Transcript 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
The Client’s
Stress
Area #1- Not Feeling
Listened To
Three Common Assumptions about Listening
(Barker, L., & Watson, K., 2000)
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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
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.
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Listening Pitfalls
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Tuning Out or Halfheartedly Listening
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Rehearsing Our Responses
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Assuming Meanings From What the Speaker Says
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Jumping to Conclusions
Four Listening Preferences
People- Oriented
Action Oriented
Content Oriented
Time Oriented
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 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
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
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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 pints to 3 or less
• Be short and to the point.
• Speak quickly.
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
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
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Sets time boundaries for conversations
Gives guidelines for conversation
Does not want “wasted” time
Tells others when they are “wasting”
time
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)
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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., 2000)
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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.
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.
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 Listening
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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
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
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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 #4Assessment/Diagnosis
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Why we as the questions we do
What the diagnossi menas
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
Planning
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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
• 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
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
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)
• 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., 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., 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., 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., 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
Relationship stage
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Identify specific defenses for that client
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Generally will be the same ones they use with you
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Use advanced empathy to understand and help them
understand why they habitually relied on them
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Sentence completion exercises help
Integration stage
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Distortions are confronted
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Lack of congruency is brought to the client’s attention
Accomplishment stage
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Productive actions and alternatives are highlighted
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Client is encouraged to act differently as he or she
would like to be
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Alternative behaviors are maintained
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A strengths-based approach is used
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
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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 hat to talk about
• Kept the administration outside of our sessions
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
• 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 #10Confidentiality/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
• 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/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
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
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)
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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
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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
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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)
• 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/reinforcement31
• 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)
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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
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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)
• 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
• 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: OtherUnderstanding the worldview of the client
• Domain III: Culturally Sensitive Working Alliance:
(respect, goal formation, collaboration throughout)
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 selfdevelopment
• “no study found that showed that empathy is harmful”
Issue #12: Doing
Confrontation
• Open, Honest identification of self defeating
thoughts or behaviors
o identify the cycle
o 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
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
The Therapist’s
Stress
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 Should
My Company Actually
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
• 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
• 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 missionpartnership?
• 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 Goals
Healthy
Unhealthy
Strong commitment of employees
Weak commitment of counselors
Strong availability/support from staff Isolation, weak involvement of staff
Co-worker relationships- encouragedMinimal 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
• 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
• 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
• 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
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Problems are rarely so well defined and linear:
if only ___, then ___.
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Many interactional variables occur at the same time.
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Any given person only has a portion of the information.
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Sometimes the most important variables are not
always revealed.
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Timing of decisions may be as important as the
“rightness or wrongness” of decisions.
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Decisions are interdependent- one decision affects
others.
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Goals in decision making may sometimes be
contradictory.
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Plan for correction and modification.
Exercises: What’s Wrong
With These Goals?
Poor Goals
Improved 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 Goals?
Poor Goals
Improved 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
Emotional Exhaustion
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“I feel drained by this work.”
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“ I feel used up by the end of the workday.”
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“ I am fatigued when I get up in the morning and
have to face another day on the job.”
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“Working with people all day drains me.”
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“I feel like I’m at the end of my rope.”
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“I have no energy left after I counseling people.”
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
• 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)
• “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, 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
•
•
•
•
•
•
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
• 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
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
•
•
•
•
•
•
•
•
•
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
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= 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
Defining Counselor Wellness
Both an outcome and a process
Involves several dimensions
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
• 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
• 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
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
• 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
• satisfaction at challenges of task completion and
quality of work
• a sense of competency
• balancing work and relaxation (doing versus being)
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)
Four Functions of Leisure
1) Serves as a distraction away from negative life eventstemporary 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
• relational connection with others
• asking for help when needed
• extending outreach to others
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)
Stamina- strength to withstand and hold up
under pressure
Seven Principles of Counselor Stamina:
1. Selectivity- intentional choosing what one
will and will not do
1.
2.
3.
4.
5.
tasks
populations served
number of cases
limiting “specialty” areas
reasonable goals/objectives
Concept of Counselor Stamina
(Osborn, C., 2004)
2.Temporal selectivity- time
consciousness
o sessions
o planning days
o juggling tasks
o work/personal
o spacing of sessions
Concept of Counselor Stamina
(Osborn, C., 2004)
3. Accountability- partnering with
credible colleagues
• Standard of care
• Ethics
• Current practice
4. Measurement/managementconserving and budgeting resources
o Role clarifications
o Supportive, positive capable
personnel choices
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., 2004)
7. Acknowledgement of agency
•
Focus on personally meaningful goals
Resiliency
Resiliency
Hardiness- mediates effects of stress
• Feeling in control
• Commitment to the work
• Change is a challenge
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
•
•
•
•
Dispositional/Trait Models
Protective Factors
Risk Factors
Protective and Risk Factors
combined
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)
• 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)
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:
o Recalling past successes
o Naming and reconceptualizing goals
o Accountability for actions and follow through
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 outcomesdeterring unwanted consequences
• Maintenance goals- sustaining the
status quo
• Enhancement goals- augmenting
positive outcomes
Reasonable Hope
Weingarten, 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 Themwilling to do trial and error and modify as needed
5. Accomodates doubt, contradictions, and despairlife can be messy
• Can also be vicarious
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
o
o
o
o
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.
• 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
• 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
• 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
• 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
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 peoplenormalizing feelings
Reducing self blame
Facilitating realistic self acceptance
EXERCISE: PLANNING
FOR WELLNESS
Word Associations:
•
•
•
•
•
•
•
HealthHealingReplenish/renewalEscapeCopingFulfillmentSatisfaction-
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
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
Effects of Traumatic Cases
Does this effect or influence counselor burnout?
Positive
• 33% actually felt more positive- made a differenceinvolvement 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 Handle
Mixed Results
• Length of years as a therapist
• Level of compassion
• Depends on degree of previously unresolved things
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
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
emotionalabuse victims, natural disaster victims,
violent crime victims, people with sudden
violent deaths
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
•
•
•
•
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
• 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 Burnout
•
•
•
•
•
lack of assertiveness
struggles dealing with ambiguity
chronic clock watching
interpersonal difficulties
more debates and struggles with colleagues
•
•
•
•
•
•
•
•
•
•
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 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 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
Serenity Prayer Exercise:
Goals for myself
control
What I can’t 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.
What I can
Cognitive-behavioral Technique:
Watch where you put your BUTS
Feelings
Concerns
Questions
Stresses
BUT
Positive self statement
Strengths based
affirmation
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
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
1. 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 les risk of an ethical violation or losing your
practice.
5. Burnout may be thwarted.
6. Options of actions can be considered.
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