Permission to be Patient

Permission to be Patient

“Whether you’re patient or not, time will pass, life will continue to move forward.  Choosing patience simply makes the journey less nerve-racking.”   Franco Colomba

   One of the greatest gifts we can offer ourselves and clients is permission to engage patience.   Our American culture is full of messages of urgency, action, don’t miss out, move faster, do more.  Just writing these messages I feel my stomach clenching, my arm muscles tensing, my breath shortening and feeling more constricted.   The physiological response to the sense of urgency is powerful.   The timer gets set on our physical system, and without awareness, can end in an emotional explosion.   Imagine, just thinking about running late, or trying to get something done, or moving faster sends a message to our brain “urgent”, “possible danger”, “high alert”.  This kickstarts the process in the brain that readies your body to survive a possible threat. Adrenaline kicks in, cortisol starts flowing, muscles tense, shortness of breath, tightening of muscles.  Pretty amazing!  And it all started with a thought.  Now imagine that we live in that state all day every day.  Without a break.  Knots develop in our shoulders, pains in our stomach, aches in our back, chronic headaches, high blood pressure, forgetfulness.    I know, I’ve been there.  And many of our clients come in presenting this way too.  And they come in and share with you their urgency.  “I need to feel better quick or …..”, “My wife said I need to figure this out or we are done”,  “I can only meet for 6 sessions so can we hurry this along?”, “I’ve heard EMDR is quick, that’s what I need”.   Pretty soon, without awareness they’ve shared urgency with us like a cold virus sneezed out and traveling through the air around us.  

We breathe it in. 

Now imagine what happens when we, ourselves, take a deep breath, settle in our chairs and invite the client to notice how they are experiencing urgency right now in their body.  Maybe they can’t access the awareness of it yet, so you observe, “I’m noticing this pressure to get this done quickly, and the more you’ve shared the faster you’ve talked.  I’m wondering if there is any part of your body that feels really tight right now?”  

I drop my own shoulders, intentionally slow my speech, smile.  Mirror neurons kick in and as I calm they calm (co-regulation).   

Then I’m curious how urgency has served them in their life.  How close of a friend has it been?  What does urgency whisper in their ear.  How does their physical system respond to the whispers?   Then I’m curious, I wonder what it would be like if they had permission to take as long as they need?  What if they had permission right now to just drop their shoulders and for a few minutes just let the couch hold them up.  

What would it be like to have a brief experience of not having to work so hard?  

Sometimes relaxation is a wave of relief that washes through the room, wrapping everyone in a warm cozy embrace.  Sometimes urgency is more reluctant to let go, has multiple hooks, and frustrates the client raising the tension in the room.  Sometimes the best response is repetition of patience, permission just for the moment, an invitation to experiment the right now without a commitment to future practice.  

The invitation to slow down, take a breath, relax the muscles; reverses the physical process in the brain.  Oxygen flow increases, blood flow returns, calm descends over the brain allowing easier access for information and thought.   

The process of change just began. 

I’m reminded of a moment in the “Will You Be my Neighbor” documentary where Francois Clemmons, who played Officer Clemmons, shared an experience he had with Mr. Rogers.  Every day Fred ends his show with “I like you just the way you are” or “It’s ok to just be you”.  One day Francois reports he noticed Mr. Rogers looking at him off screen as he was saying this statement.  After the cameras were turned off, Francois went to Mr. Rogers and said, “Mr Rogers, were you talking to me?”  and Mr. Rogers responded, “I’ve been talking to you every day for 2 years, today you could hear it.” 

Be patient, keep repeating permission.  One day, they will be able to hear it. 

Welcome and Trust: Journey to Authentic Spirituality

"Faith in the biblical sense does not mean maintaining that certain assertions are true; rather it is a relationship of trust between humanity and God. God believes in us. God trusts us and hopes that we return the compliment. Because God has confidence in us, we can develop a healthy self-confidence."

Richard Rohr

You don’t have to work so hard.  This statement feels scary, exciting, and impossible all at the same time.  It brings up skepticism, curiosity, and hope as I read it again.  I wonder what happens for you as you read it? 

In my own journey (and by journey I mean life journey of growth in professionalism, spirituality, mom-hood, wife-hood, womanhood), I am hearing this message from the Lord of “you don’t have to work so hard”.   I’m learning that this phrase means rest in him, salvation comes from him, trust in him, lean on him, look to his guidance; trust, trust, trust. 

EMDR therapy is a powerful therapy that taps into and uses the brains already created natural ability to move towards healing (AIP model).   In my faith tradition, I believe this incredible system that was created to move towards healing was created by God.  In my practice, I’m learning that when I stop working so hard to figure out how to help someone, I get to rest in the knowledge that God created a system that is designed to move towards healing.  When I rest in this and trust that the system knows what to do, the healing process emerges.  My job in this process is to trust. Trust the process of EMDR therapy.  Trust the AIP model. Trust that the person’s system knows what to do.  And Trust that God will reveal to me what is in the way of the person moving towards the healing they so desperately want.  Then my job is to welcome.  Welcome the blocks. Invite the big feelings.  Treat anything that gets in the way as Jesus treated the woman about to be stoned for her sinful acts.  Welcome it, and offer God’s grace. 

