Trauma in Supervision
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Embracing trauma counselling in supervision – Vivian Baruch, B.A., M. Couns.
Abstract: Bearing in mind the toll which is exacted on us when working with the traumatised, this article explores how supervisors can embrace a many-faceted, pre-emptive approach to self-care in supervision contexts. It argues for the continued ethical necessity to educate ourselves and our supervisees about comprehensive and empirically validated methods for minimising the impacts of working with distressed and distressing clients. These methods enhance our self-monitoring skills which in turn provide us with the necessary feedback to devise individualised approaches to self-care. In pro-active self-care we consistently attend to our bodies, emotions, minds, spirits , as well as to our cultural and social environments. Addressing each of these aspects provides ongoing means of refreshing ourselves in our work so that we can thrive as counsellors and supervisors whilst providing an ethically responsible service.
There are many frameworks for conceptualising the overarching tasks for which supervisors and supervisees are responsible. One well recognised one is laid out by Proctor (2004, p.12) who names them as formative, normative and restorative tasks, and describes them as follows: • “formative – the tasks of learning and facilitating learning • normative – the tasks of monitoring, and self-monitoring, standards and ethics • restorative – the tasks of refreshment”.
This article will elaborate on each of these tasks, showing how they may be applied for the purpose of constructing maps for guiding “good enough” work with our clients, supervisees and fellow supervisors. A particular emphasis on preventing the impacts of working with the traumatised will be addressed.
Formative (the tasks of learning and facilitating learning)
The first aspect of the formative task of learning in supervision reminds us to prioritize valuing ourselves as people. Our “self” is the instrument through which we do our work and comprises our body, emotions/shadow, mind and spirit. Each of these dimensions of the self will be expanded on below. If this instrument is not kept in good order, our work and all our personal and professional relationships suffer, and our resilience is compromised, which especially impacts our work with those who are traumatised.
The second formative aspect in supervision is learning that work with any clients, particularly working with those who have suffered traumatic experiences, increases the occupational health risks found within our profession. This is essential to remember, as our capacity for empathy is limited, and must be closely monitored throughout our careers. We must educate ourselves and our supervisees about the reality of “emotional contagion” (Hatfield et al, 1992, 1994, cited in Rothschild & Rand, 2006, p.54) and its capacity to induce stress and anxiety. The effects of anxiety have been shown to negatively impact on our learning, our performance as well as on supervisee interactions with supervisors (Bernard & Goodyear, 2009). As the role of a positive, productive relationship is central to successful supervision, our responsibility as supervisors is to monitor the quality of these relationships, to explore the interactions between us and our supervisees, and also between the supervisees, their clients and their work environments.
Rothschild and Rand (2006, pp11-12) have this message to impart: Is it possible that empathy is actually a double-edged sword, wielding both help and harm? Does the same tool that facilitates our understanding of our clients also threaten our well-being at times? The short answer is yes… many therapists suffer in their work as a result of unconscious empathy – that is, empathy processes that are outside of the therapist’s awareness. Many of the common therapist pitfalls have roots in …unconscious empathy gone awry, including…unmanageable countertransference, projective identification, compassion fatigue, vicarious traumatisation, and burnout…client distress affects the therapists’ brain and body and…training in somatic and cognitive skills (are needed) to both increase awareness and mediate the effects.
As supervisors, informing and training ourselves in these somatic and cognitive skills is the necessary precursor to teaching them to supervisees. Figley (1995, p64) uses the term ‘compassion fatigue’ interchangeably with the term ‘secondary traumatic stress’ which he defines as ‘…the stress from helping or wanting to help a traumatized or suffering person’. Secondary traumatic stress is a precursor of, and distinguished from, burnout by its rapid onset.
Any discussion of working with the traumatised necessitates an understanding of compassion fatigue and burnout. Amongst the many possible definitions of burnout, a succinct one by Hawkins and Shohet (2007, p.222) states: “Typically an individual who is ‘burnt-out’ is out of balance with what they give out to others and receive for themselves.” Therefore a third factor that we as supervisors must learn and teach is that “…striving to prevent burnout is a more pathological and less effective strategy than cultivating self-care.”(Norcross & Guy, 2007, p.55). This understanding requires pro-active focus on the balance between giving to others and receiving for ourselves. We do this by learning to practice empathy and compassion to ourselves before all else. Educating our supervisees in this formative aspect of supervision is most effectively done by modelling, and by continually reminding ourselves of the saying “We teach best what we most need to learn”.
