Trauma Counseling
Theories and Interventions
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Chapter 32: Therapist Self-Care: Being a Healing Counselor Rather Than a Wounded Healer
Introduction
The purpose of this chapter is to explore the role of self-care among counseling professionals and to illustrate the need for healthy self-interest, especially when working with trauma. This chapter highlights the relationship between counselors and their counseling work, with the hope of addressing some of the tensions involving authentic practice. Counselors want to help trauma survivors to heal, yet we are affected by the awfulness of the impact of clients’ traumatic experiences. Developing greater awareness about this sometime subconscious dialectic can be used to create a more congruent way of living and working with people. Yet such awareness development can instigate additional questions.
The questions presented in this chapter are not posed merely as rhetorical subjects for idealistic discussion but rather probing questions are intended to encourage the level of self-exploration necessary to self-actualize as well as to initiate the healing of self and others. “As counselors, we don’t always practice what we preach” (Schwarzbaum, 2010, p. 48). Research shows that 20% to 25% of therapists have never participated in their own therapy (Schwarzbaum, 2010).
One common myth is that counselors are immune to problems and can serve as their own therapists (Lawson & Venart, 2005). Another myth is that if a counselor acknowledges personal problems, this may be seen as a threat to the counselor/client relationship (Evans & Payne, 2008). If we are imperfect, how can we help others? An additional concern is that counselors do not always get needed clinical supervision: Supervision is mandated in the training and licensing of counselors but not after we become professionals (Lawson & Venart, 2005).
This chapter contains a discussion and a possible direction or road map for counselors to follow in an attempt to stay balanced in a difficult and complex world, especially when working with traumatized clients and particularly at a time when communication can be so immediate. We experience so much more stress today because disaster and tragic events are a click away; however, it is possible to discover an inner strength to combat or insulate us against outer circumstances. Once we distinguish our inner focus, we can then set some goals for our personal discipline. We must spend some time exploring dimensions of our lives to be fully present to others. Balance is a direction, not a destination. And over time, small steps can produce big results. The aim of this chapter is met through discussions of relevant issues that are presented in the following main sections: (a) counselor self-care and (b) self-care implications for counselors working with trauma. These main sections are followed by a summary of the chapter and a list of relevant resources.
Counselor Self-Care
In some ways, counselors are almost like our society’s medicine men and medicine women. They work in uncharted territories to bring comfort and healing to emotional, mental, spiritual, and physical suffering. Often times they neglect an important step in the helper/helping equation: They forget that balance or lack of it is essential in the effectiveness of their work, and balancing self-care and other care is difficult (Skovholt, Grier, & Hanson, 2001).
No other profession is so intimately connected to the joys and sorrows, heights and depths of human existence on a daily basis. Due to the intimacy of this work, counselors can be overstimulated to their own parallel pain and grief experiences. Without working on areas that are activated from past wounds and without freeing their levels of awareness to experience life in the present, impairment and burnout can occur. This can have a profound effect on how a counselor is able to balance self and other needs. Even Carl Rogers struggled with this question of balance. He stated that “I have always been better at caring for and looking after others than I have been in caring for myself. But in these later years I made progress” (Rogers, 1995, p. 80).
Ours is a profession emphasizing one-way caring and repeatedly creating empathy (Skovholt et al., 2001). This easily can lead to burnout, as selflessness can be exhausting, and intentions alone do not keep us healthy. In fact, research has shown that many counselors experience the same stress and anxiety as their clients (Stebnicki, 2008).
The American Counseling Association’s (
Counselor self-care raises a number of social and existential issues. In the remaining parts of this section, I discuss the stigma of therapy work, the role of the counselor in the healing process, and how trauma work can be traumatic.
The Stigma of Therapy Work
The helping profession is an honorable work, and mental health workers are engaged in serving others. In counselor training programs, encouragement to address therapeutic issues may be present. However, when participants admit vulnerability to their own internal problems, there is often a stigma attached. A complex relationship exists between the encouragement to do one’s work and the acceptance or lack of judgment by self and others if one actually embarks on that journey.
It is interesting that self-help is emphasized so much in our society. It is a lucrative business. Yet, again, counseling professionals have a complicated, ambivalent relationship with their own self-help. It is as if doing this work may imply a defect. Attending personal therapy is often seen as a failure (Norcross & Brown, 2000).