Want to learn more about how to use the EMDR model in this way?  Would you like to learn specific mindfulness practices to incorporate into your work with Christian Clients?  Would you like to know how to work with blocking beliefs that come up for Christian clients that keep them from experiencing a closer relationship with God?  Would you like to learn how to incorporate spirituality into your EMDR work with Christian clients?

I will be answering all of these areas and more in my webinar  “Working with Spirituality in EMDR: A Christian Perspective” on January 11^th and 12^th, 2019.  

Click the link below to register.
https://emdr-training.net/emdr-training-event/working-with-spirituality-in-emdr-a-christian-perspective/   

Relationship, Balance and Connection with Authentic Spirituality

I identify myself as several things.  I am a mom, a wife, a marriage and family therapist, a trauma therapist, a friend, a Christian.  With each part of me a commonality among all, is relationship.  I can’t seem to get away from it.  It shows up in all I do, and every part of who I am.  And at the center of every relationship I find me.  And the me that shows up varies with each relationship.  Sometimes that’s necessary sometimes it’s not….but it is what it is.  The same is true for us all.  The things we do in the presence of others, comes up….in the presence of others.  In PTI we refer to these things that we do as The Answer.  The Answer is those things we do to stay safe or stay connected in relationships.  And if we use those answers over and over, we tend to get really good at them.  And a pattern of relating to others begins.

In my work over the years I have seen another triadic relationship emerge with all my clients, the triadic relationship of emotion, physicality and spirituality.  Some clients come in dominant in one over the others.  Some come in disconnected from all three.  The use of EMDR therapy is such a natural organic tool that when used, seems to balance out this triad and clients experience more connection to their whole selves.

Many Christian clients come in disconnected from their emotions, their body, and God.  I could go into all kinds of theories and rants about why that is the case in this modern church age; but I wont.  What I will share is when we begin to integrate their spiritual concerns, worries, blocks, into the EMDR process, more happens than what they came in for.  They experience an emergence of the natural order of the triad.  They begin to experience healing in their relationships. They begin to feel connected to their emotions and their body.  And they begin to experience growth and authenticity in their relationship with God.

For a Christian, living out of their faith system means to learn how to Love God, love self, and love others.  The EMDR process is a beautiful tool that allows this to be attainable for Christian clients.

In my practice I also see a lot of people wounded by the church or by others who have identified themselves as Christians.  Sometimes these wound experiences were violent and extremely abusive.  Other times it’s pervasive emotional wound experiences that confuse and overwhelm a system with doubt.  These clients present extremely guarded and hurt in therapy.  The slow climb to trust is tedious and often times feels insurmountable for them and me.  At times it can be a struggle to even identify, “where do we begin?”.

In all scenarios though one thing remains the same; relationships.  Relationship with family of origin, caregivers, present friendships, present intimate relationships, relationship in their current place of worship and relationship with God all carry patterns.  As we notice the patterns emerge we begin to see the imbalance.  And from there, the treatment process can begin. 

In PTI one of the core principles is non-violence.  This concept of non-violence in therapy means we do not impose on our clients, we are collaborative, we are patient, we ask permission.   In my personal relationship with God, I find the non-violent principle as Biblical.  When I can keep these principles as the foundation of how I walk with people in the therapeutic journey, healing happens.   All that to say, the healing process is done in relationship.  And that starts with me.  Before they come in.  My foundation is set.  My ability to be grounded in my own trust in my relationship with God allows me to be in the present moment, in a non-violent way, with them.

My passion is to share what I have with others.  On September 7 and 8, 2018 I am launching a training on ‘Working with Spirituality in EMDR: A Christian Perspective'. In this 2 day training I will share a way to conceptualize a case through the lens of relationship. I will share tools I have used with clients that help balance out the triadic system.  And I offer a way to see and work with clients from the core Biblical Principles of non-violence.

Therapist will experience many of the tools I use throughout the training, because what I have learned through my own journey, is when I can authentically live out of my own spiritual connection, my relationship to clients is the starting point for change.  In our relationship they experience safety, security, authenticity, and a genuine care.

My guiding principles are: Be Still and Know God, love thy neighbor, let your gentleness be evident to all, trust in the Lord with all your heart, see people as a creation of God.  I hope you will join me. 

