Patricia Berendsen

By: Patricia Berendsen M.T.S., RMFT

© 2006

Abstract
Purposeful/Intentional Interactions can revolutionize the “ordinary and routine things” that we do or say into moments that can be transformative, healing experiences for clients. The authour describes three components essential to purposeful/intentional interactions and uses authentic anecdotal material to demonstrate the importance of making each interaction count!

“You never know the moment in a child’s life when you will make a difference for a lifetime.” This plaque in my office is a constant reminder of the importance of making every interaction intentional and purposeful. Every interaction counts. I have learned through experience that it is often the small and seemingly insignificant things that we do or say that most clients remember. Let me digress for a moment and share with you a couple of examples.

A goodbye celebration was being planned for a staff person and a cake had been carefully and thoughtfully made and decorated by the children from the residential treatment program. A newly admitted child asked, “Who was the person getting the cake?” A staff person overheard a more senior resident’s emphatic reply, “Oh, you’ll know her…She’s the one who has a big smile every time she sees you! And she tells you good things about yourself!”

Another child who was leaving the residence shared his first impressions. He talked about how it meant so much to him that everyone was friendly when he first came to the residence. He especially liked the welcome sign on his door, the homemade afghan on his bed that he could keep after his discharge, and the security he felt when one particular staff hung out with him for a couple of days until he was more comfortable. He fondly remembered that on his first night in his new surroundings, the staff team cooked his favourite meal (tacos with lots of hot salsa sauce).

These examples clearly illustrate how the seemingly “ordinary and routine things” that we do or say can be transformative, healing experiences for clients.

Every interaction, every encounter contains the possibility of healing. I am reminded of Mahatma Ghandi who said, “Be the change you wish to see in the world.” In this sense, I believe that as professionals we are charged with the responsibility and privilege to be positive examples and change agents in our world and especially in our work. I would suggest that everything we do and say…matters.

What are the criteria of “Purposeful or Intentional Interactions?”

1. Foster Human Contact and Connection: “The belief in the inner beauty of each and every human being is at the heart of being human. As soon as we start choosing and judging people instead of welcoming them as they are– with their sometimes hidden beauty, as well as their more frequently visible weaknesses– we are reducing life, not fostering it. When we reveal to people our belief in them, their hidden beauty rises to the surface where it may be more clearly seen by all.” (Vanier, 1998, p. 23) Our clients, the children and families we serve, are people first. Each person’s birthright is their inheritance to claim love, time, respect and attention. Diagnoses and trauma may have influenced and shaped our clients’ identity but they do not define the totality of who they are. It is essential that people encounter their inherent dignity and worth during any interaction. We must be careful not to equate the value of a person with the nature of his or her behaviour. (Satir, 1988, p.337-338)

Human to human contact is paramount. “Belonging…is a school where we learn to open up to others and to the world around us, where each person…is important and respected. We discover who we are through our mutual dependency, in weakness, in learning through belonging.” (Vanier, 1998, p. 41) I believe that it is important that people can come away from any encounter and feel richer and inspired because of it. Virginia Satir, renowned family therapist describes her view of connecting with people. “My means of making contact is in my own congruent communication and the modelling that went with it. It was as though I saw through to the inner core of each being, seeing the shining light trapped in a thick black cylinder of limitation and self-rejection.” (1988, p. 340-341) “The way to promote healing is by reversing the condition of rejection. We must be present with all our experiences as they are, in a fresh, open-minded way.” (Welwood, 2000, p. 141)

“Being real works. When people disguise their true feelings, and reactions of the moment, they lose emotional contact with those around them. And when the contact goes, so does the ability to influence.” (Edgette 2002, p.14) A youth, named Carly, illustrates the impact of poor therapeutic contact. “I think a lot of therapists are fake. I hate it when they always have to talk about how you feeeeel…[a facial expression accompanies this sarcastic remark]. It’s so annoying and it really bugs me. Then when you do tell them about something that really sucks, they just say, “Oh, you must be sad.” “Well Duh? Whaddyah think I am? I write them off then and there!”). “Great therapists are those who are likely to be more interested in what they don’t know about their clients than what they do know. When therapists operate primarily from knowledge, they are more likely to be manipulative; when they operate from not-knowing, they are more likely to embody authentic presence. Letting themselves not know what to do next invites a deeper quality of attentiveness.” (Welwood, 2000, p. 143)

