Resilient Client, Resilient Therapist:

Transcription

1 2017 EMDRIA Conference Bellevue, WA~ August 26, 2017 Resilient Client, Resilient Therapist: An Adventure in EMDR Therapy Rajani Venkatraman Levis, MFT & Anastasia Pollock, LCMHC EMDR Therapy: New Frontiers Therapy as a social justice arena that empowers clients and therapists Therapy as a collaborative cultural encounter where therapists and clients become more resilient. 1

2 Resilient Client, Resilient Therapist Primary Objective Integrate Community Cultural Wealth Resources (CCWR)(Levis & Siniego, 2016) within the phases of EMDR Therapy. Utilize vicarious resilience (Hernandez, Gangsei, Engstrom, 2007) as a protective factor against vicarious trauma and burnout Resilient Client, Resilient Therapist Objectives Reinforce mutuality and reciprocity within the therapeutic alliance Identify how therapists benefit from trauma work Discover invisible and under-utilized adaptive memory networks which benefit both therapists and clients. Resilient Client, Resilient Therapist Objectives Incorporate at least 5 culturally sensitive means for identifying and/or creating adaptive memory networks, including the use of Phase 1 (History Taking) to elicit potential resources. Identify and incorporate all eight forms of CCWR within the standard eight phase protocol. 2

3 Copyright 2017 Levis & Siniego Copyright 2017 Levis & Siniego Outline for Resilient Client, Resilient Therapist Placing Culture at the Heart of Therapy Community Cultural Wealth Resources (Levis, 2016) Method of Presentation LOTS of Client Videos Vignettes Break-out Groups Handout BREAK Outline for Resilient Client, Resilient Therapist Vicarious Trauma Self care as an Ethical Imperative Vicarious Resilience (Hernandez, Gangsei, Engstrom, 2007) Methods of Presentation Client Video Vignette Break-out Group Handout Q & A 3

4 Placing Culture at the Heart of EMDR Therapy Goals of the EMDR Therapy Approach to Psychotherapy (EMDR Institute Part 1) 2. To strengthen access to adaptive memory networks to optimize client s ability to respond appropriately to current and future life demands. 4. To incorporate needed skills, behaviors and adaptive beliefs about self and other, optimizing client s capacity to respond spontaneously and authentically. 6. To bring contentment, satisfaction and wellbeing into the client s life. Placing Culture at the Heart of EMDR Therapy EMDR Institute Part 1 Training Manual (Pg 13) Adaptive memory networks need to be present and accessible for reprocessing to occur. Therapeutic relationship is part of an adaptive memory network. Placing Culture at the Heart of EMDR Therapy EMDR Institute Part 1 Training Manual (Pg 13) Determine availability of positive/adaptive memory networks in order to proceed with memory processing Develop and strengthen positive memory networks as needed. 4

5 Placing Culture at the Heart of EMDR Therapy using Community Cultural Wealth Resources (CCWR) Create a healthy foundation for empowering clients through the acknowledgment and installation of cultural resources which may be invisible and therefore undervalued. (Levis, 2016) Justifying the Importance of CCWR in EMDR Therapy EMDR Institute Part 1 Training Manual (Pg 24) CLINICAL LANDSCAPE Use clinical judgment regarding the timing and pacing of gathering information about early childhood attachment and development, life experiences, family of origin, peer relationships, culture, gender, ethnic and religious influences. The Importance of Culture The center determining how the other components are implemented in timing and process THERAPIST ATTUNEMENT & AWARENESS Affect Regulation Systemic Dynamics Awareness of Internal Resources & Resilience Therapeutic Alliance INDIVIDUAL DEVELOPMENT Adaptive Memory Networks CULTURE Dual Awareness/ State Shifting Strategies The tire which the therapy rests on Forms the rim, determining the shape and form of treatment 5