Alice

Getting Your Money's Worth

As I move into different seasons of my life I have reflected on seasons gone by to see if there is anything I can glean from my time there.  It’s interesting that as I am now more in the supervisory role I reflect on my time in the learner role.  I have often asked myself, “did I get my money’s worth?”  For me it’s a value thing.  Did what I walk away with equal what I invested into it.   I have realized it’s more about what I personally invested vs. what I monetarily invested.  The experiences where I allowed myself to be vulnerable, (not knowing), showing up in my mistakes and insecurities were the most valuable of all.  So it’s interesting that it wasn’t necessarily about the supervisor I worked with, but what I brought into the supervisory process, that made it valuable. 

Now on the giving end of supervision I see the same truth.  Those supervisees who come prepared with hard questions, wanting to explore their mistakes, who are willing to show up and be taught in their uncertainty are the clinicians who grow so much.  The value of our time together is time and money well spent.  On this end of the relationship I so enjoy the invitation into another clinician’s growth process. 

When continuing to grow as a clinician and move through hard things, get your money’s worth!

             A) Be vulnerable-  what are you unsure of, what are mistakes you may have made, what are                      uncertainties about moving forward.

             B)  Be prepared- write out your case in a conceptualizing way: history, facts, clinical opinions,                 safety concerns, legal and ethics, treatment goals, where you are stuck.

             C)  Be Teachable- take in the feedback and be curious about it. Ask questions about how to apply             the feedback. Write down the feedback and form a plan.

We are always learning and growing in our profession and often have limited time and resources set aside for this growth.  To make the most of what you have, invest wisely with vulnerability, preparedness, and teachability.

Becoming a good therapist

How do I become a good therapist?  I remember asking myself this while I was in school (truth be told I still ask myself this). Of course this is part of who I am….all about being good or even the best I can be at something.  Sometimes in my life this drive can get in my way, but in my profession it’s really helpful.  It helps me keep being better at what I do, moving forward, changing what I do and looking for different ways to do good therapy.

The longer I work in this field, the more I know “not all therapists are created equally”.   You may be saying….well duh Alice…but really, the community doesn’t always know this.  When you are hurting and you are desperate for help, you reach out trusting you will get that help.  The truth is, there are some in our profession that are not helpful at all.  And then there are some that are very helpful.  Luckily, there are researchers out there who have looked at the difference between the two.   Wampold and Imel give us a body of information in their article The great psychotherapy debate: The research evidence for what works in psychotherapy.

What Doesn’t Matter:

Theoretical Orientation – They all work

Experience – Therapists earlier in their career are actually better than those with more experience

Therapist characteristics of age and gender

Therapists rating

How many of us spend time trying to get more experience, or working hard to find the best theoretical model?  We spend a lot of time and money here.  Research tells us, at the end of the day, these things don’t matter when it comes to being a good therapist. 

What Does Matter:

Alliance - Learn to form a collaborative working alliance with a range of clients (even challenging clients)

Make it Simple – Can explain aspects of therapy effectively and succinctly

Attuned – Can recognize metacommunication happening as it happens (example picking up on body language, seeing facial expressions that are in discord with words)

Grounded- warm, accepting, empathetic, modulate own emotional response while staying focused on client and his/her problems

Humble- questioning our own effectiveness and work to improve

Understanding- offering an explanation for client distress and a means to overcome it. (why do they do what they do and how do they minimize what is limiting them?)

So if you are like me, and you want to be the best therapist you can be, spend less time doing what doesn’t matter and more time doing what does.  If you are not sure about your ability to build an alliance with all clients, get training in that.  If you struggle taking hard concepts and making them simple, get coaching on this.  If you are not very good at being attuned to clients, consider extra learning in that area. 

To summarize, to be a good therapist, evaluate how you do on what matters. Spend less time and money on what doesn’t matter, and more time and money on the things that do. 

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate:  The research evidence for what works in psychotherapy (2nd ed.). New York: Routledge.

Wampold, B.E. (2016 September/October)  Can we become better therapists? Yes, we can!. Family Therapy Magazine, 15(5), 16-19.

Taking it Home

“This client is really driving me crazy.  I don’t know what to do with them anymore.  No matter what I say they have a reason or an argument for why it wont work.  I find myself dreading the session”.

Anyone else been here?  At some point in our careers we all find ourselves in this place.  Sometimes it’s with the ‘resistant’ client.  Sometimes it is with the client who is really good at asking for help….over and over and over….and only from you.  Sometimes it’s with the client who is in so much pain and hurting that it’s hard for either of you to see any light at the end of the tunnel.  What do all of these have in common?  No matter how hard we try, these are the clients that follow us home (figuratively…I hope). 