2. Be Present: “It is not enough to reveal to people their value, it is also to celebrate them. (Vanier, 1998, p. 26) It is important that people experience their needs as being the top priority in that particular moment. Being distracted and rushed is not ‘being present’. Josh, a 12 year old client, illustrates the importance of presence. “Like…the other day, I was seeing this person and he kept going through his papers. I don’t remember if he really looked at me…Like really… I think he answered the phone at least 3 times while I was in his office. I really didn’t think I should be there because he was so busy…Actually, I didn’t wanna be there. I thought I was just a waste of time!” “The most powerful healers or teachers [and therapists] are those who can model authentic presence and bring it into their work. Inviting and allowing another person to have his or her experience just as it is– this is perhaps the greatest gift anyone can offer.” (Welwood, 2000, p. 144

3. Reflect: It is essential in this field to make time and then take time for reflection. This may happen on the way to or from work, by debriefing with a colleague, journaling, meditating, gardening, walking during a break, shutting the door and breathing deeply for a moment etc. As social service providers, we have an accountability that we should not take lightly. We have the potential to have an indelible impact on our clients and our agency and this potential is enhanced when we pause and reflect upon our work. In doing so, we reduce the risk of making serious mistakes. Indeed, not being reflective practitioners in my opinion makes us liabilities to our profession. Additionally, I would propose that each of us consider finding a professional therapist to work with, so that we can become even more aware of any personal issues that may intersect with our professional life and to assist us in assessing and monitoring the impact of vicarious trauma. “As therapists, we must be willing to hang out with our own raw edges, or else when our clients activate these touchy areas, we will pull back, offer a quick fix, or try to steer the client in some other direction.” (Welwood, 2000, p.144). Certainly, some of this reflection can occur during supervision. The benefit is that the quality of our work improves when we have such preventative and supportive measures in place.

In conclusion, it is important that we make every interaction purposeful and make it count. This can be accomplished by a conscious decision to: foster human contact and connection, be present, and lastly to reflect upon our work. We can intentionally approach each human contact as though it was the first or potentially the last encounter we might have. “You are the difference. With every single choice, every day, all day long!” (Stinnett, 2004, p.8)

Bibliography

Edgette, Janet Sasson. (2002). Candor, Connection, and Enterprise in Adolescent Therapy. New York: W.W. Norton and Company.

Satir, Virginia. (1988). The New Peoplemaking. Mountain View, CA: Science and Behaviour Books, Inc.

Stinnett, Suzanna Beth. (2004). Little Shifts. Naperville, Il.: Sourcebooks Inc.

Vanier, Jean. (1998). Becoming Human. Toronto, ON : Anansi Press.

Welwood, John. (2000). Toward a Psychology of Awakening. Boston: Shambhala Publications, Inc.

Patricia Berendsen, M.T.S., RMFT maintains an active private practice in Individual, Couple and Family Therapy and Clinical Supervision in London, Ontario. Patricia also provides clinical services as a Clinician with the Clinical Supports Program at the Centre for Children and Families in the Justice System of the London Family Court Clinic. She can be contacted at patricia@patriciaberendsen.com

Patricia Berendsen

Abstract : Everyone experiences ‘being stuck’ with clients at one time or another. This article stresses the importance of dialogue as one of the key ways to move through this type of therapeutic impasse. The author highlights strategies that may assist helping professionals when they encounter stuck points in their work with clients.

Evaluating our ‘mistakes’ in therapy can be one of the richest resources we have for learning, yet it appears to be one the most underutilized tools we have at our disposal. We all know we make mistakes or struggle in therapeutic situations with our clients, so let’s talk about it!!

“When the teacher is ready the student will appear.”

