Professional care for care givers and prevention of vicarious trauma

Transcription

1 Co-funded by the European Commission Professional care for care givers and prevention of vicarious trauma Milton Erickson used to say to his patients, My voice will go with you. His voice did. What he did not say was that our clients' voices can also go with us. Their stories become part of us part of our daily lives and our nightly dreams. Not all stories are negative - indeed, a good many are inspiring. The point is that they change us. (Mahoney, 2003). 1 As a social species, human beings are sociobiologically connected to each other and witnessing another person s suffering (directly or indirectly) is extremely traumatic. It has long been recognized that caregiver worker jobs, family members, colleagues and other witnesses and bystanders to disasters and other trauma can experience secondary symptoms themselves. The terms that are most frequently used to describe these symptoms are secondary traumatic stress, compassion fatigue, and vicarious traumatization. Vicarious traumatization is, as defined by Pearlman and Saakvitne, the "negative effects of caring about and caring for others". Vicarious traumatization is the cumulative transformation in the inner experience of the therapist that comes about because of empathic engagement with the client s traumatic material. 2 Unexpected exposure to horror and terror has emotional consequences, no matter where the traumatic event occurs. That happens when we react with a rush of adrenalin and our brains record and sort images with nerve cells bathed in a common chemical soup. There is a fundamental neurochemistry of traumatic stress. Depending upon our genetic makeup, some of 1 Donald Meichenbaum: Self-care for trauma psychotherapists and caregivers: Individual, social and organizational interventions. 2 Ibid.

2 us will have inescapable echoes of the "trauma imprint." We will have flashbacks and nightmares and other related emotional changes consistent with PTSD. Some of us will not have this pattern, but will have profound feelings including sorrow and anger. Some of us will be relatively unmoved, detached, even numb. The "first responder" to trauma, whether a firefighter, a medic, a police officer, a soldier, or a war reporter, can be expected to have emotional consequences, although some are more likely than others to suffer painful symptoms from these biological changes. Anyone in the business of reporting trauma should recognize and understand PTSD. The symptoms of vicarious traumatization resemble those of PTSD, but also encompass changes in meanings, beliefs, schemas and adaptation, identity, sense of safety, ability to trust, self-esteem, intimacy, and sense of control. Those who are most affected by vicarious trauma are the therapists who work in an almost intimate atmosphere with clients. Out of the understanding of PTSD some clinical psychological studies led to the theory, that trauma therapists, who work a lot with trauma clients are in danger of getting PTSD. The symptoms of a secondary traumatic stress disease were put in theory by McCann und Pearlman (1990b) as well as C.R. Figley (1995 b, 2002 a, 2002b) as possible consequences of traumatherapeutic work. They are nearly identical to posttraumatic stress disease: 1.) The therapist has intrusive symptoms similar to the client in a way, that he has unwilling thoughts on the traumatic event of his client, he dreams of it and also, he can get traumatic stress symptoms, when thinking of his client or his role as helper of the client. 2.) The therapist shows avoidance behaviour. He tries not to think of thoughts, people or activities which remind him about the trauma of his client. He begins to make mistakes in planning or in the realisation of the therapy with his trauma client. The therapist feels isolated and feels that others cannot understand his situation. 3.) The therapist shows the same symptoms of arousal like his PTSD client (sleeping problems, concentration problems, inflammableness, hypervigilance, lack of concentration, skittishness.) 4.) All the symptoms produced result in the therapist facing a heavy disturbance in his professional actions and often also in his private life. 5.) Dependency: Trauma-Therapists hear about betrayal, abuse of confidence, misuse of power, dependence and violence which happens during torture. The therapist can destroy the general meaning: All men are trustworthy" and change the meaning into never trust anybody, avoid dependence and to allege other people s negative motivations.