So what do we do with them? Respond vs. React.  More often than not, when these clients are in our room, one of them triggers us into our own stuff, which causes us to react out of our old patterns.  This reaction sets off a chain of events and before we know it we are in really deep, feeling what they feel, imagining what they imagine, carrying what they carry.  All of these are reactions.  For us to do our best work, we are called to empathize without taking it on.  The best way I have found to do this is with the notion of response vs. reaction.  So here are some tips on how to respond…

11)      Setting up the internal awareness- Take a moment to close your eyes, center yourself, and then imagine an object out in front of you that represents what it is with this particular client that seems to stay with you.  As you get an image of this object, keep it out in front of you and notice it’s shape, size, texture.  As you take time with this, notice if there is a color.  Then take a moment to position your arms around the object as you currently feel like it is positioned in relation to your body.  Notice how uncomfortable that feels.  When you are ready, push the object out away from you so that it is just the right distance out. Where ever you place it in the room is just right.  Now hold your hands up like a boundary and position them just how you need them to be so that the object stays out from you vs. on you.  Anchor in that position to where it feels ‘known’.

22)      Get perspective – Consult with a colleague, see if they can offer any insight on counter-transference that you may be experiencing that pulls you in.

33)      Prepare before the session – Prepare in a way that allows you some time before the client comes to ground/center yourself into the most professional and wise self you have to offer.  Do your internal awareness exercise to put the object in it’s place. Remind yourself of your clinical goals for the session.

44)      Consider your own therapy – If the issue continues, consider exploring what it is about this particular client dynamic pulls you in.  Having the perspective of a therapist to help you work through this pull can benefit you and your current and future clients.

We are all human, and with that humanity brings the pull to connect with others.  Sometimes that connection is a reaction which is unhealthy for us and the client.  Choosing response vs. reaction is a hard choice and sometimes not one that comes easy.  However, this choice lessens the consequence of ‘taking it home’ which is something I know many of us strive for. 

The Power of Why

The Power of Why?

One of the things I have realized I do in my practice is ask myself “why?” This is really a powerful question.  I remember in school they always said avoid the question why.  So my starting off with this simple but complex word my trigger some of you or completely put off others.  If you can stay for just a few more seconds maybe an opportunity will open up for you. 

When a client comes in my office I immediately start an internal question of “why are they here?”  Really this word is motivated by curiosity, and curiosity keeps me grounded and objective.  Then as they share in the initial session of why they are here I’m asking myself “why is their problem a problem?”  Then as I form a hypothesis about this I ask myself “why are they sharing what they are sharing?”

All of these ways of asking why begin forming a hypothesis in my mind to help inform my exploration and treatment with clients. As treatment begins, I continue with the “whys”. The “why” helps me with evaluating countertransference, transference, resistance, success.   Consider curiosity to help ground you in the following treatment steps.

·       Setting client goals: “why are they here?”, “Why is the problem the problem?”, “why does the problem continue to be a problem?”

·       Client Stuck Place: “Why is the client stuck in this specific way?”, “How could this problem be helpful?”, “Why would this problem have been helpful to them at some time in their life?”

·       Countertransference: “why does this client bother me so much?”, “why do I dread this client?”, “why do I look forward to this client?”, “Why am I bothered when the client doesn’t meet treatment goals quickly?”, “why do I feel relief when the client does this?”

·       Transference: “Why am I the one the client keeps calling?”, “why is the client yelling at me?”, “why did they choose me as their therapist?”, “How is what they are doing right now normal for them?”,  “What purpose doe s this serve for them?”

·       Success: “Why did they get better?”, “Why did this work for them?”

Asking the question of why and staying in a curious place can help inform every phase of treatment.  If you ask the question why and are struggling with the answer maybe be curious about that, or call a colleague and see if they can help with exploring why.  If “why” is just too difficult for you,  try “How” or “what” inserted in the same type questions and just see what happens in your treatment process. 

The Complexity of DID

The Complexity of DID

Dissociative Identity Disorder (DID) is such a complex and highly controversial diagnosis in the field.  There are many in the medical community who deny its existence and even some in the field of mental health who are skeptical.  Despite the skepticism, it continues to find its way into the DSM and into our offices.  As a professional, I admit having a mostly healthy fascination with this disorder.  Early on in my career I began focusing most of my practice in trauma, and therefore have probably seen more than the average number of clients who would fit into the category of having DID.  Once you’ve seen this disorder play out, it’s hard to hold on to the skepticism and disbelief.  Believe me!

I find it so unfortunate that a lot of the individuals with DID who come to my office, have been through years of facilities, multiple diagnosis, and various therapies which has been in so many ways more harmful than helpful to them.  Clinicians who work with trauma, specifically complex trauma, are ethically bound to know the signs of DID.  This will allow for quick, accurate diagnosis that can then make smooth the decisions of treatment planning, treatment placement, and scope of practice.  Colin A. Ross, recently published an article in the Journal of EMDR Practice and Research, about how to notice the signs of DID and accurately diagnose.  Below are the early indicators Dr. Ross identifies for when to suspect DID.  For diagnosis, I have referenced the article below for further reading.

When to Suspect DID

1.       Trauma History  - A reported history of extensive, severe childhood trauma (which does not have to be corroborated).  This trauma does NOT have to include sexual abuse

2.       Borderline Personality Disorder – Prior diagnosis of BPD, criterion for BPD currently met or subthreshold.  It is common for depression and PTSD to be comorbid with  BPD.