I believe that it is our clients who will bring us to the place of openness. It seems that the severity of cases that are coming through our doors is the impetus for the necessity of dialogue. We need the collective wisdom gleaned from our personal and professional experiences. We require ‘all hands on deck’ to facilitate safe passage as we navigate the uncharted waters of the complexity of our cases. Now, more than ever, it is important for us to “check our egos at the door” and seek support and supervision from our colleagues.

Recently, I was one of several clinicians gathered to have a round table discussion about the experience of feeling stuck or being stuck in therapy. Most of us were comfortable sharing our successes amongst our esteemed peers. What made this discussion so significant and pivotal event was our willingness to risk and be vulnerable with one another and expose our perceived incompetence.

The level of experience ranged from those who were recent master’s level graduates to those with 30 years of clinical experience. Most of us were familiar with each other, yet we were embarking on a new frontier … having a conversation about being “stuck in therapy” in a group setting amongst our peers. After reinforcing the importance of group guidelines to achieve our goal of having a supportive discussion without judgment, we proceeded.

‘Getting Stuck’ Happens

We all get stuck sometimes. Even seasoned CYC’s and therapists! Newer staff members expressed relief because they thought their ‘stuckness’ was related to inexperience. Actually, ‘stuckness’ seemed less related to inexperience or having or using the right therapeutic knowledge, tools or technique. It appeared to reflect more about the therapeutic relationship or the isomorphic nature of the therapist, treatment team, or client’s life. Oftentimes, feeling stuck reflected our hope for the family and our wish for their situation to improve, whereas clients seemed satisfied with where they were at. At other times, it was an indicator that it was time for the client to move on and that therapy was drawing to a close. Occasionally, therapists experienced pressure to be as productive as possible within constraining timelines. This appeared to impact the time required to adequately process therapeutic impasses.

Self-awareness is the key

Most important in dealing with ‘stuckness’ is the helping professional’s self-awareness. It is essential to take the time to reflect upon one’s reactions: to clients, the content of therapy and one’s physical responses and attitudes. Often we can be stuck in therapy because we may be frustrated with a client or exasperated with the lack of progress. Perhaps we might be bored and feeling a lack of stimulation. We may even be angry with a client. ‘Stuckness’ may also indicate that we need to pay attention to a blind spot or a pattern of therapeutic behaviour that continues to lead us into the stuck place we find ourselves in.

Give permission to feel

We need to give ourselves and each other permission to feel our ‘stuckness’. Sometimes, even though we are in this helping profession, we resist feeling our ‘stuckness’ or our helplessness. Some of us may attempt to “keep it all together” when we are flailing and need assistance. We may rarely ask for help, perhaps living the fallacy that being strong means we can do it on our own. We keep telling ourselves, “that we ought to know what to do!”…that “if we asked for help we would really appear incompetent.”

Talk about it

We need the opportunity to express both our competence and our areas of growth with one another. If this opportunity does not exist I propose that we will not be doing the excellent work with clients that we are capable of. In fact, we may end up doing harm to our clients and to ourselves. Our collegial and supervisory relationships need to include being able to talk about our feelings, especially our shame about being stuck. If we do not have a supportive supervisory or collegial relationship I would suggest seeking someone out. It would also be important to highlight this issue with managers of the organization as they might be assuming that supervisory relationships are satisfactory to staff members.

Try something different

If we keep doing the same thing, we can expect the same results! The idea is to interrupt the cycle. It is important to take risks and do something different. It is up to us to take initiative in our workplace. If we are feeling stuck, request a reflective team or time with colleagues to present a case. We can seek assistance from our supervisor or a trusted co-worker to get a fresh perspective. Videotaping our work and reviewing it with our peers, asking for feedback can be helpful. It might be a useful exercise to create a “how to get unstuck list” with our colleagues. It may be essential to journal about our reactions to a client. We can ‘draw our frustrations’ using crayons and pastels or ‘finger paint our ‘stuckness’. Sometimes, shutting the door and doing some yoga or deep breathing can help ground us.

Go back to the basics

Sometimes our ‘stuckness’ is a symptom that we need to review the original goals we have collaboratively developed with a client. They are the compass for us when we feel lost or stuck. We can talk with our clients about what we are experiencing in our therapeutic relationship. Respecting the wisdom and choices that a client may make, even if it is not what we would perceive as the ‘right’ choice is essential. We can pay attention to our self-importance and when we take ourselves too seriously. We can continue to cultivate our sense of humour. “Being with” our clients, knowing that bearing witness to their pain and validating their ability to survive, is indeed a measure of success.