6 Copyright 2017 Levis & Siniego Justifying the Importance of CCWR in EMDR Therapy EMDR Institute Part 1 Training Manual (Pg 24) CLINICAL LANDSCAPE Use clinical judgment regarding the timing and pacing of gathering information about early childhood attachment and development, life experiences, family of origin, peer relationships, culture, gender, ethnic and religious influences. Justifying the Importance of CCWR in EMDR Therapy EMDR Institute Part 1 Training Manual (Pg 13) Goals prior to termination include: To ensure that the client is successfully integrated into social systems When we help a client access their own resources Create experiences of safety within the therapeutic context Highlights the transference Empowers the client through respect Models healthy relationship through mutuality and reciprocity 6

7 Copyright 2017 Levis & Siniego When we help a client access their own resources Increase access to positive internal states Address current systemic triggers through experience of alternative patterns of responses Increase ability to track emotional and somatic responses Increase threshold of affective tolerance CCWR as a Framework for Increasing Client Resilience Brings awareness to the wealth of resources the client already possesses Helps with stabilization Creates an internal locus of control Increases client confidence in self and clinician CCWR as a Framework for Increasing Clinician Resilience Brings awareness to the wealth of resources the client already possesses Increases clinician confidence in the client and in self Increases vicarious resilience within the therapist Makes the invisible visible 7

8 Iceberg Concept of Culture Adapted from Weaver. G. R.(1986). Understanding and coping with cross-cultural adjustment Stress. In R.M. Paige (Ed). Cross-cultural orientation. New conceptualizations and applications. Lanham MD: University Press of America. Community Cultural Wealth Resources (CCWR) Yosso (2005) defined Cultural Wealth as an array of knowledge, skills, abilities and contacts possessed and utilized by Communities of Color to survive and resist macro- and microforms of oppressions (p.77). Aspirational Capital (Yosso, 2005) The resiliency that allows clients to maintain hopes and dreams for themselves and their children, even when faced with both real and perceived barriers. 8

9 History Taking During the most difficult times, how did you keep going? Who benefits from you being alive? Tell me about your chosen name? Which of your loved ones have dreams that rely on your hard work? Cognitive Interweaves Using Aspirational Capital What are your hopes and dreams for your family that keep pushing you to work hard? During the challenging times, what gives you courage to continue? How do the steps you are currently taking help you towards your big goal? 9

10 Linguistic Capital (Yosso, 2005) The intellectual and social skills attained through communication experiences in more than one language/style/context and which may not be readily apparent to monolingual dominant language speakers. History Taking & Preparation Phase What are some of the terms of endearment that a loved one has called you? Each of us communicates differently: some through words, some through pictures, some through song or dance or art or gestures. Here, in our room, there is a place for all those forms of communication. Cognitive Interweaves Using Linguistic Capital Ask the client to say the words they need to say in their language of choice Have the client state the PC in their language of choice in Installation Phase Inviting the client to use movement to express a part of their story that does not have words. 10

11 Linguistic Capital in Parts Work Acknowledging that parts may want to express themselves in unique ways or different languages. Using interweaves to invite parts to express themselves through gestures, tones, words in more than one language, art, music, movement, stories, etc. will make the work deeper and more meaningful. Familial Capital (Yosso, 2005) The cultural knowledges nurtured among extended family networks Engages a commitment to community well-being and expands the concept of family to include a more broad understanding of kinship History Taking Who cares about you? From whom did you learn about values, religion, love, etc.? Who is proud of you? Who do you look forward to spending time with? Whom do you include in your family of choice? 11

12 Cognitive Interweaves Using Familial Capital What would your mom/best friend/or other valued person say about that? If this had happened to someone you cared about, what might you say to them? Social Capital (Yosso, 2005) Includes the networks of social contacts and community resources that provide instrumental and emotional support. History Taking What support do you have in your life that helps you to cope with difficult situations? What support do you have in your life that helps you to move towards your next goals and aspirations? What celebrations, holidays, or dates hold meaning for you? Where do you gather with others to renew your sense of connection? 12