3.       Voices- Auditory hallucinations which are usually chronic.  The voices may or may not have names and ages and often meets DSM-IV Criterion A for schizophrenia.

4.       Blank Spells- Discrete periods of missing time lasting anywhere from minutes to days (without use of drugs, alcohol, or medical condition).

5.       Switching- Sudden changes in behavioral state

6.       Prior Diagnoses – Extensive history with the mental health system, numerous prior diagnosis often including: BPD, bipolar disorder, schizophrenia, schizoaffective disorder, PTSD, substance abuse.

Ross, C. A., (2015) When to Suspect and How to Diagnose Dissociative Identity Disorder.  Journal of EMDR Practice and Research, 9(2), 114-118.  

As you continue in your practice, learn to see the signs that further assessment is needed for the possibility of DID.  Some helpful assessments include the Dissociative Experience Scale (DES),  Dissociative Disorders Interview Schedule (DDIS) , and for children/adolescents the Child Dissociative Checklist.

Accurately recognizing and diagnosing DID can be such a relieving experience for clients.  It also helps you, the clinician, make the best possible decisions for the client about treatment moving forward.  For more information on this article see Ross, C. A., (2015) When to Suspect and How to Diagnose Dissociative Identity Disorder.  Journal of EMDR Practice and Research, 9(2), 114-118.  

The ‘Stuck Place’

One of the most frustrating things that can happen in therapy for clients and clinicians alike is getting into a ‘stuck place’.  That place where the client is reporting no progress, the therapist is running out of ideas, and a camaraderie of hopelessness can be born.  The ‘stuck place’ can also be a petri dish for clinician and client shame (also known as transference and counter-transference).   The clinician may cycle into blaming self; ‘I’m not good enough’, or ‘I’m just too new at this’, or ‘I’m a failure and should change jobs’.  Alternatively the clinician may cycle into blaming the client ‘they are not trying hard enough’, or ‘they have a personality disorder and can never change’, or ‘they just don’t want it bad enough’.   The ‘stuck place’ is that place that everyone wants to avoid, but finds themselves on occasion throughout their career. 

I’ve found that when a client and I land in a ‘stuck place’, getting back to the basics in counseling help us get movement one way or another.  Below are some strategies to help you and your clients if you ever find yourself in the ‘stuck place’.

1.       Call it out!-  Meaning begin your next session with “I feel like we are in a stuck place, and I’m wondering if you have noticed the same thing?”.  Get the client’s thoughts and feelings about where they may be stuck and strategize together on getting movement. 

2.       Reassess Client Goals – I’ve learned that one of the fastest ways to move through the stuck place is to go back to the client’s original goals.  If I cannot clearly identify what the goals are, then the next session is spent working with the client on identifying specific measurable goals. 

3.       Evaluate therapeutic Alliance – Have a conversation with the client about how they feel about coming to therapy.  Ask if they feel like the current relationship is working for them or if they may desire something different.  Strategize with the client about other options that may be out there that have not been tried (e.g. medication, other treatment modalities, more intensive services if needed).

4.       Consult – Our profession can be a lonely profession.  Having a small community of professionals whom you can meet with regularly and staff the ‘stuck places’ with, not only helps you professionally, it benefits your clients tremendously.  We are never so seasoned that another perspective can’t be helpful.

So the ‘stuck place’ doesn’t have to be a scary place, or a petri dish.  The ‘stuck place’ is actually an opportunity for growth clinically and personally as it challenges us to get back to the basics of good ole fashioned therapy.  The ‘stuck place’ creates space to slow it down and reevaluate.  So remember the next time you find yourself there, return to the basics 1) Call it out, 2) reassess client goals, 3) evaluate therapeutic alliance, and 4) consult. 

Binge Resting

As I consult and supervise with clinicians across the country a theme that regularly comes up is that of fatigue.  Some call this fatigue all the classic signs of burnout; dread going into the office, tired of doing what your doing, frustrated with clients, frustrated with self, and just plain weary.  Approaching this topic as most supervisors would, I look for a personal balance for the clinician around self care.  What I have found is a pattern of what I coin Binge Resting.   When rest is explored a little more I hear things like “I’m just holding on till summer vacation”, or “I have a weekend planned in the mountains”, or “If I can just make it till….”  The pattern appears to be work, work, work till exhaustion, binge rest, work, work work till exhaustion, binge rest, etc.  The end result is never feeling rested.  It has become quite the phenomenon however, and one that if we look at it clinically, is just as unhealthy as all the other things that can be ‘binged’ on. 

So we have to challenge ourselves to think about it in a clinical way.  If you ate the way you rested, what would that look like?  If you drank the way you rested, what would that look like?  If you shopped the way you rested, what would that look like? And so on and so on….  You may find alarmingly that your rest life fits into one of the following categories: anorexic resting, binge resting, balanced resting. 