By persistently fine-tuning our own “self-as-instrument”, we can more effectively assist supervisees to do likewise. Using self-monitoring processes to connect with the messages received from our selves and others supplies us with invaluable feedback for cultivating personalized, yet flexible self-care regimes. It seems straightforward that as supervisors we attempt to practice for ourselves what we encourage our supervisees and clients to do for themselves (Baruch, 2004). As each of us is a unique being who exists in a system, we each respond uniquely to the stressors in our environment which require individualised strategies for effective management. Unfortunately there is no “one size fits all” self-care method. A comprehensive array of methods from which to devise such an individually tailored approach is outlined below.
Normative (the tasks of monitoring, self-monitoring, standards and ethics)
The first of our normative tasks is to inform supervisees that compassion fatigue is a given in our line of work. Compassion fatigue and burnout are characterised by physical, emotional, psychological, interpersonal and spiritual states which impede our engagement with life and which can manifest as stress, illness and/or fatigue. We need to normalize the occurrence of these hazards of psychological practice and encourage self-care methods which attend to each of these aspects. Empirical research attests to the negative toll which can be exacted by a career in counselling. The literature points to depression, mild anxiety, emotional exhaustion, and disrupted relationships as the common residue of immersion in the inner worlds of distressed and distressing people (Brady, Healy et al 1995, cited in Norcross, 2000). The imperatives of confidentiality, the realities of isolation, and the shame felt when we experience the negative impact of our work lead us to overpersonalise our own sources of stress, when in fact they are a given in psychological work (Figley 1995; Gilroy, Carroll & Murra 2002; Norcross & Guy 2007).
This important understanding demonstrates that compassion fatigue results from a multitude of factors, and not just from working with the traumatised. It arises from the interaction between our individual biopsychosocial makeup, the types of people with whom we interact, the contexts within which these interactions occur and the meanings we make of these. Norcross & Guy (2007, p.57) specifically point to the research evidence for one combination of risk factors for burnout: “Psychotherapist characteristics…Patient characteristics…Job requirements…(and) …Working conditions…” Because of the multiplicity of contributors to compassion fatigue, a number of components must be creatively combined when being pro-active. Norcross and Guy’s findings (2007) suggest that possessing any one particular skill in one’s self-care program is less important than having a variety of self-care methods. We must also educate supervisees about the research which shows that supervision and our own therapy are necessary but not sufficient to ensure thriving in our line of work (Coster & Schwebel, 1998; Dlugos & Friedlander, 2001; Norcross, 2000; Norcross & Guy, 2007; Skovholt, 2001). Including supervision and therapy in our self-care practices is important, but so is utilising activities which we can do for ourselves.
The supervisor’s second normative task of monitoring, involves enquiring into and educating the supervisee to self-monitor the number and types of clients they see, adjusting this (if possible) to accommodate the severity and urgency of the issues in their current caseloads, the support (or lack thereof) for the supervisee within their organisation or counselling practice, and the extent of support and feedback they are able to ask for and receive from their families, friends and social networks. The interrelationship of these to self-care provides a way of understanding the reciprocal influences of client, therapist, culture and context on each other and how both healing and dysfunction can result from the encounter between people and their environments. By educating supervisees to monitor these factors, we help them devise “good enough” standards for work. Cozolino (2004) portrays this as the ability to surrender to our imperfections, mistakes and human frailties, while still being able to encourage the therapeutic work towards a positive outcome.
The third supervisory normative task is to assist in the development of self-awareness and self-monitoring. This requires a continuous process of reflecting on and exploring our changing motivations and philosophy about work and life, practicing taking different perspectives on ourselves and others, responding as empathically to our own needs as we do to our client’s needs, listening to feedback from valued others, journaling our thoughts and feelings, and tracking our distress and self-care. This takes us directly into engaging with our shadow, exploring our own needs and owning a healthy relationship to power. The word shadow is often misunderstood as referring only to the negative aspects of our unconscious or preconscious selves. It is useful to note that the disowned (or not yet manifest) aspects of our “higher” self, which contains our best parts, may also be accessed by shadow work. These disowned parts, residing in the prepersonal, personal, or transpersonal aspects of our being, can disrupt our ability to maintain healthy functioning in our personal and professional lives.