13 Cognitive Interweaves Using Social Capital How did it feel for you when your friend Sonia reached out to you for support? Bring to mind the community that is supporting you as you move through the work. Navigational Capital (Yosso, 2005) The skills of maneuvering through social institutions that were not created with Communities of Color in mind. Includes inner resources, social competencies and cultural strategies that draw upon a lifetime of personal and community experiences of living as a marginalized individual. History Taking How have you negotiated your needs in an environment that can be hostile/unfriendly? How do you function in an environment that may often feel biased or unfair? How did you navigate the most challenging parts of your migration journey? How have you mastered surviving in two different worlds/cultures/places? 13

14 Cognitive Interweaves Using Navigational Capital You have made many smart choices about whom to share information with, when and how. How did you learn to do this? Remind me, how did you get through that dangerous time in your life? If your wiser self could give one piece of advice to the current you about navigating this current situation, what would that be? Resistant Capital (Yosso, 2005) Refers to the knowledge and skills that are generated or fostered through thought or acts that challenge inequality. Knowledge and skills developed in opposition to oppression, grounded in a legacy of resistance to subordination. 14

15 History Taking This is a category where we rarely ask direct questions, but usually find rich information through eliciting and installing the other forms of CCWR. You will find your own unique way to accessing a client s resistant capital as you begin to explore the richness of the client s cultural wealth as well as the therapeutic alliance. Cognitive Interweaves Using Resistant Capital Videos Brainstorm Spiritual Capital (Huber, 2009) From an existential perspective, it is the ability to make meaning of our difficulties, pain, suffering and trauma, which allows us to transform it into healing. Thus, spirituality and a connection to a reality greater than oneself serve as valuable resources for many culturally diverse individuals. 15

16 Cognitive Interweaves Using Spiritual Capital What types of cognitive interweaves have you successfully used to elicit a client s spiritual capital? Cultural Intuition (Delgado-Bernal, 1998) A unique way of knowing that relates to both personal experience, as well as collective experience, which includes community memory. Acknowledges that members of marginalized groups may have a unique sensitivity, perspective and ability to interpret information based on their experiences. History Taking & Preparation In your life experiences, there have been times when you have made decisions related to safety based on your internal guidance. Therapist can then provide examples to support client in identifying such situations and their own cultural intuition. When has your intuition kept you safe? 16

17 Cognitive Interweaves Using Cultural Intuition How did your cultural intuition keep you safe in that situation? How did your internal compass and wisdom guide you at that time? FROM Vicarious Trauma & Burnout TO Vicarious Resilience as Self-Care 17

18 What is Burnout? An emotional condition marked by tiredness, loss of interest, or frustration that interferes with job performance. Burnout is usually regarded as the result of prolonged stress. Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. What is Compassion Fatigue? The emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events. Compassion Fatigue can occur due to exposure on one case or can be due to a cumulative level of trauma. Also called vicarious traumatization or secondary traumatization (Figley, 1995). Secondary Traumatic Stress Secondary traumatic stress refers to the experience of tension and distress directly related to the demands of living with and caring for someone who displays the symptoms of posttraumatic stress disorder (Figley, 1998, p. 7) 18

19 Empathic Stress Disorder Weingarten s (2003) term empathic stress disorder refers to severe stress reactions occurring and persisting over time, which may include burnout, Vicarious Trauma, and secondary traumatic stress. Vicarious Trauma & Therapist Burnout Vicarious Trauma (VT)(McCann & Pearlman, 1990) is a concept is based on the Constructivist Development Theory (Saakvitne and Pearlman). VT is defined as the transformation of a person's inner self as a result of the person's empathic engagement with traumatized clients in the context of a helping relationship. 19

