Emotional responses

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Emtional responces of people working with tramatised popolations

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Emotional responses

  1. 1. EmotionalResponsesVicarious Trauma,Burnout andTransformationPresentation byChris Lobsinger“That which is to give lightmust endure burning”Victor FrankelClinical Pastoral Education2012 1
  2. 2. Emotional Responses This presentation concerns the emotionalresponses of careers working withtraumatized people. The effects that these emotions have oncareers. And some ideas about managing thenegatives effects and enhancing thepositives effects.Emotional Responces 2006 2
  3. 3. Overview“Many mental healthprofessionals unconsciouslyassume that their profession‘magically’ shields them fromtraumatic experience.” (Kreichman1984)
  4. 4. Definition of Trauma Dictionary definitiontrauma, n., pl. -mata -mas 1. Pathol. A bodily injury. 2.Psychol. A startling experience which has a lasting effecton mental life; a shock. - traumatic, adj. The MacquarieDictionary New Budget Edition (1985). Working definitiontrauma: an inescapably stressful event that overwhelmspeoples existing coping mechanisms.Emotional Responces 2006 4
  5. 5. RAA :Basics of traumatic symptoms Re-experiencing Arousal AvoidanceEmotional Responces 2006 5
  6. 6. Post Traumatic Stress Disorder The essential feature of Post TraumaticStress Disorder is the development ofcharacteristic symptoms followingexposure to an extreme traumatic stressorinvolving direct personal experience of anevent that involves actual or threateneddeath or serious injury,American Psychiatric Association (1994) Diagnostic and statistical manual of mentaldisorders (4th edition) (DSM-IV). Washington DC.Emotional Responces 2006 6
  7. 7. Emotional Responces 2006 7
  8. 8. Acronyms VT (Vicarious Trauma) CT (Counter-transference) STS (Secondary Traumatic Stress) CF (Compassion Fatigue) Burnout Is the ‘devil in the detail’?
  9. 9. Terms Compassion FatigueA general term for any one who suffers as aresult or serving in a helping capacity.(Figley 1995) BurnoutDescribes anyone whose health is sufferingor whose outlook on life has turnednegative because of the impact ofoverload of work.Emotional Responces 2006 9
  10. 10. Terms Primary TraumatizationThe impact of traumatic incident on theobvious victim of the incident. Secondary TraumatizationIncludes the family members and closeassociates of the victim.Also refer to therapists, and helpers whoare eyewitness to incident they are try tomediate.Emotional Responces 2006 10
  11. 11. Terms Vicarious TraumatizationEven when a therapist has not witnessestrauma they can still vicariouslyexperience the client trauma in theirnervous system. Even though they are notexposed to the event they can feel it.Barbette Rothschild Help the helper 2006Emotional Responces 2006 11
  12. 12.  “These constructs have not provenempirically separable, and the consensusview now is that they share many features,but primarily in their affective domains,which are self in-efficacy in relation toburnout, and fear in relation to vicarioustraumatisation”(Linley and Joseph 2007)
  13. 13. Vicarious Traumatisation By witnessing or hearing about someoneelse’s trauma, people can be vicariouslytraumatized, hence the term vicariousTraumatisation.Pearlman, L. & Saakvitne, K. (1995) Treatingtraumatised therapists. In Figley, C. (Ed.), Compassion fatigue: secondary traumatic stress disordersin those who treat the traumatized. Brunner-Routledge: New York.Emotional Responces 2006 13
  14. 14. Secondary Traumatic Stress Secondary traumatic Stress is a naturalconsequence of caring between two people, oneof whom has been initially traumatized and theother of whom is affected by the first traumaticexperience. Risk factors for (STS) are empathyand exposure. Additional risk factors are thecare giver’s Previous trauma experiences andthe extent to which these have been resolved(Figley 1995)Emotional Responces 2006 14
  15. 15. Burnout Being involved in emotionally demandingsituations over a long period can cause physical.emotional and mental exhaustion. This is knowas burnout and is a cumulative process ratherthan a fixed condition. Burnout begins graduallyand become progressively worse. The mostsalient factor associated with the symptoms ofburnout include client problems- chronicity,acuity, complexity-that are perceived to bebeyond the capacity of the service provider.Emotional Responces 2006 15
  16. 16. Whats most important to know? Vicarious Trauma= symptoms of PTSD Burnout = DepletionEmotional Responces 2006 16
  17. 17. Burn Out Process and Experience Process: A helper becomes overlyinvolved or overly extends him/herself intheir professional role. The helper experiences overloadEmotional Responces 2006 17
  18. 18. Emotional Responces 2006 18 Emotional exhaustion Feelings of being drained and empty thatis caused by excessive psychological andemotional demands. Depersonalization The feeling of callousness and cynicismand a reduced sensitivity towards others. Reduced Personal accomplishment The feeling that one’s action and effortsare wasted and worthless.(Schulz and Schulz 2006)