3 6.) Security: the trauma therapist recognizes probably himself and his family in a more vulnerable manner compared to a normal person without such experiences. He might feel more need for safety precautions and might lead him to be excessively sorrowful and face limitations in everyday life. 7.) A traumatic situation is also defined by extreme helplessness. This also can lead the therapist to a higher perception of the own powerlessness. He develops a feeling, that all what is important to him might be destroyed at any time, without him having chance to avoid this. This might lead him to resignation and desperation. It also might bring the therapist to extraordinary feelings of dominance. 8.) An additional psychological need is, that therapists like to interpret their circumstances and environment to understand their own role. They create a pattern of causality. Events are ascribed to certain credos and reasons. If this pattern were to be changed, because the frame of reference does not provide explanations, it might lead to a feeling of disorientation within the therapist. 9.) When the trauma therapist has his/her own traumatic situations in his life, it might happen, that those are also reactivated. In such a situation, it is often impossible to listen to the client with empathy. The theory of the secondary traumatisation recommends that the therapist in a case like this avoids confrontation with descriptions of traumatic situations and to follow the road of avoiding trauma focussed therapies. The therapist could carry out resilience therapy or other helpful trauma therapies. This theory was clarified by a workgroup of diploma-psychologists in the trauma research centre of the University of Constance (Florentine Jurisch1, Iris-Tatjana Kolassa1,2 und Thomas Elbert1), and published in: Zeitschrift für Klinische Psychologie und Psychotherapie, 38 (4), under the heading: Traumatisierte Therapeuten? Ein Überblick über sekundäre Traumatisierung The workgroup of diploma-psychologists in the trauma-research-centre of the University of Constance found in 2008/9 in specific literature 38 studies, which deal with secondary traumatic stress or so called vicarious trauma. They proved that 21 studies out of them were reliable for researching secondary trauma of trauma therapists. They postulated: That therapy work carried out is with more than half with traumatized clients the symptoms of PTSD are clearly recorded the study regarded the graveness of the therapist's trauma symptoms The result of this study was that 10 studies concluded that there is an effect between

4 traumatisation of the clients and the therapist, especially when the therapist is young and does not have extensive experience. But 11 studies said that working with traumatized clients does not affect the therapist. So, as the result of this study the workgroup of diploma-psychologists in the trauma-research-centre of the University of Constance remarked that there is no reason to warn trauma therapists not to work with trauma focussed therapy methods, because of the chance/danger to be traumatised themselves. It is important to be seen in the background, that trauma focussed therapy is much more effective in its results in comparison with other symptom focussed therapies (National Institute for Clinical Excellence, 2005; Bisson et al., 2007), and other trauma therapies, that do not work with trauma focus. Nevertheless, the general norm for all psychotherapists to have regular supervision, or at least having the possibility of supervision if the therapist feels the necessity, stays especially for trauma therapists a perpetual duty!! Beside the therapist, there are other care givers like social workers or case managers who are also in close contact with the clients. Such care givers are themselves the tool of their trade their perspective, mindset, problem solving skills, decision making capacity, analytical skills, empathetic engagement, non-judgmental presence, cognitive abilities, compassionate regard, emotional boundaries, deep listening, and human kindness form the heart and foundation for their work. Who care givers are, along with what they are doing, forms the quality, engagement and performance within their various care giving roles as well as within their respective workplaces. 3 Risk factors for developing vicarious traumatization are, according to literature, on in three areas: characteristics of the client, characteristics of the helper and characteristics of the job/work setting. In line with those characteristic, also interventions and the ways how to cope with vicarious traumatization are based on three levels: individual level: practicing self-care, peer and collegial level and organizational and agency level. Self-care is an ethical imperative for care givers given the innate occupational hazards relevant within the field including job stress, professional burnout, primary trauma, vicarious trauma 3 Lynda Monk: Self-Care for Social Workers, A precious commodity, an ethical imperative.

5 and compassion fatigue (Kahn, 2005; Figley; Maslach, 1982; Rothschild, B. & Rand, M., 2006; Saakvitne, K. & Pearlman, L., 1996). For many care givers, the nature of the work itself often involves three elements high stress, high trauma (direct or indirect), and high touch (high emotion with emotional labor/caring being a key task within many care giver roles). Self-care, the way a person tends to their emotional, psychological, physical, and spiritual well-being, becomes foundational to maintaining health and wellness as a care giver, since it serves to mitigate the occupational hazards relevant within the care giver professions. Therefore, it needs to be a top priority for both individuals and the profession at large. Too often the focus in the helping fields is on the tasks at hand and the intense human needs before the care givers. 4 Caregivers are at even higher risk if they have a history of trauma in their own backgrounds and if they extend themselves beyond the boundaries of good self-care or professional conduct. 5 It is crucial to step also into a macro, systemic and structural perspective specific to addressing and ensuring the well-being of professional care givers, as well as for sustainability and succession planning within the care giver professions. While individuals are responsible for their self-care, there is a great deal that organizations/employers and other stakeholders can do to contribute to the wellness of care givers. Care givers can benefit from information, inspiration, and support with the task of self-care and greatly benefit from working within healthy workplace environments. For example, there are significant sources of systemic stress that many care givers deal with including such things as high workload, lack of supervision, pressure to do more with less, and role ambiguity, which are areas of risk that contribute to both stress and burnout among care givers. When considering the health and well-being of care givers as a shared responsibility with opportunities for contribution from employers through creating healthy and responsive workplace cultures where systemic stress factors are addressed; schools of caregiver worker jobs through education, as well as professional associations and unions, where relevant, through educational opportunities. 6 One important aspect within the transnational meetings was to reflect on the implementation of the project but from the point of view of the wellbeing of project staff. As mentioned in this paper, vicarious trauma is a phenomenon which is influenced by many factors. Each individual member of the team had their own approach and strategies and these were discussed and exchanged. The process was greatly supported by Dr. Subilia who attended the transnational meetings as an expert. Since vicarious trauma is insidious, some of the discussion and exchange 4 Sandra L. Bloom: Caring for the Caregiver: Avoid and Treating Vicarious Traumatization (Chapter 22). 5 Ibid. 6 Medial Research Council South Africa: Guidelines for the prevention and management of vicarious trauma among researchers of sexual and intimate partner violence.