Every ethical code of mental health professionals includes stipulations about the need for self-care. Our role is to ensure that supervisees are familiar with the codes of ethics of the professional body to which they belong as well as with the codes of the organisations or agencies for which they work. This leads to the fourth vital normative task of supervision, which is expanding our understanding of the ethical necessity for comprehensive self-care. This is stressed by Gilroy, Carroll & Murra (2002) who posit that the key to prevention of burnout, lies in the establishment of a professional ethos in which self-care is viewed as a moral imperative. They assert: “It is important that such self-care action plans be comprehensive in nature and include attention to the physical, cognitive, emotional, recreational, and spiritual dimensions” (Carroll et al., 1999, cited in Gilroy et al., 2002).
Restorative (the tasks of refreshment)
The restorative task of supervision outlines a comprehensive, pro-active approach to self-care. This empathic attitude to the self helps ensure resilience in our line of work. In addition, attending to the five “modules” outlined below, assists in restoring the quality of our functioning, should this be compromised as a result of working with the traumatised. Creating a personalized self-care regime entails using our self-awareness to guide us in choosing one or two practices from each of the five modules, focusing on those to which we generally give insufficient attention. The literature on well-functioning therapists shows five common themes in their self-care methods: balance between their work and other parts of their lives, diversity within their work (conducting multiple forms of therapy; engaging in multiple activities in work; and working with multiple types of clients and problems), robust selves (their personalities were such that they tended to meet obstacles as challenges; they could embrace diverse theoretical orientations and had a continuing fascination with human development and change), empathy to self, and pro-activity. These factors proved to be far more essential components in maintaining wellbeing than supervision and engaging in personal therapy (Dlugos & Friedlander, 2001, p. 301).
Research clarified a sequence of behavioural steps taken by therapists when they sensed their functioning was compromised. These consisted of admitting to themselves they were not coping, asking for help (from family, friends, colleagues, and supervisors), pulling back on their work commitments, taking breaks when possible, and focusing on relaxing and diverting activities. Overall the research contradicted beliefs that well-functioning “just happens.” These thriving therapists were pro-active in their self-care. They sought out continuing education to diversify their work and to keep abreast of changes and they utilised support from peers, spouses, friends, mentors, therapists, supervisors, and other support networks.
The restorative task entails paying attention to the five generic modules. As supervisors, we set an example by modelling “good enough” standards in our body, emotions, mind, spirit and ethics so as to be able to guide our supervisees in doing likewise. The figure below (Baruch, 2008) summarizes the components of a comprehensive self-care regime. Each generic module must be tailored to suit our individuality. This skill requires choosing one or two items from each of the modules and practicing them concurrently. Each module is described in more detail under the figure, which utilises the concept of multiple intelligences, as elaborated by Gardner (1999).
A good place to begin is to pay attention to our diet. The overall aim is towards balancing the macronutrients (lean proteins, complex carbohydrates, and good fats) and the micronutrients (vitamins, minerals, and hormones). Including fresh vegetables and fruit is beneficial for the maintenance of health in the body, as is watching the level of caffeine and alcohol. The balance of macro and micronutrients will be unique for each of us, and needs continuous adjustment to account for differences in gender, age, personality, body type, and any existing health problems, in addition to the level of physical activity undertaken.
Another focal area for the body module is exercise, as the sedentary occupation of counselling often leads to imbalance in this area. In addition, attention needs to be paid to the length of our working hours, which may impinge on getting the quality sleep and physiological rest time appropriate for our individual needs. With respect to the neurological system, pharmacological means of restoring or maintaining balance may at times be required. This can be achieved by allopathic or holistic medical means, via prescription medication, herbs, vitamins, minerals, and hormonal supplements. While we as therapists may encourage clients to take medication, we can feel ashamed when we may need them ourselves. This aspect of self-care is perhaps too frequently overlooked. It is a useful reminder that massage, acupuncture, shiatsu, kinesiology, osteopathic and chiropractic treatment methods (among others) address neurological balance as well.
Mind (Framework, View, Perspective)
The mind module involves developing an orienting framework for the many possible perspectives related to our work. Our cognition or consciousness spans through levels ranging from subconscious/prepersonal to self-conscious/personal to superconscious/transpersonal, and includes interior as well as exterior modes of awareness (Wilber, 2000, p. 20). Being mindful of this span assists us in maintaining a multiplicity of perspectives while engaged in counselling and when reflecting on our work. Other means of fostering our ongoing development in this module are continuing education and keeping abreast of changes in our fields of interest. Further useful practices are those which clarify our philosophy of life, in the broad sense, and ourselves as practitioners, in the more focused sense. Techniques such as visualization and affirmation may also be included in the mind module.
