Sustaining the WorkFabiana Wallis, PhDClinical Psychologist

© Fabiana Wallis 2014 – Do not reproduce without permission

What is sustaining?

Having a useful, evidence-based framework Having effective tools Fostering Resilience Being Centered or Present/Mindfulness (Siegel,

2010)

Eight Therapeutic Lifestyle Changes (Walsh, 2011)

Exercise, nutrition and diet, time in nature, relationships, recreation, relaxation and stress management, religious or spiritual involvement, and service to others

What sustains me is ___________________________

Goals

Trauma informed care: building on the basics Complex Trauma Understanding the Therapeutic Relationship Understanding the role of power and

privilege Provider, Team and Organizational foci

What can we do?

What is Trauma?

Any experience that overwhelms the individual’s capacity to cope.

Overwhelming experiences that cannot be integrated and elicit subcortical animal defensive mechanisms and dysregulated arousal

Ogden, Minton & Pain (2006)

Survivors of interpersonal trauma (ongoing, single, multiple) experience more symptoms than survivors of non-interpersonal trauma - natural disasters, accidents, traumatic loss.

Green et al. (2000)

Complex Trauma: Alterations in…

Desnos/Adults

Regulation of Affect and Impulses

Self-Perception Attention or

Consciousness Perception of the

Perpetrator Relationships with

Others Somatization Systems of Meaning

Childhood Developmental Disorder/Child and Adolescent

Attachment Behavioral Control Biology Affect Regulation Dissociation Cognition Self-Concept

The Therapeutic Relationship“It is much more important to know what sort of a patient has a disease than what sort of disease a patient has.” - Sir William OslerWell-documented effect of patient-provider relationship on health. For example:PCP’s who are more “present” with patients experience less burnout, more resilience and more positive attitudes towards patients (Krasner 2009)

Increased physician empathy leads to increase in patients immune function and shorter colds (Rakel, 2009)

The Therapeutic Relationship The therapy relationship makes substantial

& consistent contributions to outcome independent of the type of treatment

Other findings Adapting or tailoring the relationship to patient

characteristics (in addition to diagnosis) Goal consensus and collaboration Considering the transdiagnostic features of the

individual Positive regard - which has a higher effect size

with racial/ethnic minority clients.Norcross, 2011

The Therapeutic Relationship Remembered Wellness (Benson & Friedman, 1996)

Current research lends further support to the role of the relationship, and a need to recognize the relationship as an intervention with shown efficacy.

The placebo effect yields beneficial clinical results in 60–90% of diseases that include angina pectoris, bronchial asthma, herpes simplex, and duodenal ulcer.

The placebo effect is predicted by positive belief and expectation from both client and patient, and a positive relationship between them.

Power and Privilege

Privilege “I have come to see white privilege as an invisible package of unearned assets which I can count on cashing in every day, but about which I was‘meant’ to remain oblivious.”

“I can be sure that if I need legal or medical help, my race will not work against me”“I can go home from most meetings of organizations I belong to feeling somewhat tied in, rather than isolated, out-of-place, outnumbered, unheard, held at a distance, or feared”If my day, week or year is going badly, I need not ask of each negative episode or situation whether it has racial overtones”

McIntosh, 2003

Power and Privilege

OppressionThe systemic and pervasive nature of social inequality woven throughout social institutions as well as embedded within individual consciousness.Oppression denotes structural and material constraints that significantly shape a person's life chances and sense of possibility.Oppression also signifies a hierarchical relationship in which dominant or privilege groups benefit, often in unconscious ways, from the disempowerment of subordinated or targeted groups

Adams, Bell, & Griffin, Eds. (1997)

Diversity Considerations

Wellness (CDC)The presence of positive emotions (e.g.,

contentment, happiness), and the absence of negative emotions (e.g. depression, anxiety), as well as a general satisfaction with life, feelings of fulfillment and positive functioning within an individual’s life.

Social Power (M. Jean Gilbert, 2010)

Access to resources that enhance one's chances of getting what one needs or influencing others in order to lead a safe, productive, fulfilling life.

Power and Privilege

Trauma and Diversity•Insidious Trauma•Intergenerational or historical trauma•Societal trauma•Race-based or Racist incident-based trauma•Racism, Heterosexism, Ableism, Sexism, etc.

Bryant-Davis, 2007; Carter, 2007

How are trauma, power, oppression and wellbeing related? All types of traumatic experiences involve the

loss of power and/or control and have a negative impact on wellbeing whether we experience trauma directly, witness it, or are exposed to it through helping professions.

When individuals or organizations are unaware of the dynamics of power and oppression, unintended traumatization and re-traumatization can occur resulting in secondary trauma for helpers and worsening of symptoms for individuals in recovery from trauma.

A better understanding of power and oppression can lead to healthier and thriving communities.

It all adds up

Poverty and “isms” are traumatogenic because they lead to interpersonal traumatic experiences

Reactions include conflicted identity or self-concept, internalized rage, low self-worth, chronic indignation, loss of hope

All forms of prejudice are a constant stressor - from general messages in media to microaggressions

Reactions such as self-harm or aggression may seem confusing to those who do not know the person’s trauma history

Systemic “isms” and institutionalized oppression can exacerbate these reactions

Peacock & Daniels, 2006

Fostering Resilience

Assess current levels of burnout, compassion fatigue, vicarious trauma, and compassion satisfaction ProQL measure http://www.proqol.org

Vicarious resilience is a process “characterized by a unique and positive effect that transforms therapists in response to client trauma survivors’ own resiliency.” Hernandez, Gangsei, & Engstrom, 2007, p. 237

Strength-based approaches

Fostering Resilience

Provider vs. Organizational focus Patient-provider is not the only relationship

that matters Provider training alone does not lead to

sufficient change Provider-administrator & peer relationships

modeling Trust is earned not assumed Policies and procedures that are conducive to

productivity and efficacy Advocacy within organization/systems

What can we do?

Disease model vs. strength-based perspective: Identify personal strengths and resources

Universal assumption See patient both as an individual and within a

group Multi-dimensionality & Intersecting identities Psycho-education: share your knowledge – it’s

power! Ask for permission & Explain why you ask/do Transparency Predictability and structure – explain any new

approach Clear and consistent boundaries

What can we do?

Offer real choices Patient active involvement in decision

process Genuineness Providers must earn the patient’s trust Clear and direct style will elicit trust Providers must create safety What to ask your patient: Invite feedback What is the context vs. focus solely on client Know what to ask yourself: Why am I doing

this work? Countertransference Acknowledge differences

What can we do?

Articulate your worldview and evaluate its sources

Develop a sufficiently complex set of cultural categories for yourself and others

Be an ally: offer support, level hierarchies Practice self-awareness: no one is free of bias Practice self-care: seek support, supervision

and consultation, form peer consultation/study groups and advocacy teams, etc.

Cultural Humility – know what you don’t know Avoid culturally-based assumptions – check

yours regularly