Alterations of Self

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					Alterations of Self in Trauma
Implications and Directions

  Chris Lobsinger M.S.W.
  Forrest James M.An.Psych.

 “Many    mental health
    professionals unconsciously
    assume that their profession
    „magically‟ shields them from
    traumatic experience.”
   (Kreichman1984)
   “Analysts are people who have learned to
    practice a particular art: along side of this,
    they may be allowed to be human beings like
    anyone else.”
    (Freud 1937)
 “What is to give light must
 endure burning”
 Victor Frankel

“To keep a lamp burning we
 have to keep putting oil in it”
 Mother Teresa

   VT (Vicarious Trauma)
   CT (Counter-transference)
   STS (Secondary Traumatic Stress)
   CF (Compassion Fatigue)
   Burnout

   Is the „devil in the detail‟?
   “These constructs have not proven
    empirically separable, and the consensus
    view now is that they share many features,
    but primarily in their affective domains, which
    are self in-efficacy in relation to burnout, and
    fear in relation to vicarious traumatisation”
    (Linley and Joseph 2007)
Research Findings

   Social Workers experienced statistically
    significant levels of cognitive disturbance;
    evidenced by intrusive thoughts and
    depressive symptoms (Hodgkinson and
    Shepard 1994)
   Elevated levels of trauma symptoms
    experienced by sexual violence counsellors
    (Pearlman and MacIan1995)
   Counsellors a higher % of sexual violence in
    their case loads experienced more
    disruptions in their basic schemas of self and
    other; more symptoms of PTSD; more self
    reported vicarious trauma
    (Schauben and Frazier 1995)
   Counsellors with high % of trauma cases
    experience high levels of trauma related
    symptoms at a level that in traumatised
    person would suggest a need for clinical
    attention (Cassim-Adams1999)
   Counsellors involved with traumatised clients
    demonstrated increased levels of trauma
    symptoms (Chrestman1989)
   Physical effects such as nausea, headaches
    and exhaustion, and psychological distress
    such as feelings of horror and intrusive
    imagery in counsellors who worked with
    survivors or perpetrators of domestic
    violence. (IIiffe and Steed 2000)
   18% of general mental health workers in
    Australia experience symptoms with the
    quality, quantity and intensity that are
    equivalent to PTSD symptoms
    (Meldrum, King and Spooners 2002)
Aspects of Alterations of Self:
Changes in…
   Perceptions of self and other
   Personal identity
   Worldview
   Spirituality
   Personal capacities
   Ego resources
   Psychological needs
   Sensory systems
Changed Worker Sense of:

   Safety
   Trust
   Esteem
   Intimacy
   Control
Other Factors

   As postgraduate training increases, traumatic
    symptoms in workers decrease
   Greater involvement and greater caseload
    elevate levels of trauma symptoms
   Women report more symptoms than men
   Workers with administrative responsibilities
    (multiple roles) and longer service have more
    severe symptoms
   Symptoms reduce with years of experience
   Under 2 years experience increased
   Personal history of sexual abuse /trauma
    exhibit highest levels of symptoms (mixed
Implications and Directions

   Alterations of self may be inescapable if not
   Self (both personal and professional) is a
    relational and contextual process
   Worker „self-care‟ is an ongoing collective
    responsibility with implications for
    organisations and systems
   Positive growth is a potential alteration of self
    given the right conditions
‘Self-Care’ Programs

   Little evaluation of effectiveness of programs
    to reduce worker distress
   No evidence of programs reducing acute
    distress and symptom levels
   (Bober and Regehr 2006)
‘Self-Care’: An Individual Strategy?

   “As mental health professionals dedicated to
    the fair and compassionate treatment of
    victims in society, we have been strong in
    vocalising concerns that those who are
    abused and battered not be blamed for their
    victimisation and their subsequent traumatic
   “… Yet when addressing the distress of
    colleagues, we have focused on the use of
    individual coping strategies, implying that
    those who feel traumatised may not be
    balancing work and life adequately and may
    not be effectively making use of leisure, self
    care, and supervision”
   (Bober and Regehr 2006)
Post Traumatic Growth (some good news)

   Positive and sometimes profound
    psychological change experienced as a result
    of the struggle with highly challenging life
    circumstances that pose significant
    challenges to individuals‟ way of
    understanding the world and their place in it.
    Tedeshi & Calhoun (2004).
Other Factors found to Contribute to
Worker Growth
   Personal Therapy
   Clinical Supervision
   Personal Trauma History (helps)
   Gender (being female helps)
   Therapeutic Orientation
       Humanistic / transpersonal better than CBT
   Lifetime Work
   Current Workload
    Linley and Joseph (2007)
Therapist as Psychobiological Regulator
(Gill 2009)
   Recent research in trauma, attachment,
    neuroscience and psychoanalysis
       Explicit communication – verbal, symbolic,
        meaning making
       Implicit – affective, process based, unconscious
   Therapist interacts with client to support
    meaning making (explicit) with affect
    regulation (implicit)
Relationship, Relationship, Relationship

   Correlation between impact of traumatic event and
    relational supports available following the event
   Most robust predictor of therapeutic change is the
    quality of the alliance (or relationship)
   “A trauma therapy supervision is always a
    consultation on a therapy relationship, not the
    client” (Pearlman and Saakvitne1995)
Current Focus in Trauma Treatment

   Mutual influence in therapist-client
   Importance of self and interactive regulation
    of affect
   Importance of the role of implicit
    (unconscious) communication
   Disruption and repair
   Above relies on well developed capacity for
    empathy and emotional attunement
Risk or Protective Factor?
   Empathy is „the intersubjective bridge”
    between the worlds of the client and therapist
   “Many theorists have speculated the
    emotional impact of…traumatic material is
    contagious and can be transmitted through
    the process of empathy”
    (Bell, Kulkani and Dalton 2003)
Risk or Protective Factor?
   Empathic engagement can be a protective
    practice for clinicians that work with
    traumatised clients (where there is „exquisite
   The inability to disengage from the client‟s
    world rather than empathy itself is
What have Workers found Useful?

   Based on a study by Harrison and Westwood
   Countering isolation
       Supervision as relational healing
       Training, professional development, and organisational
       Diversity of professional roles
   Developing Mindful Awareness
   Embracing Complexity
What have Workers found Useful? (cont.)

   Active Optimism
   Holistic Self-Care
   Clear Boundaries and Limits
   Exquisite Empathy
   Professional Satisfaction
   Creating Meaning

Harrison and Westwood (2008)
Ethical Considerations

   Educate workers of risks to alterations of self
   Train how to cope with „exposure‟
   Train in empathic disengagement
   Titrated exposure vs being thrown in „at the
    deep end‟
   Evaluation of capacity to cope
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)
   “It is not sufficient for employers…to instruct
    their therapists to take care of themselves off
    the job: active preventative measures should
    be a regular part of the work environment.”
    (Monroe 1999)
   Sommer and Cox (2005) noted that:
   agencies should structure schedules to allow
    ample time for supervision and avoid dual
    relationships in which the supervisor is the
    agency director
Sense of Coherence: Develop at Personal
and Organisational Levels
    Basic construct of „salutogenic‟ approach
     (Antonovsky 1987)

    Three Components:
1.   Comprehensibility
2.   Manageability
3.   Meaningfulness

   In line with the construct of „sense of
    coherence‟ we consider it important to
    develop work systems, processes and
    cultures that support
   Understanding
   Meaning making
   Emotional responsiveness
Questions - Discussion

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