Therapist Burnout in Psychosexual Therapies: Impairment, Ethics, and Transformation. Sam Wallace, MS, LPC 12/2/10

Transcription

1 Therapist Burnout in Psychosexual Therapies: Impairment, Ethics, and Transformation Sam Wallace, MS, LPC 12/2/10

2 Agenda Effects of Psychotherapy on the Therapist Impact on Sex Offender Therapists Burnout Research Ethical Implications Transformation and Self Care

3 On Being a Therapist A career as a psychotherapist is a mixed bag of benefits and liabilities. Few careers offer the rewards experienced by the dedicated clinician. Most psychotherapists discover that encounters with distressed individuals and repeated confrontations with the painful aspects of human existence can undermine vitality and optimism (Norcross & Guy, 2007)

4 Work Hazards The therapist that denies clinical work is grueling and demanding is in Thorne s (1998) view, mendacious, deluded, or incompetent. Therapists challenged with engaging clients on an emotional level while at the same time regulating and sometimes suppressing their own emotional reactions (Moulden & Firestone, 2010)

5 Risks of Providing Therapy Emotional Depletion: The psychotherapy profession consists mainly of working long hours in isolation. Therapists deal primarily with people in crisis and pain. They are supposed to offer these people support, empathy, interpretation, explanation, direction, or advice (Zur, 2008)

6 Risks of Providing Therapy Helplessness and Sense of Inefficiency: Unlike carpenters, gardeners, or surgeons, psychotherapists rarely see immediate, profound, or tangible results from their efforts. The work is often slow, and with difficult or charactologically impaired people, they may never see improvement (Zur, 2008).

7 Risks of Providing Therapy Depression, Sadness and Vicarious Traumatization: Working constantly with people in pain, who feel suicidal, or are grieving over the loss of loved ones, or those severely traumatized, often takes a heavy toll on practitioners (Zur, 2008).

8 Thematic Therapist Challenges Transient difficulties: based on competency deficits; we literally do not know what to do or how to do something Paradigmatic difficulties: based on therapists enduring personality characteristics Situational difficulties: based on features of particular clients and circumstances (Norcross & Guy, 2007)

9 Thematic Therapist Challenges Transient difficulties call for improved knowledge, training and wider experiences. Paradigmatic difficulties call for enhanced self awareness and countertransference measures Situational difficulties require tolerance, support, and acceptance (Norcross & Guy, 2007)

10 Individual Risk Factors for Burnout Socially isolated individuals who have an overly idealistic perspective. Dedicated, service oriented, with a high need for recognition and positive feedback. Married women with children. (Norcross and Guy, 2007)

11 Client Factors and Burnout Suicidality, violence, hostility and aggression Overly demanding and early terminators Consistently seeing the same type of client linked to increased burnout risk (Norcross & Guy, 2007)

12 Clinical Work with Sex Offenders Working with sex offenders is viewed as one of the most challenging populations in the mental health field. Working in the trauma field prolongs exposure to intrusive imagery and may increase expenditure of emotional energy relative to general mental health clinicians thereby increasing the potential for exhaustion and burnout (Lee, Wallace, Puig, Choi, Nam, & Lee, 2010)

13 Clinical Work with Sex Offenders Mistrust of others sexual behavior; especially if they have access to children Projection of abusive motivations onto innocuous interactions or events Experiencing fleeting feelings of titillation or sexual arousal while listening to descriptions of sexual abuse (Bengis, 1997)

14 Clinical Work with Sex Offenders Direct feelings of fear or anger in response to details of a case Indirect impacts of emotional hardening or desensitization to material over time Decreased interest in sexual behavior Perception of the world as less safe compared to before working in this area (Moulden & Firestone, 2010)

15 Burnout Studies Counselor Burnout Inventory (Lee et al., 2007) 20 item measure with five subscales Exhaustion: I feel exhausted due to my job as a counselor Incompetence: I do not feel like I am making a change in my clients Devaluing Client: I am not interested in my clients and their problems Deterioration in Personal Life: My relationships with family members have been negatively impacted due to my work as a counselor Negative Work Environment: I feel frustrated with the system in my workplace