What is healthy rest?  Other cultures do this well.  In some cultures there is a mid day ‘siesta’ or ‘rest time’.  In other cultures one day a week is devoted to rest.   Individual rest life can be personalized.   Below are some things to consider when examining your ‘rest life.’

1   

--       * Examine your priorities: What are your priorities in life?  Does your current work life, play life, social life, rest life fit nicely with those priorities?  Or are they in conflict?

2    

      * Get a clear picture of balanced rest. How would a balanced rest life look in YOUR life?  If it were possible to imagine having a balanced rest life, how would you know it was happening?  What would be different? How would you see yourself being with others? What would be present if stress and anxiety were not there anymore? How would I know by looking at you that you were a rested person?

3      

      * Set small goals: Start daily.  What is one thing you can do each day that would be restful?  A space of time where you are not DOING anything (including watching t.v. or reading books).

4       

      * Consider starting a daily mindfulness or Prayer practice for at least 30 min.:  Research supports the use of mindfulness and prayer in the reduction of stress, anxiety, and burnout.  There are many user friendly apps, books, and videos on how to do mindfulness exercises with guided options for first time attempters.  There are also books and videos on centering prayers which act in the same way as mindfulness exercises. 

Our goal driven, product driven culture lends itself to setting anorexic and binge resting as the norm.  As a profession that works to help promote health and balance, I challenge us to set a new standard of balanced rest.  Begin by 1) examining your priorities, 2) get a clear picture of what balanced rest would look like for you, 3) set small goals, and finally 4) consider starting a daily mindfulness/prayer practice.  

Compassion Fatigue

“How do you listen to those stories all day long then go home to your family?” 

“How do you separate work and home?”

These are questions I get asked all the time by clinicians and non-clinicians alike.  The answer isn’t an easy one.  It’s actually more of a journey.  I have spent more than 12 years working in some capacity with trauma victims.  The terms ‘compassion fatigue’, ‘secondary trauma syndrome’, ‘burnout’ have all been thrown around, trained on, and warned about throughout my entire career.  I learned early on what this was when I would go to dinner with my husband and space out thinking back on a client’s session I’d had that week.  Or when I would jump when someone would hug me, preparing for them to attack me.  Then there were the times that I would wake up from a nightmare in which I experienced my client’s ‘story’ as they had told it to me.   Quickly I learned that something had to change about what I was doing in order for me to keep helping in the field I loved.  I was so fortunate to have great mentors who spoke into me early on in my career and whom I felt safe enough to ask for help.  What I learned from them are 5 ways to help prevent compassion fatigue. 

1.      Set Boundaries – With clients and with your friends and family.  You should not be the only one your client relies on.  Use community resources and hotlines, create safety plans that involve other numbers and people to call other than you.  Set boundaries with your friends and family by not going to gatherings if you need the rest and self care time.  Find other resources to help your friends and family so that you are not the main provider for them as well as your clients.

2.      Set a ritual to leave it at the office- For me I bow my head and offer up each of my clients I’ve seen for the day in prayer.  I give them to the Great big God that I serve who can help them a lot better than I can outside of the office.   I then get up and literally leave it there in God’s hands.  As I leave my office I turn my mind over to what needs to be done when I get home and call my husband to switch gears into home life.   Setting some kind of ritual for yourself that you do every time you leave your office as a way of ‘Leaving it there’ can greatly increase your separation from it when you leave.

3.      Create your own container- In EMDR Therapy we use a resource called a container where we use guided imagery to create a container of any shape and size needed to contain disturbing materials for clients.  I have my own container for the hard stuff I hear.  When I can’t seem to stop thinking about it, I close my eyes and send it to my container in my office to be pulled out and examined when I have time and space set aside on a work day.

4.      Practice Mindfulness living – Learn the art of gently bringing yourself back to the present moment.  When you catch yourself recalling a session with a client, gently let it fade out of consciousness and pull your focus back to the present moment focusing on the 5 senses of sight, smell, taste, touch, hearing.  Continue to do this whenever you catch yourself and let yourself truly feel the moment you are living in.

5.      Seek your own therapy if needed- One of the greatest forms of self care is realizing that you may need some help getting past either your own story or a client’s story.  Finding your own therapist to process with and learn some additional tools to help separate it can be very beneficial to both you and your clients.

As you continue to listen to the hard stories and struggle with figuring out ‘can I keep doing this?’ know that it is possible to do this work and stay separated.  Know that there are strategies available for helping make that easier.  And know that it is a journey.  A journey that can begin by implementing the 5 prevention steps mentioned above 1)boundaries, 2) setting a ritual, 3) creating your own container, 4) practicing mindfulness living, and 5) seeking your own therapy.

If you are wondering if you may be struggling with compassion fatigue or secondary trauma, Click Here for a helpful assessment resource that you can take, score, and then help guide you as you begin your journey to self care.