6 was on how to identify signs of it and early enough so that long- term negative impacts can be avoided. The discussion went as far as discussing that trauma affected clients who are victims of torture cannot be treated by everyone. Sometimes it is necessary to refuse a patient and refer the person to a colleague rather than risking one s own health. For those who feel they can work with such clients, the issue is to develop strategies to manage vicarious trauma rather than trying to avoid its existence. When a professional decides to work with a client, it should be within a multi-professional team and not struggle as a loner. Helpers should be able to accept the fact that vicarious trauma can get anybody and not be ashamed when one is affected. Efforts must be made to recognize and accept it and then work on the problem. Creating awareness and reflecting on one s own style of working. Self-care is a skillful attitude that needs practice throughout the day (Mahoney,2003, p.25a) The discussions also led to some suggestions as to how each individual staff member could reflect on their own work and recognize signs of stress and possible traumatization. There were suggestions which are familiar to all like individual relaxation methods, activities to wind down, conducting rituals that clearly demarcate work and free time, developing a healthy distance to the clients and their problems etc. It is also helpful to think about a pool of people both at work and in private who can be contacted if the need should arise. This is advisable even if there are no signs of vicarious trauma. Creating a comfortable environment at the office or therapy room which also carries a personal note is useful. It is also helpful to experience that each professional works in a team and can always fall back on the other team members for advice. Another aspect that must be dealt with by all staff members is to set realistic goals and not to expect too much of oneself. It is necessary to experience success. Expecting clients to be upset and very often in a helpless state is necessary. All helping professions are there for this reason. What the client goes through, especially during therapy must take place before the healing process can start. It is also important to accept what was done to victims of torture cannot be wiped away. The client can learn to live with it. There will be change but not everything can be made new. The sooner the helper accepts this fact, the easier it is to keep vicarious trauma at a distance. Besides, the helper cannot take responsibility for the client s life by being pulled into the role of Savior. Very often, all that the clients need is a neutral person who listens and is non-judgmental and not somebody who wants to solve the problem immediately. In the social work profession, much value is laid on self-dependence of the clients which also strongly includes self-care. The same principles should also be applied to one s own style of work. The client has networks of support other than the professional helpers which create life balance. The same should apply to

7 helpers who should be able to rely on self-care but also use other sources of help when necessary. These resources could include the family as well. A very important aspect is finding enough support at the workplace. This support could be in the form of supervision, intervision, team meetings or one to one meetings and should be held in regular intervals. Such support helps to reflect on one s own approach and attitude. When colleagues tell the concerned persons that he/she is doing an excellent job, it helps to be lesser self-critical. Reviewing difficult cases and de-briefing also is of immense help. The concept of resilience does not only refer to clients but also to the staff. Staff members can work towards nurturing resilience by looking at cognitive and affective factors which either block or help to nurture resilience. This requires looking into one s own self and then developing an attitude which is marked by monitoring one s own thinking processes, avoiding assumptions, reflecting on deeply rooted beliefs, seeing things in the right perspective, developing calmness and staying focused and stay grounded in everyday life. A lot lies in the hands of the organization or institution which employs professional helpers. The risk of vicarious trauma must be recognized and accepted as such at the management level. Much of the alleviation of the potential risk can be initiated through structural conditions which reduce the probability. Such structures could be plain and simple for example fixing dates for supervision and team meetings for the entire year, transparent communication and regular information bulletins, organizing joint activities for the whole staff, on the job training, one to one meeting with the management to discuss job satisfaction and future perspectives, attending seminars and conferences, etc. The organization must also represent a highly professional profile and expect the same from its staff. In conclusion, it can be stated that helping professions have existed for a long time and are developing all the time. Efforts to better the services offered as well as improving the working conditions is an ongoing process. There are certain characteristics which mark a professional helper and empathy is one of them. Empathy is the helper s greatest asset and possibly his/her greatest liability. When the roots of vicarious trauma are understood, it can be prevented; when the signs and symptoms are well understood and given the appropriate attention, vicarious trauma can be well-managed. 7 7 Donald Meichenbaum: Self-care for trauma psychotherepists and caregivers: Individual, social and organizational interventions.