Spirit (Meditation, Prayer, Stillness)
Research by Dlugos and Friedlander (2001) showed that “passionately committed psychotherapists” experience a strong sense of spirituality. They suggest that for the field to retain motivated, competent professionals, training and education programs need to emphasize balance, integration of work with the rest of life, and the spiritual and transcendent nature of therapy. It seems imperative to emphasise this in post-training supervision as well. Consistent practice of spiritual disciplines inherent in any established spiritual tradition may facilitate a direct experience of the transcendent. This corresponds to the third of Wilber’s (2000) definitions of spirituality (see footnote 1). The literature on thriving and well-functioning therapists refers to the centrality of spirituality in self-care. Dlugos and Friedlander (2001) found that an interest in activities unrelated to work as therapists, and attention to spiritual disciplines and development were as crucial, if not more crucial, than the pursuit of professional avenues of achievement to maintain well-functioning. Norcross (2007) and Skovholt (2001) also refer to the importance of cultivating spirituality and mission as well as nurturing the spiritual or religious self of the therapist. A broad range of spiritual practices is readily accessible to those interested in this endeavour. These include spending time in nature, shamanic practices, contemplative or centering prayer, and many methods of meditation.
Shadow (Fixations, Subpersonalities, Projections)
Dealing with shadow aspects assists us in shifting perspective on the parts of ourselves that we unconsciously repress or deny, and which therefore interfere with our optimal performance and development as counsellors and supervisors. Both our lower and higher self can be concealed in the shadow (Wilber, Patten, Leonard & Morelli, 2008, p. 59). A study on professional psychologists and programme heads of psychology showed that working with shadow via self-monitoring and self-awareness was found to be the top-ranking contributor to optimal functioning (Coster & Schwebel, 1998). Assisting supervisees to engage in self-monitoring exercises fosters awareness of their behaviour and motivation during and about their counselling sessions. There are also many highly effective practices that can be done on our own or with trusted others which help us identify and integrate the disowned parts of ourselves. These include dream work, journaling, dialoguing, and drawing, among others.
Ethics (What We Do. How You Act! Why Should I?)
This module deals with our self-discipline, our personal and professional codes of conduct, and our different social and ecological levels of activism as well as any vows or oaths we have undertaken. The Oxford Compact English Dictionary defines ethics as “the branch of knowledge concerned with moral principles” as well as “the moral principles governing or influencing conduct” (Soanes, 2000). As supervisors, our task is to keep abreast of our codes of ethics and to embrace the complexity involved in ethical decision making. In this way, we encourage ourselves and our supervisees to periodically ask these questions: “What do I do, or not do about self-care? and “What are my commitments/intentions regarding self-care?” As the self is the primary instrument used in our work, it is imperative that we honor it by treating it as an instrument worthy of pro-active attention. Doing so ensures the maximum functionality and flexibility of the self. An ethical perspective on self-care holds it as a moral responsibility to keep this instrument as finely tuned as possible so as to bring the best “self-system” to our interactions with others, with the intention of being of service to all those with whom we come into contact.
To conclude with the wisdom of Ingram (2007):
We can only be working on so many things at once and still do any of them well. We need breaks, downtime, and balance. However, if we are wise and discerning, we can craft a set of priorities for ourselves that honors our unique spiritual needs, relationship needs, career needs, recreational needs, and family needs, as well as the needs of others. We can do this in a way that is realistic and allows us to keep making good use of our life without burning out or stagnating. No one can ever tell you exactly how to do this. You have your own needs and life situation. Work with it as best you can.
Author notes: Vivian Baruch, B.A., N.D., Dip.Hom., M. Couns., is a registered counsellor, psychotherapist, and supervisor in private practice in Sydney. She has worked as a counsellor, therapist, and group worker since 1981. She has a Bachelor of Arts (UNSW), a Diploma of Naturopathy, a Diploma of Homoeopathy, a Graduate Diploma in Emotionally Focused Counselling and Therapy, a Master of Counselling (UWS), a Certificate in Integral Psychotherapy (I.I.), and a Graduate Certificate in Professional Supervision (UC). She has trained in Jungian dreamwork and sandplay, psychosynthesis, stress management using yoga and meditation, and has practiced yoga and various forms of meditation and contemplation since 1981. Vivian currently is an educator at the Australian College of Applied Psychology and at the University of Canberra, where she teaches supervision at the postgraduate level.
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