The round table discussion came to a close but not before several people noted how energized and lively the discussion had been. There was great enthusiasm for when our next courageous conversation could occur. We had crossed the threshold of our fear of being judged into the reality that we were not alone in our ‘stuckness’. Instead, we found understanding, compassion and encouragement. We were hungry for more!

Each of us wants excellence in our work. It is our personal and ethical responsibility to ensure that our clients get the highest quality of care that they deserve. We need to trust the therapeutic process, knowing that ‘stuckness turbulence’ is normal. Establishing a community of practice may help us achieve this goal.

Reading

Kottler, Jeffrey A. and Carlson, Jon. Bad Therapy- Master Therapists Share Their Worst Failures. New York: Brunner-Routledge.

Orbach, Susie. (2000). The Impossibility of Sex. New York: Scribner Publishing.

Stream, Dr. Herbert S. (1988). Behind the Couch- Revelations of a Psychoanalyst. Toronto: John Wiley and Sons.

Patricia Berendsen, M.T.S., RMFT maintains an active private practice in Individual, Couple and Family Therapy in London, Ontario. Additionally, Patricia provides clinical services as a Clinician with the Clinical Supports Program at the Centre for Children and Families in the Justice System of the London Family Court Clinic.  She can be reached at patricia@patriciaberendsen.com.

Abstract:
Persons working in social services are vulnerable to experiencing negative effects from working with traumatized clients. It Can Happen to You!” describes the gradual and often subtle changes that can occur as one traverses from generalized job related stress to compassion fatigue and vicarious trauma. A case example is used to demonstrate the insidious nature of how symptoms can develop over a period of time. The article also highlights the necessity of self-care strategies as a means of prevention and recovery.

It Can Happen to You!
By Patricia Berendsen

Keeping the soul in our work is not as easy as it sounds. Most of us have heard the words burnout, secondary traumatic stress, compassion fatigue, and vicarious trauma. These terms are often used interchangeably (much to the chagrin of many professionals), in an attempt to describe the impact on helping professionals working in the area of trauma. No one engaging in working with traumatized clients is immune to or can avoid its effects. (Health Canada, 2001) We take care of others all the time! Surely we would be able to recognize our own issues related to wellness and self-care because this is our forte. We know this stuff! Besides, we have grown accustomed to the difficulty of our work and have been doing just fine. Unbeknownst to many of us, however, we have become numbed to the reality and hazards of our job descriptions. “Through the inevitable participation in traumatic reenactments in the therapy relationship, the therapist is vulnerable through his or her empathic openness to the emotional and spiritual effects of vicarious traumatization.” (Health Canada, 2001). The bottom line is- that when we are in the business of caring, we will be affected in some form or another.

Most of us begin our careers with a clear resolve to maintain personal and professional boundaries, passion for our work and hold fast to our conviction in earnest of being the best helping professionals ever! We might acknowledge that tiredness and fatigue could eventually happen down the road (likely to someone else)…but that we would be different! We would work on self-care and avoid what we have heard described by senior staff persons as the painful reality of burnout. “It may have happened to them”, we think, “but it won’t happen to me!”

Vicarious trauma may be described as, “the energy that comes from being in the presence of trauma and it is how our bodies and psyche react to the profound despair, rage and pain. Personal balance can be lost for a moment or for a long time. Waves of agony and pain bombard the spirit and seep in, draining strength, confidence, desire, friendship, calmness, laughter, and good health. Confusion, apathy, isolation, anxiety and illness are often the result.” (Health Canada, 2001). Often the personal impact of vicarious trauma is experienced in 6 areas: cognitve, emotional, behavioural, spiritual, interpersonal and physical. (Yassen, 1995). The effects are cumulative and permanent, and evident in both a therapist’s professional and personal life” (Figley, 1995).