Addressing Sexual Behavior in Children

“I caught my 7 year old child hiding in the closet with our neighbor’s child.  Their clothes were off and they looked guilty.  I told them to get dressed and sent the neighbor child home.  I don’t know what to do now.  I’m tore up inside and do not want my child suffer the rest of their life because of this”.

The call came from a desperate mom just hours after this event took place.  It really is one of a parent’s worst nightmares.  After the initial shock, the questions  set in, “will this affect them for the rest of their life?”  “What do I do?”  “Does my child need help?” “Do I call the police?”

While this is one of the worst moments a parent can find themselves in, there is a step by step structured approach you can help them take in the moment of discovery and post discovery.  If you are a professional who gets this phone call, consider walking that parent through the following steps. 

Instructions to Parents---

If you catch them in the act:

1.       The most important thing is stay calm.  Take a deep breath and ask the children to either dress, or stop engaging in the behavior they are engaging in.

2.       Separate the children and ask what was going on- After the children have dressed ask one to stay in one room and another in the other room.  Calmly talk to each child to get the story of what they were doing, what made them decide to do it, and how often have they done it.  (avoid shaming the child by telling them what they did was dirty, disgusting, or bad)

3.       Bring the children back together and talk about Sexual Behavior Rules:  Say it’s ok to be curious about body parts however it is not okay to do the following with that curiosity:

School Age

1.       It is not ok to touch other people’s private parts.

2.       It is not ok to show private parts

3.       It is not ok for other people to touch your private parts

4.       It is ok to touch your private parts in private

5.       It’s not ok to make other’s feel uncomfortable with your sexual language or behavior

Preschool Age

1.       No touching other people’s private parts

2.       No other people touching your private parts

3.       No showing private parts to other people

4.       No touching your own private parts when others are there

5.       Touching your own private parts when you are alone is ok

Begin enforcing these Sexual Behavior rules in your home from here forward.

4.       When trying to decide if you need to call your local authorities, you may find the following link for TN related sexual behaviors and reporting helpful.  Click Here  (Be aware that the laws are different in each state, so check out your own state Gov. website to be sure).

5.       Allow your child to come talk to you about what they did or experienced as they need too.  If they have questions you do not know how to answer, let them know you would like to talk with them further but would like to set a specific time and place to do that.  Then you can find some helpful resources to help prepare you for that conversation by contacting an area professional or even your local pediatrician.

Lastly as you worry about if this will have a lasting impact on your child, consider watching for the following signs.  If they are present, your child may need to see a professional about what happened.  If they are not present you may just continue monitoring your child, allow space for them to talk to you more and trust that they have processed what happened in a way that will not make a lasting impact.

Signs you may need to consult a mental health professional:

a.       Extreme change in their behavior (they go from outgoing to isolated or vise versa)

b.      They become fearful of people or places

c.       They begin wetting the bed

d.      They begin having regular nightmares

e.       They play with their toys in a sexual nature

f.        They become aggressive

g.       They complain of their tummy or head hurting

To summarize for them remind them they are being a great parent by being concerned.  Moving forward  they need to 1) Address rules about touch  2) allow space for their child to talk about it  3) monitor their child for signs they may need additional help. 

Checking Out

The ‘checking out’ phenomenon, otherwise known as dissociation, is one of the most feared symptoms experienced in our profession (next to suicidality and psychosis of course).  Specifically, those clinicians who have decided to dedicate their career to focusing on trauma, addictions, eating disorders or personality disorders are starting their path with an understanding that dissociation may show up somewhere along the journey.  Other clinicians hold the blissful denial that they will never have to deal with it.  Reality is, dissociation shows up in all of our offices at some point, and it is advantageous to know when it does.  Then of course is the logical next step, what to do.

In the context of experience, dissociation is a natural phenomenon in all human beings. Consider a time you took a regular route in your vehicle and you remember getting into your vehicle, starting it, backing out, then starting on your way.  Then sometime later you realize you are pulling into your destination with little memory of actually how you got there.  A phenomenon we can all relate too.  This is the most basic of dissociation levels.  Bruce Perry, M.D., Ph.D. postulates “Dissociation is the most primitive of reactions: earliest life forms, infants, and the very young rarely escape dire situations of their own accord. For infants and young children, dissociative response to extreme stressors is common. If it’s prolonged it is connected with increase in PTSD symptoms.”  Under this explanation we understand that trauma in the developmental timeframe of childhood, commonly results in dissociation.  Continual trauma in childhood results in the regular occurrence of dissociation which can eventually become habitual. 

What does it look like in your office? On the simple end of the spectrum it can be experienced as a client stating they feel foggy, floaty, or numb.  On the more complex end the client may describe feeling robotic, disconnected from the present moment, or even shift before your eyes into someone quite different than what you have experienced in your client before.  A lot of times clients do not really know they are dissociating.  Those who do it often do not know that it is something unusual, and frankly if they do they are embarrassed to let others know.  In my experience they do not come out and tell you this is something they do regularly, because they think it makes them ‘crazy’ (their word not mine). 