  19. 19. The difference, Burnout and VT Burnout begins gradually Vicarious Trauma can happen quickly Burnouts main symptoms are aroundexhaustion. Vicarious traumas main symptoms mirrorPost traumatic stress.Emotional Responces 2006 19
  20. 20. Stress Vs BurnoutStress BurnoutCharacterized by over-engagement Characterized by disengagementEmotions are overactive Emotions are bluntedProduces urgency and hyperactivity Produces helplessness and hopelessnessExhausts physical energy Exhausts motivation, drive, ideals and hopeLeads to anxiety disorders Leads to paranoia, detachment anddepressionCauses disintegration Causes demoralizationPrimary damage is physical Primary damage is emotionalStress may kill you prematurely, and you wonthave enough time to finish what you startedBurnout may never kill you, but your life maynot seem worth livingEmotional Responces 2006 20
  21. 21. Stressors uniquely associated withcounseling and other similar rolesinclude  Maintaining concentration, disciplineand skill. This intensity is rarelyunderstood by others not working in thefield.  The high level of continuous output ofenergy.  Issues are often intense, painful andsometimes irresolvable.Emotional Responces 2006 21
  22. 22. Role expectations of counselors are oftenout of proportion to what is reasonablyachievable.Limited organizational support forcounselors.Feelings of isolation and havingexpectations placed upon them.Feeling inadequate and having self-doubtwhen outcomes are not achieved.(Potter, 1987)Counseling-orientated problems, with other factors previously mentioned, have thepotential to place counselors at a high risk of burnout.Emotional Responces 2006 22
  23. 23. PictureEmotional Responces 2006 23
  24. 24. Emotional Responces 2006 24
  25. 25. Aspects of Alterations of Self:Changes in… Perceptions of self and other Personal identity Worldview Spirituality Personal capacities Ego resources Psychological needs Sensory systems
  26. 26. Changed Worker Sense of: Safety Trust Esteem Intimacy Control
  27. 27. Post Traumatic GrowthPositive changes have been reported bypeople who experience psychologicaltraumaEnhanced relationship and increasedcompassion and altruism.( Tedeschi and Calhoun)Emotional Responces 2006 27
  28. 28.  Improved view of themselves as be moreresilient, or more accepting. Some report changes in life philosophyand finding more appreciation in daily life.( Tedeschi and Calhoun)Emotional Responces 2006 28
  29. 29. Other factors to consider As postgraduate training increases,traumatic symptoms in workers decrease Greater involvement and greater caseloadelevate levels of trauma symptoms Women report more symptoms than men Workers with administrativeresponsibilities (multiple roles) and longerservice have more severe symptoms
  30. 30.  Symptoms reduce with years ofexperience Under 2 years experience increasedsymptoms Personal history of sexual abuse /traumaexhibit highest levels of symptoms (mixedresults)
  31. 31. Vicarious TraumatizationThe transformation of the person’s innerexperience resulting from empathic exposure tothe client’s material (Pearlman, Saakvitne 1995) Occupational hazard Effects are cumulative and permanent Vicarious traumatisation is a response to theeffects of traumatic exposure on our clients.Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.),Compassion fatigue: secondary traumatic stress disorders in those who treat thetraumatized. Brunner-Routledge: New York.Emotional Responces 2006 31
  32. 32. Impact -Vicarious traumaIncludes changes in the person’s: Sense of identity Relationships with self/others/world Beliefs about self/others/world Tolerance of feelings Psychological needs Memory and imagery changes (vulnerable to PTSDsymptomatology)Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.),Compassion fatigue: secondary traumatic stress disorders in those who treat thetraumatized. Brunner-Routledge: New York.Emotional Responces 2006 32
  33. 33. Impact of Vicarious traumatisation Depression Despair Cynicism Inability to find enjoyment Alienation from self/others Professional impairment Re-enactmentEmotional Responces 2006 33
  34. 34. Organizational impact of VicariousTraumatisation Reduced team effectiveness High staff turnover Reduced morale Loss of hope/faithEmotional Responces 2006 34Figley, C. (1995) Treating therapists with vicarious traumatisation and secondary traumatic stress disorders. In Figley, C. (Ed.), Compassion fatigue:secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.Pearlman, L. & Saakvitne, K. (1996). In van der Kolk, B., et al. (Eds.), Traumatic stress: the effects of overwhelming experience on mind, body andsociety. The Guildford Press: New York.der Kolk, B., et al. (Eds.), Traumatic stress: the effects of overwhelming experience on mind, body and society.The Guildford Press: New York.
