ethical attunement and compassion fatigue 2016 · 2016-10-28 · +hdolqj *urzwk dqg &kdqjh...
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10/28/2016
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ETHICAL ATTUNEMENT AND COMPLEX TRAUMA
Mary Jo Barrettwww.centerforcontextualchange.org
Ethical Attunement■ The range of what we think and do
■ Is limited by what we fail to notice
■ And because we fail to notice
■ That we fail to notice
■ There is little we can do
■ To Change
■ Until we notice
■ How failing to notice
■ Shapes our thoughts and deeds -
R.D.Laing
Performance, health and happiness are grounded in the skillful management of energy
Jim Loehr
Awareness, Stamina, Creativity, Resources
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Healing, Growth and Change
Healing,change and growth comes from a process of encircling a person with a sense of being valued and empowerment. This is done by identifying and engaging with them through their own natural cycles of growth. Collaboratively gathering resources from within a person, their family and their community
Abuse/Neglect and Complex Trauma
■ Traumatic experiences embedded in ineffective hierarchies and/or hostile contexts: Behavior makes sense.
Fight ----- Flight ----- Freeze– Difficulty regulating emotions and impulses
– Difficulty in ego adaptive capacity/cognitive consciousness
– Somatization
– Self loathing, negative perceptions of others, victim/perpetrator cycles (sexually and violently acting out)
– Meaning making impaired
The Effects of Abuse and Complex Trauma
■ I experience myself as powerless
– Symptoms as attempted solutions
■ I am disconnected from myself, others, and the world around me
– Interactional Cycle of Survival
■ I experience myself as devalued
■ I am out of control
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Therapist Use of Self
Ethical Attunement Role of Mindfulness Interventions that decrease helplessness, extreme
behaviors and increase mastery Collaboration An Effective Model to build therapist’s confidence and self
empowerment-Stage oriented integrative model Supervision and Consultation
Five Essential Ingredients for Healing
Relationships connecting to a deep set of values that provide a meaningful vision of present and future Collaboration/Power/Attachment
Skills: Psycho educational Experiences/Cognitive Behavioral/Neuro-Mind-Body/Communication/Mindfulness/Thought Process/Self Regulating
Resource Based Guidance/Vulnerability and Resilience
Safe Context/Boundaries/Structure
The Creation of Workable Realities/Hope
Essential Elements of Trauma Informed Treatment
■ Co-creation of secure, safe, attachment, in and outside office
■ Assess and access resources of both clinician and client
■ Structured and Transparent Collaboration
■ Understanding and Implementing the Dynamic nature of self regulation and Co-regulation- client and clinician
■ Recognizing the moments that are opportunities to co-create change
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Guidelines for Standard of Care
Therapy enhances clients’ capabilities-of faith; creativity;and control response to a situation
Skills training
Cognitive Stability
Behavioral Stability
Interpersonal Regulation and Stability
Stabilization of Core sense of self
Therapy must improve the clients’ motivation for change
■ Collaboration: understanding of process, engaging in process, and investing in outcome.
■ Enhancing Positive Emotions not focusing on Negative
■ Interventions that help quickly
■ Clear Treatment Plan
Assure generalization to natural environment
What happens in sessions can be applied out side of room
Homework assignments and practice
In session Practice of Skills and Experience
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Enhance therapist capabilities & therapists’ motivation to treat effectively
■ Therapist Use of Self Ethical Attunement-self and other
■ Interventions that decrease helplessness, extreme behaviors and increase mastery
■ Collaboration
■ An Effective Model to build therapist’s confidence and self empowerment-Stage oriented integrative model
■ Supervision and Consultation
Structured Environment
■ Clarity of Model
■ Clear Boundaries
■ Coaching strategies
■ Predictability
Family Therapists’ Journey
Evolving
Judgmental Ruminative
HopefulDiscerning
Unreasonable Optimism
Cynical Naïve Stuck in Despair
Barrett and Stone Fish, 2016
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Mirror NeuronA mirror neuron is a neuron that fires both when a person acts and
when the person observes the same action performed by another.
■ You each become the reflection and extension of the other
■ A back and forth energy emerges between you- liken to an electrical energy flow
■ Positive resonance needs certain ingredients to exist-safety being primary
Collaborative Stage Model
Creating a Context for Change
Challenging Patterns/Cycles and Expanding Realities
Consolidation
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■ What the caterpillar calls the end of the world,
the masters call a butterfly
■ Richard Bach
Ethical Attunement with Clients■ Before Session
– Grounding with the knowledge that by being equally attuned to our emotions, body experience, and autonomic arousal, rather than ignoring our experience to “be there” for the client, we are centered and present
■ During Session– By welcoming challenging responses as opportunities, I can
regulate my body’s reaction to anger, shutdown, resistance, and stuckness, and the client’s experience will be changed
■ During and After Session– If I transform my somatic responses, the client’s experience is
transformed. It’s hard to be angry, resistant or stuck when your therapist is enjoying being with you and being a psychotherapist!