The symptoms of vicarious trauma reveal themselves gradually with a missed lunch here and there, from taking some work to more work home, overextending ourselves for the client, the agency or the community, missing work out times at the gym, cancelling massage therapy appointments, and increased isolation from family and friends. Oftentimes, we might experience more physical difficulties such as: chronic constipation, stomach/digestive problems, ulcers, urinary tract infections, headaches, sleep disturbance, general aches and pains, a loss of libido, teeth grinding and jaw dysfunction, and an impaired immune system.

In keeping with the wisdom of Dr. Seuss, “I’m sorry to say so but, sadly, it’s true that Bang-ups and Hang-ups can happen to you. You can get all hung up in a prickle-ly perch. And your gang will fly on. You’ll be left in a Lurch.” Yes, it (stress, vicarious trauma, burnout or whatever you wish to call it) can happen to you…and more likely than not, it will happen to you!

Case Example

I am reminded of a gifted child and youth worker, who was revered by his coworkers. Joel, a recent graduate, was an obvious leader and role model and a positive influence on everyone around him. Joel was an initiator of new ideas and programs for the residential team of a children’s mental health center that he was a part of. His creativity knew no bounds and any involvement he had with clients were met with great reviews. Children were drawn to him and often wanted him to be their primary worker. Colleagues relied on him for support. When chaos ensued, Joel was grateful to be needed and was pleased to provide calm and comfort to his coworkers. Joel was proud of his accomplishments as a Child and Youth Worker and was living up to his expectations of what he thought a good CYC should be.

Gradually, Joel began to get behind in his paperwork. Almost every time he would attempt to begin a report, a colleague would interrupt him, needing to debrief about something that happened on a previous shift. Joel, valuing being a team player, set aside his report time to listen to the plight of his peer. Initially, Joel was grateful that his colleagues could depend on him for support. However, now after almost two years, he was beginning to feel somewhat resentful toward his peers. Joel felt that he was being taken advantage of and gradually found himself wanting to avoid his team members. It was noticed that Joel was often quieter and withdrawn.

Program initiatives previously enticing to Joel became more burdensome and less interesting. Joel was increasingly reluctant to be nominated or designated as the committee representative or to lead the new project. The lion’s share of the workload seemed to fall primarily on Joel’s shoulders. Joel’s co-workers noticed that he seemed less organized. Oftentimes he would forget that he had meetings or would need several reminders to follow through with details that he normally would have been on top of.
Joel’s stellar attendance record now included more sick days. Joel began to have more migraines and suffered longer than he previously did, with colds and flues. Joel noticed that he was regularly feeling sluggish and tired and began to drink more coffee relying on the extra ‘caffeine kick’ to make it through his day. “It’s just one of those weeks!” he would tell himself, and hoped that his feelings of dread and fatigue would somehow magically disappear. Except every week was becoming “one of those weeks!”

Joel’s relationships with his coworkers became strained. Joel’s hallmark of infectious humour slowly transformed itself into sarcasm whose edges were sharp, cutting and alienating. Joel was observed to be impatient with his clients and tended to be more punitive than understanding. “They are resistant and not workable. If they’d only do what I told them to, things would be fine!,” he would mutter under his breath.

Homelife? What homelife? Joel, single and looking, could only plop himself on the couch with a beer or two after work and escape from the stress by staring mindlessly at the reality shows on television. Joel’s previous routine of working out at the gym had gradually been replaced by working extra shifts and attending work-related meetings. He could see no way to fit exercise into his schedule. And he had no energy to go out with friends, even though he used to at least 2-3 times a week.

Nightimes were the worst. Joel struggled to get to sleep. When he finally fell asleep he would awaken suddenly with his heart racing and worrying whether he counted the meds correctly before leaving his shift. Joel also found himself dreaming about his clients or work situations. Joel, who used to sleep deeply and soundly, now, would wake in the morning feeling worn out due to a restless night’s sleep.