  35. 35. VT’s impact on clinical work“” In Clinical Work secondary trauma( VT)involves a violation of the therapists senseof basic trust, where the therapistsassumptions are undermined or shattered.As the assumptions are undermined, thebehavior of the therapist is likely to beaffected as well””Charles Figley’in compassion fatigue 1995 Brunner/Mazel inc New York, New YorkEmotional Responces 2006 35
  36. 36. Emotional Responses Helplessness Guilt Anger Hate Erotic transference Dread and horror Idealisation Personal vulnerability Avoidance reactions FulfilmentAristotle, P., Kaplan, I. & Mitchell, J. (1998) Rebuilding shattered lives training guide. Victorian Foundation for Survivors of Torture Inc: Victoria. (p. 148-152)Emotional Responces 2006 36
  37. 37. Flow on of Strong Emotions Helplessness—loss of confidence—underestimation ofclients resources and increased advocacy,-- doingeverything leads to exhaustion. Guilt—viewing survivors as fragile --- taking excessresponsibility—avoidance of painful topics Anger—dismay at bystanders—identification withdestructive thoughts—perpetrator victim split—anger atvictim—for not being morally superior Dread and horror—feeling of being overwhelmed byEmotional Responces 2006 37
  38. 38. Flow on of Strong Emotions Idealization—view survivors as superhuman—minimizing pain in self and others. Personal sense of vulnerability intolerance ofviolence Avoidance reactions—denial detachment—disassociation—self medication Fulfillment—growth , deeper awareness ofhuman conditionEmotional Responces 2006 38
  39. 39. Patterns of Traumatic Engagement Splitting Re-enactments Parallel process Transference / Counter transference.Emotional Responces 2006 39
  40. 40. Dadi Janki of India Wisdom Keeper 1992Dadi Janki- “ to take on the their sufferingwould be to double the amount of pain in theworld”Interviewer- “how do you help then”Dadi Janki- “I try to wrap the others personssuffering in love”Toxic Emotions at work, Peter J Frost Harvard Business school 2003 p107-108Emotional Responces 2006 40
  41. 41. Dis-identification Exercise Find a quit space Take three deep breaths Acknowledge your care and responsibility Say tour full name and age 3 things you like about yourself 3 ways you are different from your client Repeat a few times.Emotional Responces 2006 41
  42. 42. Risk Factors Too high demands from others and the situation. Lack of resources, personnel and time. Lack of control over the situation. Lack of support from leaders, organisations,colleagues. Unrealistic expectations. Lack of acceptance and acknowledgment.Smith, B., Agger, I., Danieli, Y. & Weisaeth, L. (1996) Health activities across populations: emotional responses ofinternational humanitarian aid workers. In Danieli, Y. et al. (Eds.), International responses to traumatic stress:humanitarian, human rights, justice, peace and development contributions, collaborative actions and futureinitiatives. Baywood Publishing: New York.Emotional Responces 2006 42
  43. 43. Contributing factors Characteristics of work- Clients with traumatic histories- Clients who are continually exposed to danger- Clients who are difficult to understandPearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue: secondary traumatic stress disorders in thosewho treat the traumatized. Brunner-Routledge: New York.Emotional Responces 2006 43
  44. 44. Contributing factors Characteristics of the worker- Vulnerabilities- Experience of personal trauma- Ideas, values- Ability to attend to their own careneedsPearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.Emotional Responces 2006 44
  45. 45. Contributing factors Characteristics of society- Society’s tolerance of abuse- Society’s attitude towards violenceand social justice e.g.. misogynist, racist and hetero-sexistand victim-blaming contexts.Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.Emotional Responces 2006 45
  46. 46. Reducing RiskPERSONAL STRATEGIES Maintain a personal life Use personal life Identify healing activities Attend to your spiritual needsPearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.Emotional Responces 2006 46
  47. 47. Reducing RiskPROFESSIONAL STRATEGIES Arrange supervision Develop professional connection Develop a balanced work life Remain aware of your goals Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New YorkEmotional Responces 2006 47
  48. 48. Reducing RiskORGANISATIONAL STRATEGIES Attend to physical setting Arrange for adequate resources Create an atmosphere of respect Develop adjunctive service Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New YorkEmotional Responces 2006 48
