditation, physical activity, walking, physical labor, prayer, hobbies, et.

issue 10 what cases you can can t handle
Issue #10: What Cases You Can/Can’t Handle

Effects of Traumatic Cases

Negative

  • Personal trauma history
  • Female versus male
  • Overidentification with traumatic elements
  • Extremely in depth detailed trauma work
  • Long term trauma work
  • Trauma cases with little sense of justice and closure
  • First responders- anxiety, substance abuse, burnout, PTSD risk
  • Sleep interruptions
  • Chronic fatigue
  • Milder versions of the victims symptomology
what cases you can can t handle
What Cases You Can/Can’t Handle

Effects of Traumatic Cases

Does this effect or influence counselor burnout?

Positive

  • 33% actually felt more positive- made a difference- involvement in disaster or trauma
  • Personally helpful to some degree if help counselor reaffirm resilience about their own life stressors
  • Sense of coherence- all humans go through some traumatic things to some degree
  • Willingness to get therapy personally if indicated
  • Ongoing involvement in supervision
  • Post traumatic growth
  • Witnessing the resiliency of others
what cases you can can t handle1
What Cases You Can/Can’t Handle

Mixed Results

  • Length of years as a therapist
  • Level of compassion
  • Depends on degree of previously unresolved things
compassion fatigue
Compassion Fatigue

Examples:

  • Dreaming the client’s dreams
  • Experiencing intrusive thoughts and images
  • Hyperarousal
  • Sleep problems
  • Difficulty concentrating
  • Being easily startled
  • Sense that no one understands my distress

NOTE: May also extend to family of the counselor and support systems of the counselor

v icarious traumatization
Vicarious Traumatization

Vicarious Traumatization

  • Reactions to cases of those abused or in trauma
  • not a pathological reaction
  • based on empathic reactions to trauma survivors triggered by our own application of our counseling skills
  • “empathy at full throttle”, “exaggerated empathy” (Rothchild, B., 2002)
  • Less than 10% in most cases

Examples:

Child abuse, terrorism victims, physical or emotional abuse victims, natural disaster victims, violent crime victims, people with sudden violent deaths

critical factors for processing traumatic cases
Critical Factors For Processing Traumatic Cases
  • Key how the clinician processes the inner experience of the traumatic material
  • How personally they take their ability to control or fix things around them
  • How much they have worked on their journey toward a professional identity to this point
  • How well they can compartmentalize life between professional and personal
  • What meaning the clinician assigns to the event (assumptive worldview)
  • Access and willingness to use resources for self care
  • Balancing all aspects of personhood
  • Regular consultation and supervision
  • Resisting “savior syndrome”
issue 11 my identity
Issue #11: My Identity

Those Most Prone To Burnout

  • Those who desire excellence
  • Those who pride themselves on “really caring”
  • Those who were “on fire” before
  • Those whose life meanings are intricately tied to others’ reactions
behaviors which indicate burnout
Behaviors Which Indicate Burnout
  • drag yourself into work most days
  • find yourself repeating the same things
  • give advice as a shortcut rather than helping clients learn and grow
  • begin sessions late and/or end early
  • doze off or space out during sessions
  • experience a noticeable decline in empathy
  • do things that seem ethically questionable
  • push your theory, technique or agenda rather than listening and adjusting
  • feel relieved when clients cancel
  • self disclose in ways that don\'t help the client
  • do things more for your purposes than for the client
  • defining clients in dehumanizing ways
  • loss of/significant change in faith/meaning in life
  • general pessimism
  • greater struggles with self/professional identity
behaviors which indicate burnout1
Behaviors Which Indicate Burnout
  • lack of assertiveness
  • struggles dealing with ambiguity
  • chronic clock watching
  • interpersonal difficulties
  • more debates and struggles with colleagues
burnout beliefs
Burnout Beliefs
  • I feel I am an incompetent counselor,
  • I am not confident in my counseling skills.
  • I feel frustrated by my effectiveness as a counselor.
  • I do not feel like I am making a change in my clients.
  • The quality of my counseling is lower than I would like.
  • I am not a good counselor.
  • I feel ineffective as a counselor.
  • It is hard to establish rapport with my clients.
  • I feel like I have a poor professional identity as a counselor.
  • I am not connected to my clients.
burnout beliefs1
Burnout Beliefs
  • Due to my job as a counselor, I become physically ill.
  • I feel like I need a vacation.
  • I feel drained after sessions.
  • I have a chronic feeling of general fatigue.
  • My job as a counselor makes me feel depressed.
  • I feel stressed by the size of my caseload.
  • I feel bogged down by the system in my workplace.
  • I am treated unfairly in my workplace,
  • I feel negative energy from my supervisor.
  • I feel frustrated with the system in my workplace.
  • I feel negative energy from my coworkers.
  • I often feel irritated in my workplace.
  • I feel that there is too much emphasis on paperwork in my workplace.
burnout beliefs2
Burnout Beliefs
  • I have Iittle empathy for my clients.
  • I have become callous toward clients.
  • I am no longer concerned about the welfare of my clients.
  • I am not interested in my clients and their problems.
  • I am relieved when clients do not show up for sessions.
  • I have become inattentive in sessions.
what i can can t control
What I Can/Can’t Control

Serenity Prayer Exercise:

Goals for myself What I can’t control What I can control

I want to be helpful

to people who have

limited life skills or

resources.

I want to make a

change in other’s lives.

cognitive behavioral technique watch where you put your buts
Cognitive-behavioral Technique: Watch where you put your BUTS

Feelings BUT Positive self statement

Concerns Strengths based

Questions affirmation

Stresses

exercise what do i want to be remembered for
Exercise: What Do I Want To Be Remembered For?

Plan a eulogy for yourself. Write at least 3-5 important variables that you want memorialized about yourself.

What are you doing to pursue these now?

exercise create a self p ledge
Exercise: Create a Self Pledge
  • Balance of time.
  • Responding to client demands
  • Setting boundaries professionally and personally.
  • Re-assessing my goals.
  • Doing one thing just for myself.
  • Allowing leisure for some time every day.
how personal therapy may help
How Personal Therapy May Help
  • Increased empathy for what others, especially clients go through.

2. Ability to catch and challenge triggers so they don’t repeat themselves.

3. Personal issues are caught before they spill over into client relationships.

4. There is less risk of an ethical violation or losing your practice.

5. Burnout may be thwarted.

6. Options of actions can be considered.

bibliography
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Angus, L.E., & Kagan, F. (2009). Therapist empathy and client anxiety reduction in motivational interviewing: “She carries with me the experience.” Journal of Clinical Psychology in Session, 65(11), 1156-1167.

Bachelor, A., & Salame, R. (2000). Participants’ perceptions of dimensions of the therapeutic alliance over the course of therapy. Journal of Psychotherapy Practice and Research, 9, 39-53.

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