And so the cycle would continue…more sarcasm and resentment, less productivity, more coffee, forgetfulness, increased illness…

Stress is the result of personal investment in difficult situations. If no investment exists, there is no basis for stress (Johnson, 1989). The empathic response of helping professionals is at the core of the commitment to service. It is this empathy that creates the greatest risk and vulnerability to vicarious trauma (Health Canada, 2001). The stress inherent in helping professions and leading to vicarious trauma is a slippery slope. It is the insidious way that the experiences slip under the door, finding ways to permeate the counsellors’s life, accumulating in different ways, creating changes that are both subtle and pronounced (Health Canada, 2001).

I would suggest that our vulnerability to vicarious trauma is one of our blind spots. We can usually identify changes in our behaviour when we can connect it to a specific event. But the nature of stress and vicarious trauma is that it is cumulative. It often grows quietly and patiently and can develop very deep roots. In our minds we know that vicarious trauma is a very real and present danger, yet we remain in denial as our lives, especially our bodies, tell the real story.

So what can we do about it? Recovery takes time just as it took time to develop the symptoms. The simplest (which does not necessarily mean easiest) description I have seen is the ABC’s of addressing vicarious trauma from Transforming the Pain (Pearlman and Saakvitne, 1996). These components of Awareness, Balance and Connection are most effective when applied to the personal, professional and organizational realms of our lives. More specifically, the ABC’s refer to:
Awareness: being attuned to your needs, limits, emotions and resources.
Balance: maintaining balance between work, play and rest.
Connection: developing and maintaining connections to self, others and to something larger.

In general self awareness and self-care strategies are essentials in prevention and healing. For many of us, evaluating our personal and professional expectations of ourselves is required. We may need to learn to pace ourselves and live life moderately instead of at breakneck speed. Even batteries need to be re-charged! Getting honest feedback from a few good friends can be an eye-opening experience. Boundaries need to be re-evaluated and/or re-negotiated so that we can take a step back and detach from taking on too much or “overnurturing’ others. Personal therapy can also be invaluable as can collegial support and supervision.

On the physical end of things…it is important that we take care of our bodies by drinking water, breathing deeply, eating well and developing regular sleep habits. Incorporating physical activity that is enjoyable to you and that works with your lifestyle is critical. I have known several people who have unused or lapsed memberships at fitness clubs because it wasn’t really ‘their thing’. Another significant aspect of attending to physical health is by making and keeping medical and dental appointments. (adapted from Freudenberger and North, 1986)

Joel, in our case example was beginning to show signs of fatigue. I imagine that the challenge for Joel and those around him was the gradual nature of the changes in his personality and professional demeanour. It is an example that illustrates for us the importance of regular reflection, honest feedback from friends, family, coworkers and supervisors to help us stay true to ourselves and our initial conviction to be the best we can be in our field.

In closing, may I quote some wisdom from Oh the Places You’ll Go by Dr. Suess… “On and on you will hike, And I know you’ll hike far and face up to your problems whatever they are. You’ll get mixed up, of course as you already know. You’ll get mixed up with many strange birds as you go. So be sure when you step. Step with care and great tact and remember that Life’s a Great Balancing Act.”

Resources

Dr. Suess. 1990). Oh, the Places You’ll Go! New York: Random House.

Figley, Charles, R. (Ed.). (1995). Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York: Brunner/Mazel

Freudenberger, Dr. Herbert J and North, Gail (1986). Women’s Burnout-How to Spot It, How To Reverse It and How to Prevent It. New York: Viking Penguin Books

Health Canada (2001). Guidebook on Vicarious Trauma: Recommended Solutions for Anti-Violence Workers. Ottawa: National Clearinghouse of Family Violence

Johnson, Kendall Ph.D. (1989). Trauma in the Lives of Children. Alameda, CA: Hunter House.

Saakvitne Karen W. and Pearlman, Laurie Anne. (1996). Transforming the Pain: A Workbook on Vicarious Traumatization. New York: W.W. Norton and Company.

Stamm, B. Hudnall. (2002). Professional Quality of Life: Compassion Satisfaction and Fatigue subscales-III. http://www.isu.edu/~bhstamm. (This is a good questionnaire to use regularly as a means to self-monitor compassion fatigue)

Yassen, J. (1995). “Preventing secondary traumatic stress disorder.” in Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. C.R. Figley (ed.). New York: Brunner/Mazel.