Psychotherapy can be a demanding calling. Freud said it best (1933): “No one who, like me, conjures up the most evil of those half-tamed demons that inhabit the human breast, and seeks to wrestle with them, can expect to come through the struggle unscathed” (p. 184). And he encouraged revisiting personal therapy (Freud, 1937/1964):
Every analyst should periodically—at intervals of five years or so—submit himself to analysis once more, without feeling ashamed of taking this step. This would mean, then, that not only the therapeutic analysis of patients but his own analysis would change from a terminable into an interminable task. (p. 249)
The Role of the Counselor in the Healing Process
The role counselors believe they must fill in their work dictates their therapeutic approach. For this reason, counselors must examine the personal, ethical, and philosophical meanings that they ascribe to life, as these underlie counseling work. And a counselor’s view of human nature influences belief or lack of belief in the healing process.
The early psychotherapists such as Freud and the behaviorists had a more pessimistic and predetermined view of human nature. They saw us being driven by animal instincts and repetitive behaviors that were set early in development. But psychodynamic and learning theorists were more encouraging about the possibility of change. For example, Rogers believed that people have what they need to become whole if given the proper conditions in the therapeutic relationship. New research indicates that much about us is hardwired, yet our brains allow us simultaneously to be fluid and to be responsive to external stimuli.
Trauma Work Can Be Traumatic
Clients come to therapy in a state of upset. Often the degree of disturbance is extreme. Counselors must find a curative way to connect with pain. The hardest thing in life is to have compassion for others, if we do not have it for ourselves. Thus, our healing work, or lack of it, is affected by our ability to feel our own pain. Yet uncovering our own trauma can be traumatizing.
The ability to be present is of the utmost necessity when working at the deep, suffering end of the pool, when others are drowning in severe loss and hurt. Often, counselors quickly close this open wound, as it reactivates wounds that exist in their own inner landscapes. Therapy can be a parallel process, and if counselors are not open and present, they can hinder others from resolution. We just cannot be present to others if we have lost connection and integration in our own lives; burnout is a real possibility. Osborn (2004) defines burnout as “the process of physical and emotional depletion resulting from conditions at work or, more concisely, prolonged job stress” (p. 319).
One of the dangers of the reoccurrence of posttraumatic stress symptoms is the effect on our internal physiology. When painful events are remembered, an arousal response is repeatedly reactivated. The original wound may be from an external source, but the relieving of this wound reinjures a person over and over again (Allen, 2005). This repeated conditioning is difficult to extinguish. Thus, our work with trauma can be traumatic on physical and emotional levels.
The risks in working with trauma are great, as are the rewards. The risks are external and internal. Many realities of a counselor’s job could strain a counselor’s cognitive and physical resources (Lee, Cho, Kissinger, & Ogle, 2010). The external risks are situational in the environment and systems in our workplaces. We have little control over these factors such as organizational issues, mandates from departments of mental health and counseling boards, dictates from funding sources such as managed care agencies and insurance companies, financial cuts, and large caseloads (O’Halloran & Linton, 2000). The internal risks are factors residing in us—our state of health, life experiences, sensitivities, boundaries, compassion, and resilience. The constant drain on our inner resources, coupled with external factors over which we have no control, can leave us vulnerable. The inner risks can be the very wounds, which we sustained in childhood, that sensitize us to empathize with others and draw us to the helping profession. These, however, need to be addressed, balanced, and mitigated.
Stress is caused by a life event, which interferes with a person’s balance (Figley, 1995). The stress response can be adaptive, in that it may assist in making needed adjustments to a situation, or maladaptive, when it compromises our ability to adjust. Figley (1995) claims that trauma occurs when stress responses cause a failure to readjust our prestress lifestyle balance. If the mechanisms of stress response are at play long enough for counselors, burnout may be a reality.
Research on burnout concentrates on the three components of exhaustion, cynicism, and inefficacy (Maslach, Schaufeli, & Leiter, 2001). The first symptom is exhaustion, and it may exacerbate the other two. A protective emotional withdrawal from clients and their concerns is a natural reaction to stress; yet, this detachment can be counterproductive. Additional research shows that therapists who work with victims of sex crimes, for example, report diminished hope, increased cynicism and pessimism, emotional hardening, and exhaustion (Farrenkopf, 1992).