20 Vicarious Trauma & Therapist Burnout VT can affect our cognitive schemas, views of self and the world, belief systems, sense of safety/trust/control, sense of independence and selfesteem, ability to be emotionally intimate with others. Overempathizing without appropriate boundaries may put us at risk for VT (van Dernoot Lipsky, 2009) Contributing Factors for Vicarious Trauma Personal history Personality style Coping style Current life context Training and professional history Supervision or lack thereof Personal therapy or lack thereof Vicarious Trauma & Therapist Burnout Weingarten (2003) hypothesizes that helplessness is the greatest risk for developing Vicarious Trauma. Weingarten, K. (2003). Common shock: Witnessing violence every day. New York: Penguin 20

21 Weinegarten s Four Witnessing Positions Weingarten, K. (2003). Common shock: Witnessing violence every day. New York: Penguin Vicarious Resilience Model The move towards Awareness & Empowerment also requires a move towards increased Self Care 21

22 Self Care as an Ethical Imperative Successful therapy requires a good relationship with yourself first! Emotional Physical Spiritual Sea Star Balancing Exercise (Echterling, 2002) 22

23 Self Care as an Ethical Imperative Successful therapy requires a good relationship with yourself & with your client Struggles of Overworked, Overwhelmed & underpaid therapists Self Care is an Ethical Imperative Resilient Client, Resilient Therapist A Shift from the quicksand of vicarious trauma, compassion fatigue & burnout TO Empowered therapists actively eliciting, installing & honoring client resilience Thereby allowing therapist to practice good self care and experience vicarious resilience. 23

24 Copyright 2017 Levis & Siniego What is Resilience According to Dictionary.com 1. the power or ability to return to the original form, position, etc., afterbeing bent, compressed, or stretched; elasticity. 2. ability to recover readily from illness, depression, adversity, or thelike; buoyancy. Building Resilience When building resilience is an explicit therapy goal, client and therapist are more likely to make proactive plans to use identified strengths to foster future resilience and improve well-being important goals to many clients. Kuyken, W., Padesky, C.A. & Dudley, R. (2009). Collaborative Case Conceptualization: Working Effectively with Clients in Cognitive-Behavioral Therapy. New York: Guilford. 24

25 Nancy Davis 1999 Research on Resilience 1. Physical (good health, easy temperament) 2. Spiritual (faith that one s life matters, seeing meaning in pain and suffering, sense of connection with humanity) 3. Moral (ability to contribute to others and engage in socially or economically useful tasks) 4. Emotional (emotional regulation, ability to delay gratification, self-esteem, creativity, sense of humor) 5. Social Relational (secure attachment, basic trust, social support) 6. Cognitive (high EQ, language/reading skills, capacity to plan, self-efficacy, self-understanding, adequate cognitive appraisal) Resilience and the AIP Model Ungar (2008): In the context of exposure to significant adversity, resilience is both the capacity of individuals to navigate their way to the psychological, social, cultural and physical resources that sustain their well-being, and their capacity individually and collectively to negotiate for these resources to be provided to them in culturally meaningful ways. Resilience and the AIP Model Zaghrout-Hodali, M., Alissa, F., & Dodgson, P. (2008) AIP Model helps to better understand mechanisms for building resilience Memory networks work toward integration Traumatic events prevent appropriate integration EMDR helps client to link traumatic memories to appropriately connect to adaptive memory networks 25

26 Resilience and the AIP Model Zaghrout-Hodali, M., Alissa, F., & Dodgson, P. (2008) The model leads to the hypothesis that EMDR could help a person change patterns of response and enable a person to develop resilience in an ongoing situation such as war or armed violence, perhaps by integrating experiences into semantic, accessible memory, thereby making it possible to make a considered response and informed choices. Viewing Resilience Through the EMDR Therapy Lens Greater Resilience = Higher proportion of functional, adaptive, positive memory networks. The scaffolding necessary for effective and complete reprocessing. Vicarious Resilience (Hernandez, Gangsei, & Engstrom, 2007) Positive transformation of the therapist s inner experience Results from empathetic engagement with the client s trauma material. Transforms the therapist in response to client s own resiliency. 26