16 Study 1 Lee, J., Wallace, S. L., Puig, A., Choi, B., Nam, S., & Lee S.M. (2010) Factor Structure of the Counselor Burnout Inventory in a Sample of Sexual Offender and Sexual Abuse Therapists. Measurement and Evaluation in Counseling and Development 204 therapists identified as working only with sexual offenders, survivors of sexual abuse, and both offenders and survivors 29% direct mail response rate 37 States represented Predominantly Caucasian sample (93%)

17 Sample 73% Female and 27% Male Age ranged from M = SD = % sex offender therapists 32% survivor therapists 20% both Years of experience: M = SD = 9.25

18 Results Sex offender and abuse survivor therapists found to have higher scores (M=1.69 SD.53)than their counterparts, general mental health therapists (criterion sample) (M=1.53, SD.49) on Devaluing the Client (.31 small to medium effect size) Similar results found with Deterioration in Personal Life (M=2.48, SD=.67) vs (M=2.29, SD =.72)

19 Results Therapists working with sex offenders only had higher scores on Devaluing the Client when compared to those working with survivors only and both offenders and survivors (effect size.58 medium to large) Negative Work Environment scale was also higher for sex offender only therapists versus those who only worked with survivors (effect size.37 small to medium)

20 Demographic Variable Interaction Work hours, job stress were significantly related to elevated scores on all 5 subscales of CBI Years of experience was negatively related to exhaustion, incompetence and negative work environment Age was also negatively related to exhaustion and incompetence Income was not related to any of the CBI subscales

21 Study 2 Wallace, S.L., Lee, J., & Lee, S.M. (2010) Job stress, coping strategies and burnout among abuse specific counselors. Journal of Employment Counseling. 232 abuse specific counselors (sexual abuse and substance abuse) 36.67% Response rate by mail Age ranged from M = SD = % Female 29% Male 93% Caucasian

22 Instrumentation The Job Stress Scale (Caplan, Cobb, French, Van Harrison, & Pinneau, 1975) Counselor Burnout Inventory (Lee et al., 2007) The Brief COPE Inventory (Carver, 1997) Multiple Regression/Correlation (MRC) analyses by the Baron and Kenny (1986) model (i.e., mediation and moderation analyses) were used to analyze the 19 variables.

23 Mediation of Burnout Higher job stress subscales (workload, role conflict, and role ambiguity) and greater selfdistraction and behavioral disengagement uniquely predicted a more counselor burnout [t(197)=2.62, p<.05 and t(197)=3.74, p<01, respectively].

24 Moderation of Burnout Active coping strategies moderated the relationship entry of the interaction between the workload and active coping increased the explained variance by a statistically significant amount (b=-.17, DF=16.59, DR 2 =.02, p<.01). In addition, venting coping strategies moderated the relationship entry of the interaction between role ambiguity and venting increased the explained variance by a statistically significant amount (b=.14, DF=25.00, DR 2 =.27, p<.05). Humor coping strategies also moderated the relationship entry of the interaction between role ambiguity and humor increased the explained variance by a statistically significant amount (b=.13, DF=20.42, DR 2 =.23, p<.05).

25 Study 3 N= 114 Therapist working with sex offenders Age range: years M = SD = % Caucasian Years in sex offender field: SD = 7.32 Settings: 33% prison based, 24% residential based, 43% outpatient/private practice

26 Analysis/Results MANOVA between groups using Wilk s Lambda criteria was significantly significant (.88) F (4, 220) = 3.36; p = ANOVA of the response variable showed significant differences on the CBI scores across groups

27 Results Group Yrs Exp. Mean CBI SD Novice Experienced Senior * 9.37 p<.05

28 Ethical Practice Beneficence and Nonmaleficence Autonomy Justice

29 Ethical Practice Beneficence and Nonmaleficence direct therapists to promote and enhance the welfare of the client and explicitly acknowledge the role of the therapist in achieving these aspirations Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work (APA, 2010)

30 Beneficence and Nonmaleficence Historically sex offender treatment has colluded with personal negative reactions, whereby therapists sometimes took a confrontational approach with offenders, and this was passively condoned as therapeutic (Moulden & Firestone, 2010) Marshall (2002, 2003) therapists ability to convey warmth, empathy, and be directive accounts for significant treatment effect

31 Beneficence and Nonmaleficence Negative emotional experience/consequences of this work may compromise the therapists ability to genuinely engage clients in ways that are known to be effective therapist style Burnout may affect choice of intervention strategies. May lead to choice of maladaptive strategies Therapist use of personal coercive influence strategies were negatively associated with client s perceptions of quality of care (McCarthy & Frieze, 1999)

32 Beneficence and Nonmaleficence Psychologists are instructed to refrain from initiating an activity when they know there is a substantial likelihood that their personal problems will prevent them from performing work in a competent manner Psychologists take appropriate measures such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work related duties (APA, 2010) Because self identifying can be difficult (lack of self reflective processes) consultation and supervision; either formal or informal is critical (Moulden & Firestone, 2010).