Counselors listening to trauma can become traumatized. This vicarious experience affects us through empathic concern for others (Saakvitne, Pearlman, & Staff of
The Governing Council of
The
Norcross (Norcross & Brown, 2000) encourages us to increase our awareness of the hazards of our profession, asserting that we should: “Begin by saying it out loud: Psychotherapy is often a grueling and demanding calling” (p. 710). Studies show that depression, anxiety, exhaustion, and broken relationships can result from a career in psychological practice (Brady, Healy, Norcross, & Guy, 1995).
Wounded Healer and Inner Child
Carl Jung (1985) first used the term “wounded healer” to address the unconscious pain an analyst may have, which could be triggered by a client’s experience. Many even contend that, in some ways, all counselors and healing professionals are wounded healers. Existentially, we are searching for our wholeness and a way out of our personal pain. Pain is a universal experience, and in sharing, it dissipates and frees us from darkness and bondage. And our pain is what breaks the shell enclosing our awareness. So must we be free to help others find freedom, or do we need only to be just a bit further up the tunnel? Counselors surely cannot use clients for their own personal gain, but this often happens, as one easily can see from reading the lists of those who have been sanctioned and lost counseling privileges and licenses. This sets up a transference and countertransference process that could be useful in therapy. Yet therapists often are uncomfortable with the emotional reactions that can be released in this unconscious identification process. Without understanding and integration, this resistance and defensiveness can lead to therapist burnout.
Countertransference is an emotional reaction that a therapist may have toward a client, which is triggered by a therapist’s unconscious reaction to a client’s transference (Freud, 1959). This is a process of seeing self in the client (awareness enhancing), or meeting needs through the client (pathology). A more contemporary definition of countertransference involves the sum total of emotional reactions a counselor might have toward a client (Johansen, 1993). Because we are all imperfect human beings, we would never, in theory, be so clear as to be unaffected in our work with clients. However, it is believed that if we could make more of our unconscious material conscious, we would not be reactive when working with others, and our awareness of our own defenses would not be detrimental to the healing process. In fact, the more conscious we are of our countertransference, the more adept we may become in productively using the countertransference in a particular case.
Aligned with the concept of the wounded healer is the concept of the inner child or the blind side of trauma. This happens when our blind spots or unprocessed traumatic events prevent us from protecting and assisting others in similar situations. For example, unresolved trauma can sustain an intergenerational abuse cycle. It is known that parents who have experienced sexual abuse and not worked on this trauma often are unable to protect their children from the same. In parallel fashion, the places that counselors avoid in their own awareness can blind them to the present reality of others’ victimizations.
Erik Erikson (1950) observed that there are developmental stages in the life cycle, and that certain tasks are to be mastered with each stage on the journey from child to adult. It is suggested that what is not learned with each progression can later become inappropriate responses in adult behavior, as when the inner child’s needs supersede proper adult responses. If, in childhood, we learned improper responses to have our needs met, then as adults, these needs may remain incomplete. To heal the adult self, we must become one with the child within. Jung called this archetype the divine child, a concept of innocence and perfection before life events wrote a negative script.
If counselors have not uncovered their own trauma, how can they be with others in ways that are clear and present? If we are not committed to healthy lifestyles, how can we encourage others to do their work? In the remaining parts of this section, I discuss the following issues: wellness, mind-versus-body symptom presentation, and the holistic model and wellness paradigm.