  49. 49. Overinvolvement-Underinvolvement ContinuumTowards working with survivors Away from working with survivors• wanting to knowmore• empathy• responsibility forone’s behaviourand the reactionsof others• developingstrategies• advocacy forintervention• ‘crusader’approach• doing it alloneself• excessiveresponsibility forpeople’s feelings• excessiveaccommodationof people’sdifficulties• observing faculty• professionaldetachment• maintainingboundaries•involvement in arange of activities• preoccupation withefficiency• cynicism• minimising contact• no responsibilityfor people’sreactions• insufficientallowance forproblems• displacement ontoother issuesOVER-INVOLVEMENT IDEAL RANGE UNDER-INVOLVEMENT
  50. 50. Self care Physical Psychological Emotional Spiritual Workplace care BalanceEmotional Responces 2006 50
  51. 51. Active Ingredients of self care Intentionality Connection Self soothing Self care Exercise, meditation, nutrition, spirituality Working harder creates an sense of entitlement andcan lead to a breach of professional boundaries.Compassion fatigue: A crucible of Transformation Eric Gentry. PhD (Cand), Mt.Cac 2002 Haworth Press Journal oftrauma practice 1(3/4), 37-67.Emotional Responces 2006 51
  52. 52. Active Ingredients of self care Narrative timeline Desensitization and reprocessing. Nutrition Sleep Routine Entertainment Fun Activity/Exercise Talking about itCompassion fatigue: A crucible of Transformation Eric Gentry. Phd (Cand), Mt.Cac 2002 Haworth Press Journal oftrauma practice 1(3/4), 37-67.Emotional Responces 2006 52
  53. 53.  “” when caregivers fail to maintain a lifethat is rich with meaning and gratificationoutside the professional arena then theyoften look to work as the sole source ofthese commodities.In this scenario, caregivers interact withtheir clients from a stance of depletion andneed, It is completely understandable thatthis orientation would produce symptomsin care givers””Emotional Responces 2006 53
  54. 54. Making Meaning “The making of meaning is the opposite of the erosion ornegation of meaning that results for VT.”’ Meaning can be found in simple activities The pursuit of the aesthetic Existential awareness here and now Acceptance of change allowing for transformationEmotional Responces 2006 54
  55. 55. Healing compassion fatigueand burnout Relaxation Perceived threat (when listening to clients orwhen remembering experiences) Building and maintaining relationships( getting supportallowing other to confront when symptomatic; telling onourselves when we breach integrity; accountability) Sharing Narratives -Painful work experiences(with clientsand co-workerEric Gentry prevention and Resiliency for the WorkforceEmotional Responces 2006 55
  56. 56. Implications and Directions Alterations of self may be inescapable ifnot inevitable Self (both personal and professional) is arelational and contextual process Worker ‘self-care’ is an ongoing collectiveresponsibility with implications fororganisations and systems Positive growth is a potential alteration ofself given the right conditions
  57. 57. Implications and Directions Alterations of self may be inescapable ifnot inevitable Self (both personal and professional) is arelational and contextual process Worker ‘self-care’ is an ongoing collectiveresponsibility with implications fororganisations and systems Positive growth is a potential alteration ofself given the right conditions
  58. 58.  “… Yet when addressing the distress ofcolleagues, we have focused on the use ofindividual coping strategies, implying thatthose who feel traumatised may not bebalancing work and life adequately andmay not be effectively making use ofleisure, self care, and supervision” (Bober and Regehr 2006)
  59. 59. Winnocott and supporting careers 1. Helping the primary care giver feel well caredfor and providing a sense of social security andhope for the future. 2. Supporting the authority of the primarycaregiver while allowing for splits 3. Enrich the life of the one receiving carethrough the personal quality, ideals andknowledge and liveliness of the other.Winnicott, D. W.1964 The child the family and the outside Wourld Reading Mass Addison WesleyEmotional Responces 2006 59
  60. 60. Team care “” a community absorbs –the traumaticexperience of an individual by diffusing itseffects among many people anddemonstrating that the survivors feelingsare understood”” Like direct trauma then secondary traumaviolates trust severs contact to communityand destroys meaningEmotional Responces 2006 60
  61. 61. Team approach to VT Team identifies trauma emergent patterns Therapist with trauma patterns like a client may have anarrowed focus and be unaware. Team expects to see staff with traumatic behavior on aregular basis and confront them as early as possible. Team maintains supportive trusting communityenvironment A community absorbs the traumatic experience of theindividual by diffusing its effects among many people.Emotional Responces 2006 61