Barrett and Stone Fish, 2016
Unlock their bodies
Activate effective fight/flight
Tolerate their sensations
Befriend their inner experiences
Cultivate new action patterns
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Ethical Attunement■ Therapeutic Talent and Complex Trauma:
– Our Gift■ Energy Resources: Emotional, physical, spiritual, intellectual,
sensual
– Giving and Receiving
– Natural Cycle of Contraction and Expansion in Relationship
■ Therapeutic Wisdom: – Mindfulness (Empowerment)
– Open Hearts (Value/Attachment)
– Influence (Idiosyncratic or Relational Power)
■ Individual Thoughts/Your Wisdom– How do you think change happens?– Think of a time you changed– What were the essential ingredients of your change?
■ Relational/Therapeutic Thoughts– What are your idiosyncratic gifts for influencing others?– What are the core therapeutic ingredients you bring to your relationships?– How do you take care and nurture your gifts
■ Heart– Think of a time you gave to another and your gift was received– Think of a time you gave to yourself and you allowed yourself to receive it
■ Engaged Mindstate– What is going to help you feel supported today?
You as Therapeutic Resource
The therapeutic journey requires ENERGY –for our clients and for ourselves
Five Domains of Human Energy■Emotional■Intellectual■Physical■Sensual■Spiritual
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Compassion Fatigue
…..is the exhaustion, fatigue, and subsequent symptoms that are the result of passionately, skillfully, and compassionately giving of yourself to help others.
Performance, health and happiness are grounded in the skillful management of energy
- Jim Loehr
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In order to be a successful therapist (or caregiver)
■You need to be mindful of the possible of effects of your compassion
■You need to understand the energy exchange –what you give out and what you get back
■You need to understand your vulnerability and the need for balance in the expenditure of energy and replenishing of energy
When We Are Not Ethically Attuned• The client’s dysregulated emotions, attachment styles, and behavior
can have contagion effects
■ We may experience impending threat; e.g., violence, self-destructive and addictive behavior, threats to self/other, eating disorders
■ We may experience responsibility without power to change the outcome
■ We have difficulties tolerating details of abuse and neglect and holding clients’ terrible knowledge
■ We may experience client’s pleas for help as entitlement, intrusions, boundary challenges
■ We may experience client’s passivity, numbing, disconnection as an insurmountable barrier to progress and/or the relationship
Barrett and Stone Fish, 2016
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Feeling Helpless
and Hopeless
A Sense That One Can Never Do Enough
Hyper-vigilance
Diminished Creativity
Inability to Embrace
Complexity
Minimizing
Chronic Exhaustion
/Physical AilmentsInability to
Listen/Deliberate
AvoidanceDissociative Moments
Sense of Persecutio
n
Guilt
Fear
Anger and Cynicism
Inability to Empathize/Numbing
Addictions
Grandiosity
An Inflated Sense of
Importance
DYS-REGULATIO
N EXPOSURE RESPONSE
• Submission: we become numb, robotic, lose energy or
apathetic, become more depressed or detached in our own
personal lives.
• Flight: it is harder to pay attention, to want to go to work.
We may dream of vacations or of terminating the client
• Fight: we become more irritable, tense, or defensive. Or
quicker to ‘try to save the day.’ Our hyper vigilance or posttraumatic
paranoia may affect our personal lives, interfering
with sleep or relaxation
• Attach: our separation anxiety increases in tandem with
their instability and un-safety.
When we are depleted
Possible Consequences
■ Compassion Fatigue
■ Vicarious Traumatization
■ Burnout
■ Rigid boundaries
■ Confusing boundaries
■ Inconsistent boundaries
■ Loose boundaries
Barrett and Stone Fish, 2016
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Validation
What is it?
Definition: To accept, legitimize, support, attempt to understand and assign benevolent meaning to your own and/or someone else’s emotions, thoughts and behavior.
Invalidating Environments
Characteristics of Invalidation
• Communication of private experience met with exaggerated, inappropriate, extreme response.
• Communication of private experience not validated, often punished and/or trivialized.
• Painful emotions and factors causing them are disregarded.
• The individual’s interpretations of his/her behaviors and motivations for behaviors are dismissed.
• Tells the individual he/she is wrong in both the description and analysis of the experience particularly what is causing the emotion, belief or action.
• Attributes the experience to socially unacceptable characteristics or personality traits.
• Failure to live up to expectations brings disapproval, criticism, sarcasm, or attempts to change the individuals attitude.
Invalidating Environments
Consequences of Invalidation
• Individual does not learn to label private experiences and emotions in normative manner.
• Individual does not learn to modulate emotional arousal.
• If problems are not recognized, problem-solving skills are not learned.
• Extreme problems or emotional displays become necessary to provoke a response.
• Inhibition or extreme emotional states occur.
• Individual does not learn to tolerate distress or form realistic goals and expectations.