33 Beneficence and Nonmaleficence Counselors are alert to the signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others. Counselors assist colleagues or supervisors in recognizing their own professional impairment and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients. (ACA, 2005)

34 Autonomy Autonomy emphasizes the client s needs and rights for respect, dignity, and self determination. Potential for punitive, overly directive, nonreinforcing, and confrontational approaches, particularly when therapists are feeling emotionally drained and are at risk for burnout (Norcross & Guy, 2001).

35 Autonomy Fatigue has been associated with tendency to be collusive and avoidant regarding client thoughts and actions in need of challenging Risk for superficially or didactic engagement with clients in attempt to protect self from further distress (Mitchell & Melikian, 1995). Therapeutic disengagement deprives clients of care and responsiveness and puts client at risk as well as the community (Moulden & Firestone, 2010)

36 Autonomy Counselors continually monitor their effectiveness as professionals and take steps to improve when necessary. Counselors in private practice take reasonable steps to seek peer supervision as needed to evaluate their efficacy as counselors (ACA, 2005) Psychologists take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm (APA, 2010).

37 Justice Justice obliges caregivers to ensure that all individuals have access to and benefit from quality services To achieve this goal therapists are urged to recognize biases and limitations within themselves and their practice and endeavor to protect clients from such conditions.

38 Justice Cognitive and emotional shifts are documented in research on sexual offender therapists. May disrupt objectivity in assessments, may be desensitized to risks, may compare among cases rather than to the standards of appropriate sexual behavior (Moulden & Firestone, 2010)

39 Justice ATSA encourages ongoing educational and professional growth activities in the field (ATSA, 2001) Clinician education and professional development were associated with positive effects of sexual offender treatment for the clinician (Sheela, 2001) Opportunities to challenge developing biases may rejuvenate fatigued therapists Moulden and Firestone (2010) suggest therapists should interpret this principle to include education about issues of countertransference and burnout and activities of enhancing self care.

40 Justice Counselors recognize the need for continuing education to acquire and maintain a reasonable level of awareness of current scientific and professional information in their fields of activity. They take steps to maintain competence in the skills they use, are open to new procedures, and keep current with the diverse populations and specific populations with whom they work (ACA, 2005) psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study. (APA, 2010)

41 Therapists Ethics Ethical responsibility to be aware and respond appropriately to negative effects associated with the treatment and assessment of sexual abusers.

42 Self Care First step is awareness Attending to and addressing the effects of one s work requires clinicians to be reflective about their experience, biases, and reactions Self monitoring thoughts, emotions, and behavioral responses to clients, colleagues, and work related topics as well as family and friends

43 Self Care Reasons to overlook self care may include: The assumption that a therapist should not be affected by their work Embarrassment about being affected by their work Supervisors discomfort in addressing personal issues in the clinician

44 Burnout Prevention Affirm the universality of occupational hazards by sharing your stressors with trusted colleagues Invite family members to point out when you become too interpretative and objective when it would be healthier to be spontaneous and genuine (Norcross & Guy, 2007).

45 Burnout Prevention Adopt a team approach in dealing with high stress clinical situations; distribute the burden and lighten the individual load Address your own limitations and needs in an open manner Adopt the long perspective as a healing practitioner experience correlates with reduced burnout (Lee, et al., 2010)

46 Burnout Prevention Tailor your self care to your personality and context by disentangling transient, paradigmatic, and situational difficulties in your practice as each requires a different self care plan (Norcross & Guy, 2007). Consider the amount of physical isolation you experience each day and find steps to create more contact with other clinicians

47 Burnout Prevention Humor, venting and active coping have been shown to moderate effects of burnout Monitor for behavioral disengagement and self distraction as they associated with higher burnout risks (Wallace, Lee, & Lee, 2010)

48 Thank You