I’ve learned to ask in my intake process about childhood experiences, this can be done in a psychosocial, genogram, timeline, or family history assessment.  When trauma’s are mentioned by the client, I make it a point to add in an element of psychoeducation on trauma, it’s impact on the brain and common reactions/symptoms of trauma.  Part of that psychoeducation includes explanation of dissociation.

That is the beginning process of how to notice it and then what to do.  As the clinician the next step is teaching the client ‘present living’.  Present Living is part of many treatment models today, including many marital/relationship models, family models, and solution oriented models.  These models are about helping the client live in the moment and out of reactivity.  This is exactly what the objective with clients who dissociate is as well.  For those clinicians who practice ‘present living’ models, just add one additional step of teaching a client who regularly dissociates how to ground.  Simply put, it’s teaching the client to be mindful or aware of when dissociation is happening and then giving them the tools to stop the dissociative process and return to the present moment. 

Watch the following video to get an example of an effective therapeutic tool to use to help ground clients who are dissociating. 

Or click on the following link to watch a demonstration of the “Senses Bag” a technique I use to teach clients how to ground.

Dissociation doesn’t have to be scary.  At the simplest explanation it’s a symptom.  Now you the clinician have some resources that can help address and eliminate this symptom for a client.

****Dislcaimer- Complex forms of dissociation should only be addressed by clinicians trained to address the complexity of those symptoms (e.g. DID, dissociative fugue, and depersonalization disorder). However basic forms of dissociation can be addressed by all clinicians.  If the symptom persists or gets worse, seek consultation. ****

Preventing Drop Out

Preventing Drop Out

In a previous post “Helping People”, we looked at variables that can impact client retention within the therapist.   As we continue to study ‘client drop off’ with the intent of preventing it, we must consider the question “is there anything I can do to prevent client’s from dropping out of therapy”.  

This question may be uncomfortable for many of us.  I mean we have spent so much time as a profession making ourselves less responsible for client’s change and empowering them to take that responsibility for themselves.  What if both can happen… what if we can take responsibility and they can take responsibility for that change.  Whew…I can feel anxiety rising from here.  But before you stop reading consider a better question… where does my responsibility end and theirs begin?

I recently attended a webinar with Scott Miller around outcomes based treatment approaches.  I have heard this concept over the past few years and have allowed the concept to percolate in my mind.  But it wasn’t until recently, during this, webinar that I feel like I truly grasped the concept to it’s fullest in terms of my responsibility and the client’s responsibility. So bear with me as I try to put into words my ‘light bulb’ experience. 

Clients are coming to therapy for something to change.  Either a loved one has encouraged (or forced) them to come in the hopes of change, or they themselves have come in again with the hopes of change.  So if that is the product….change, then I have a responsibility to that client to: 1) understand the change they want 2) Identify if I’m the best person to help them get to that change 3) Know who are other people in the community that could help get them that change if I can’t.

The client has a responsibility to 1) Tell me the type of change they are wanting 2) Tell me if and/or when that change is occurring 3) Provide feedback on the customer service they are receiving through the change process.

So you may say ‘how does this prevent drop out?’  Well imagine with me what could happen differently if you were to add 3 simple things to what you are already doing…just three. What if you added a brief assessment of the change the client is desiring into every session. This gives them the responsibility of looking for their change and reporting that it is or isn’t happening.  Second, what if you had a way of getting feedback on your customer service, again giving client the responsibility of telling you what is/isn’t working for them.  Finally, what if you had a structured protocol to follow when change isn’t happening, giving you the responsibility to direct client to where change may better happen. The only thing that will happen differently when you add these three things is catching potential drop out clients early, before drop out.  With the prevention of drop out, clients get the opportunity to share what is not working for them, and can collaborate with you on what may work better.

When considering these three additions, here are some helpful tools:

1.     *  Change Assessment – Outcome Rating Scale (ORS)

Trauma Recovery Scale (part III) TRS- 

Outcome Questionaire (OQ-45)

Partners for Change Out5come Management Systems (PCOMS)

2.   
*  Customer Feedback Assessment (Therapeutic Alliance) -  Session Rating Scale (SRS) 

3.      

*          *  Structured Protocol –

·       If after 3 visits no change – staff case with colleague/supervisors

·       If after 5 visits no change – Start looking for other places/referrals and begin talking to client about that option. (Referral may include medication management, psychological assessments etc.)

·       If after 8 visits no change- Recommend referring

Based on research that if change has not occurred by the 12 week of treatment a decline or drop out most likely will occur.

Resources: http://www.scottdmiller.com/wp-content/uploads/2014/06/The-Outcome-of-Psychotherapy-2013.pdf

http://counsellingresource.com/lib/what-works/

http://scottdmiller.com/wp-content/uploads/documents/BeyondIntegration.pdf