Wellness—Noun Versus Verb
The need for professional helpers to attend to their own health and wellness has been noted in the literature (Mahoney, 1997). Many schemata of the facets of wellness exist. Hettler (1984) was one of the pioneers who outlined components of a wellness lifestyle. Yet the first counseling-based model of wellness was not developed until 1991 by Witmer and Sweeney (1992). Myers, Sweeney, and Witmer (2000) have defined the concept of a holistic, balanced lifestyle as:
A way of life oriented toward optimal health and well-being in which body, mind, and spirit are integrated by the individual to live life more fully within the human and natural community. Ideally, it is the optimum state of health and well-being that each individual is capable of achieving. (p. 252)
Myers and Sweeney (2008) claim that the following ingredients are necessary for a wellness-oriented lifestyle: a good self-concept, clarity of role definition, and job satisfaction. However, the concept of balance in life is more complicated to achieve than simply to discuss. We can address some personal factors while others are out of reach. Yet, what might be a somewhat lofty goal for some becomes a must if we are to encourage others to find their own life fulcrum. It is good to have understanding and insight to outline changes for others to execute, but it is more difficult to make these changes in ourselves. Jung (1961, p. 132) clearly states that “[t]he psychotherapist, however, must understand not only the patient; it is equally important that he must understand himself.” I may be a therapist (noun) but am I being therapeutic (verb)?
I like to use a metaphor with my clients, that of comparing our lives to a house with various rooms: We each have many rooms within our structures of being and understanding. Some of these rooms inhabit the spaces of physical, mental, emotional, and spiritual or philosophical dimensions. To stay balanced, we need to look into each room every day—even if it is only simply opening the door to each facet of our life.
Wellness models can become very elaborate. I try to keep things simple. I often ask clients which room they most frequently avoid. Invariably, it is the emotional room. It is almost as if we have become a world of “smart” people and being emotional implies a weakness or inadequacy. Our emotions often are avoided like vestiges of ugly prehensile tails and treated with that much hatred and resistance. People are upset that they are upset. And as therapists, we are upset that we cannot fix them. Perhaps we need to look in our own hearts before we try to treat others. Therapy can be an ugly or shadowy place for all to hide.
Mind Versus Body Symptom Presentation
Psychological disturbances often remain unrecognized by medical doctors. Yet, frequently, people who are suffering psychologically first go to their medical practitioners. One report revealed that 11% of U.S. adults (18 or older) experienced serious psychological illness, but that only 44.6% of these received any kind of mental health services. This amounts to approximately 24.3 million people who are untreated. These data were released by the Substance Abuse and Mental Health Services Administration (
Individuals have a tendency to express physical or psychological distress in an idiosyncratic fashion. Whereas one person may choose to describe turmoil in purely physical terms, regardless of whether the origin is physical or psychological, another may express this turmoil in purely psychological terms. This constitutes a single dimensional view of illness, which perhaps has been prestaged by physicians and mental health professionals. Traditions and, in many cases, current practice, have clearly communicated to the consuming public that physicians deal only with physical illness, and that psychological problems are left to the mental health professionals. This has been an unfortunate circumstance. Researchers slowly have come to recognize the impact of one’s psychological state upon physical functioning and vice versa (Smith, 1990).
The dualistic orientation to health is not the sole property of the medical doctor: “Mental health professionals are trained to accept that 98% of what they encounter is psychological in origin” (Smith, 1990, p. 2). Many mental health professionals may believe that assisting individuals with physical concerns is beyond the purview of their interests. However, physical concerns can affect the duration and intensity of psychological symptomatology, especially if a person suffers from a real physical problem that has not been recognized or has been misdiagnosed (Smith, 1990).
The omission during graduate training of studies concerning physiological and biochemical disturbances and imbalances can leave the professional counselor with only part of the picture. To complicate the diagnostic issue, those suffering from psychological illness often report their symptoms as physical complaints. This may be the norm rather than the exception.
This preset view of diagnosis affects treatment when working with trauma victims. There are often deep wounds on more than one layer of being. A counselor must be able to assess and understand all the facets of a client’s problems (all the rooms of his or her house that may be affected). Yet, we are not trained across the relevant multiple dimensions in which we need to be trained. We are instructed to be expert in addressing only part of a human being’s existence, not the whole gestalt.
An additional complication of the diagnostic issue is the therapist’s own view of human nature. How do we see a human being? Is this definition a part or a whole? How do we understand being human? Do we see a Diagnostic and Statistical Manual of Mental Disorders (
The definition of holism implies whole versus a part. The medical model emphasizes parts; likewise, we have become increasingly more specialized in our training and diagnosis. The conceptualization of human problems and pathology affects treatment. Can we see how all the parts work together? Can we address all the rooms in a person’s house? Or do we stay in only one room?