27 Copyright 2017 Levis & Siniego Vicarious Resilience Hernandez, Gangsei & Engstrom, 2007 Transforms the therapist in response to client s own resiliency. Positive meaning making, growth and transformation in the therapist s experience resulting from exposure to client s resilience in the course of therapeutic process addressing trauma recovery. Vicarious Resilience & Therapist Gains Deconstructing the therapeutic relationship using this concept Creating balance in the hierarchy, and empowering clients VR as a protective factor against VT 27

28 Copyright 2017 Levis & Siniego Vicarious Resilience & Therapist Gains Name some of the ways in which you benefit from your clients Wages Supervised Hours Experience Job Satisfaction More??? Mutuality and Reciprocity Mutual impact in the therapeutic relationship. Effects of context and positionality on the therapist s ability, as well as the therapist s ability to learn vicariously. Effects of Context & Positionality in eliciting CCWR Phase 0: Therapist Humility (Chang, 2016) Increasing cultural competence: Increasing awareness Acquiring knowledge and skills All with HUMILITY 28

29 Copyright 2017 Levis & Siniego Copyright 2017 Levis & Siniego Therapist Humility Therapist humility may also be regarded as a position, lens, or ongoing dynamic process through which any and all healing may occur rather than a simple or discreet skill that can be attained. (Chang, 2016) Therapist Context and Positionality Race/Culture Ethnicity Age Class Immigration Status Sexual Orientation Education Gender Language Therapist Context and Positionality 29

30 Copyright 2017 Levis & Siniego Copyright 2017 Levis & Siniego Copyright 2017 Levis & Siniego Effects of Context & Positionality on Vicarious Resilience 1. Increased recognition of clients capacities and resources for healing and recovery, and being inspired by these capacities 2. Increased resilience (e.g., perceiving and reassessing problems as more manageable, increased perception of self as resourceful, increased capacity to cope with challenges in life and at work, etc.) 3. Changes in life perspective (e.g., life direction, goals, priorities, connection with others, etc.) Acevedo & Hernandez-Wolfe, 2014; Engstrom et al, 2008; Hernández et al., 2007 Effects of Context & Positionality on Vicarious Resilience 4. Increased self-reflection, self-attunement, mindfulness, and self-care practice 5. Increased comfort with the therapeutic process, engagement, and trusting clients to do their own work in therapy 6. Increased recognition that clients social contexts have an impact on their ability to overcome adversity Acevedo & Hernandez-Wolfe, 2014; Engstrom et al, 2008; Hernández et al., Key Themes 1. Placing Culture at the Heart of Therapy 2. Vicarious Resilience as Self-Care 30

31 Copyright 2017 Levis & Siniego Copyright 2017 Levis & Siniego Placing Culture at the Heart of EMDR Therapy through CCWR Allows client s culture to be placed center-stage Makes the invisible visible Contextualizes rather than pathologizes Trauma Informed & Strengths Based Vicarious Resilience Mutuality and Reciprocity of the therapeutic alliance Empowers clients and therapists to become allies and social justice advocates A protective factor against vicarious trauma 31

32 Copyright 2017 Levis & Siniego Vicarious Resilience &Therapist Gains Vicarious Resilience as Self Care An important concept in therapist self care Encourages therapist to prioritize self-care as an ethical imperative Therapists who feel vicariously resilient become trauma stewards (van Dernoot Lipsky, 2009) Copyright 2017 Levis & Siniego Placing Culture at the Heart of EMDR Therapy through CCWR New Frontiers Empowers therapist & client to fight social injustices Focuses on the individual & community CCWR allow therapists to become allies for marginalized clients Activates the role of therapists as educator, social justice advocate and ally Embraces Self Care as an ethical imperative 32

33 Debrief: How do you feel now? How do these tools increase your sense of competence and wellbeing? How do these tools increase your client s resiliency and yours as well? Rajani Venkatraman Levis, MFT, PPS, CTS therapy@levistherapy.com Anastasia Pollock, MA, LCMHC anastasia@lifestonecenter.com 33