• Individual does not learn to trust his/her own emotional response.
• Self-invalidation and shame.
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Function of Validation
• Creates safety (verbal, emotional, physical and sexual)• Establishes the environmental context for constructive,
useful, effective behavior (verbal and nonverbal; with self and others)
• Enhances connections in relationships• Teaches trust and helps it to evolve• Strengthens empathy• Generates feeling understood and supported• Generates comfort through emphasis on naturalness of
responses• Generates encouragement and effectiveness
What to Validate
• The value of each individual as a person.
• The value of the relationship to those involved.
• One’s own and other’s behaviors that are legitimate, natural and effective. This includes: emotions (feelings and needs), thoughts (beliefs, intentions, goals), and constructive actions.
• Facts when they are factual, what is actually happening.
• Worries and fears as worries and fears - not facts.
• Self-initiated actions by a person for themselves consistent with their own values, feelings, desires and goals.
GOALS OF BRAIN-DIRECTED INTERVENTIONS
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Body Regulation –Balancing the accelerator and the brakesEmotional BalanceResponse FlexibilityEmpathyInsightModulating fear and AngerIntuition
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FIVE FACETS OF MINDFULNESS PRACTICES
1. Decreased reactivity to inner experiences
2. Increased capacity to remain present even with
painful emotions and sensations
3. Increased capacity to react with awareness and
intention
4. Increased capacity to describe/label with words
5. Non-judgmental of experiences
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AWARE MIND PARADIGM
Integrated
Present in the
moment
Balancing
Internal locus of control
Trigger and Reaction
I need to create a
pause and bring the
anger down
Focus on safety and effectivene
ssSelf-observing
Assessing Needs
Enact a goal-driven action plan
WarmIncreased heart rate
NegotiableNeither self nor others
are less than human
Resilience
■ Awareness/Realism
■ Creativity
■ Humor
■ Courage/Intiative
■ Flexibility/Adaptability
■ Faith/Trust
■ Social Support
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We fall into Negative Energy with FatigueOur goal is to recognize this and Create Positive Energy
■ Positive Energy- High and Low– High Positive; Joy, Happiness, Playfulness, Movement…
– Low Positive; Meditation, Prayer, Stroll in Nature…
■ Negative Energy- High and Low– High Negative; Anger, Critical, Judgment, Irritable…
– Low Negative; Depressed, Withdrawn, Isolation …
The Collaborative Change ModelBarrett, M.J. and Stone Fish, L. (2014). Treating complex trauma: A relational blueprint for collaboration and change. NY: Routledge.
Creating a Context for Change
Sharing our vision of ethical boundaries
Creating safety inside and outside of office
Discussion of boundaries
What makes you feel safe? You- meaning both you and the client
In session, out of session, between session
Barrett and Stone Fish, 2016
Creating a Context for Change, Cont’d. ■ Digital Boundaries Explored:
– Passwords on phones and computers
– Lock computers like file cabinets
– Assume your clients can get on Facebook and Google
– Establish text and email boundaries from beginning
– In session use of phone
Barrett and Stone Fish, 2016
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Challenging Patterns and Expanding Realities■ Our boundaries get challenged. The more intimate we
become and the more fatigued we are the more vulnerable we become.
■ Inside the office
– Self disclosure, gifts, role reversal bids
■ Outside the office
– Spilling
■ Organizational
Barrett and Stone Fish, 2016
Consolidation
■ On-going Consultation
■ Consistency
Barrett and Stone Fish, 2016
How to Maintain our Energy to Ensure We Make Wise and Ethical Decisions■ Acknowledgment of how caring for others has impacted our
lives and changed us-both positively and negatively. Recognizing our expenditures and replenishers
■ Designing the program that will re-create the proactive energy which lies within all of us in each domain. Constructing a personal energy formula
■ Commitment to ongoing practice of replenishment in all 5 energy domains- through an energy efficient personal formula
Barrett and Stone Fish, 2016
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Worksheet
■ Your Symptoms you want to change:
What behaviors at home or work -do I want to change?
What beliefs about myself and others no longer serve me- in fact expend my energy?
What reactions of mine are problematic at home and work?
■ Your Energy Expenditures:
What tasks?
With Whom?
What Life Style Choices?
Wellness Plan
Write your Personal Vision:
How would you like to see yourself as a person.
What are your Top personal energy expenditures
What are your Positive energy replenishers
Create the specific plan and formula that is realistic for you-what, when, and how
Write your Professional Vision:
How would you like to see yourself as a person.
What are your Top energy expenditures
What are your Positive energy replenishers
Create the specific plan and formula that is realistic for you-what, when and how
Keys to Success
■ Boundaries
■ Explain phenomena to others-work and home
■ Mindfulness
■ Be Creative
■ Watch what you say to yourself
■ Plan something every month/every week /every day that you look forward to
■ ASK for what you want and need
■ Create an energy plan
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