  62. 62. Three tenants of team based care 1. Acceptance of the reality of Secondarytrauma. 2. Acceptance of secondary trauma as anatural and valuable process, rather thena defect. 3.That others can accurately observeworkers responses to secondary trauma.Munroe et al 1995Emotional Responces 2006 62
  63. 63. TRUST Validating affect Identifying patterns Proposed healthily alternatives Patterns that restore trustEmotional Responces 2006 63
  64. 64. Team Care“a community absorbs –the traumaticexperience of an individual by diffusing itseffects among many people anddemonstrating that the survivors feelings areunderstood”Emotional Responces 2006 64
  65. 65. Self-care vs. Transformation Self care approach address the stress andapplies self and soothing and stress reductionmethods. Transformation addresses the need to transformthe negative beliefs, despair and loss ofmeaning. Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New YorkEmotional Responces 2006 65
  66. 66. Transformation Self Care Nurturing activities Escape Create meaning Infuse a current activity with meaning Challenge your negative beliefs and assumptions. Participate in community building activitiesPearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassionfatigue: secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New YorkEmotional Responces 2006 66
  67. 67. What have Workers found Useful? Based on a study by Harrison and Westwood(2008): Countering isolation Supervision as relational healing Training, professional development, and organisationalsupport Diversity of professional roles Developing Mindful Awareness Embracing Complexity
  68. 68. What have Workers found Useful?(cont.) Active Optimism Holistic Self-Care Clear Boundaries and Limits Exquisite Empathy Professional Satisfaction Creating MeaningHarrison and Westwood (2008)
  69. 69. Ethical Considerations Educate workers of risks to alterations ofself Train how to cope with ‘exposure’ Train in empathic disengagement Titrated exposure vs being thrown in ‘atthe deep end’ Evaluation of capacity to cope
  70. 70. Organisational Responsibilities Organisational culture (sets expectations) Workload (diverse and manageable) Environment (safe, comfortable, private) Education (duty to warn of VT, ongoing education) Group support (informal peer debriefing) Supervision (regular, with focus on impact on self) Resources for self-care (stress-reduction, yoga etc)
  71. 71. “” For therapist, organizations, institutions,the key to successfully working withtrauma victims is understandingsecondary trauma and the risksassociated with hearing traumatic materialand finding ways to process and cope withit. “.Secondary Trauma: how Working with Trauma Survivors Affects therapists , Amy R.Hesse CSWClinical social work journal Vol 30, No3 Fall(2002)Emotional Responces 2006 71
  72. 72.  “It is not sufficient for employers…toinstruct their therapists to take care ofthemselves off the job: active preventativemeasures should be a regular part of thework environment.”(Monroe 1999) agencies should structure schedules toallow ample time for supervision and avoiddual relationships in which the supervisoris the agency director Sommer and Cox (2005)
  73. 73. “Addressing secondary or vicarioustrauma is without a doubt in thebest interest of the recipients ofout services our--- clients.”Secondary Trauma: how Working with Trauma Survivors Affects therapists , Amy R.Hesse CSWClinical social work journal Vol 30, No3 Fall(2002)Emotional Responces 2006 73
  74. 74. “What is to give light mustendure burning”Victor Frankel“To keep a lamp burning wehave to keep putting oil in it”Mother Teresa
  75. 75. ReferencesAmerican Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4thedition) (DSM-IV). Washington DC.Bustos, E. (1990) Dealing with the unbearable. Reactions of therapists and therapeutic institutionsworking with survivors of torture. In Suedfeld, P. (Ed.), Psychology and torture. HemispherePublications: New York.Figley Charles R (1995) Compassion Fatigue, New York: Brunner/MazelGentry Eric J. Phd cand Mt,Cac Compassion Fatigue: A crucible of Transformation, 2002 HaworthPress incJournal Of Trauma Practice 1(3/4),37-67Pearlman, L. & Saakvitne, K. (1996) in van der Kolk, B., et al. (Eds.), Traumatic stress: the effects ofoverwhelming experience on mind, body and society. The Guildford Press: New York.Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassionfatigue: secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.Winnicott, D. W.1964 The child the family and the outside World Reading Mass Addison WesleyWilson, J. & Lindy, J. (1994) Countertransference in the treatment of PTSD. Guildford Press: NewYork. (p. 15)Horowitz, M. (1976) Stress response syndromes. Jason Aronson Publishers: New York.Emotional Responces 2006 75
  76. 76. ResourcesDavid Balwins Trauma Pageswww.trauma-pages.comEmotional Responces 2006 76

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