An even more important question to ask is: What is our philosophy of health and healing? Do we even believe that people can change? Can they be well? Is our approach to the whole or part, disease or wellness? The implication here is for a holistic model that encourages wellness. But how can we see health potential when we are trained to diagnose parts of illness? How can we see the whole?
A Holistic Model and the Wellness Paradigm
. . . when there is a significant negative impact on a counselor’s professional functioning which compromises client care or poses the potential for harm to the client. Impairment may be due to: substance abuse or chemical dependency, mental illness, personal crisis (traumatic events or vicarious trauma, burnout, life crises) or physical illness. (Definitions, para. 2)
This highlights the need for wellness awareness and programming, as again, traumatic events or vicarious trauma can impair counselors.
In view of this explanation of impairment, counselors are on the continuum from wellness to impairment at any moment in time. According to the U.S. Department of Health and Human Services (
How can counselors take care of the self? How can they develop a more dynamic view of human beings? What is wellness? What is holistic health? Is wellness just the absence of illness?
I see wellness as a choice. It is one’s own philosophical stance, which includes how we feel about ourselves. Traumatic events shatter lives. How can counselors work to reassemble the parts? How can we assist others? We must first ask questions about our own fragmented lives. As noted earlier, there are many models of wellness. The dimensions can include physical, mental, emotional, spiritual, social, work, leisure, and so forth (e.g., Hettler, 1984; Witmer & Sweeney, 1992); however, these are merely the parts or facets of our whole lives.
Wellness Self-Assessment
As I stated earlier, I like to keep the therapeutic process simple when possible. Therefore, I like to use this wellness self-assessment with my clients. The dimensions of wellness include the following questions:
What area/areas is/are comfortable? Why?
What area/areas is/are uncomfortable? Why?
What dimensions need to be added?
Was there a time when I was more in balance? When? What happened?
What can I do right now?
What can I plan for the future?
As clients’ lives and traumatic experiences must be examined across all facets for healing to occur, so must counselors’ lives if we are to stay healthy and strong enough to do counseling work. If we follow a rubric of our living that is composed of facets or pieces of a whole, we more easily can examine and develop integration in a self-regulatory manner.
To continue this exploration of the dimensions of wellness, I refer back to the metaphor of physical, mental, emotional, and spiritual or philosophical rooms of our lives. More advanced taxonomies are described and can be explored in Witmer and Sweeney’s (1992) work; however, I think that it is constructive to establish a simple initial working map with clients.
In drawing or visualizing multiple dimensions of life, we again can conceptualize these aspects as rooms. It is important to ascertain which room is most avoided, as this is often the place to start the real discussion. The rest of this section is devoted to an exploration of the various rooms, including the physical room, the mental room, the emotional room, and the spiritual or philosophical room; the section concludes with a discussion about connecting the rooms.
The Physical Room
Our physical room is the most easily accessible, and the state of our physical health can be affected by all the other facets of our being. The lack of physical balance also can impair emotional and cognitive functioning. Many studies show the relationship between stress and illness. Our knowledge about physical health is vast, but our lifestyle practices are not always consistent with what we know. As such, Americans have become increasingly overweight and unhealthy.
So much tension can be stored in our physical body that finding healthy ways to release it becomes essential. If possible, some aerobic exercise and stretching is ideal. Most counseling work is sedentary and not too healthy. And as we sit, lots of pain is dumped onto our laps, which adds to our health security risks. Simple health remedies are abundant and commonplace. These include drinking water, dietary intervention, food choice, and exercise.
Alternative health regimes have become increasingly popular as the baby boomers are aging. These include yoga, tai chi, meditation, massage, and acupuncture. Breathing exercises and creative visualization techniques are helpful to relieve stress and can be used in conjunction with walking as form of physical meditation and tension release. We are living longer, and thus we are increasingly more interested in the quality of our lives.
I advise others to find some type of exercise that they really like to do, to keep it simple, and to keep doing it. This is more easily said than done. We all know that we must exercise, but we just do not always keep our commitments. Yet how can we remain balanced in an unbalanced world if our physical structure is not healthy?
Research has shown that healthy people make healthy choices. This highlights the role of self-esteem issues in healthy lifestyle commitments. We must think we are worthy to make healthy choices. Self-esteem is the driver here.
Health is a direction that we create. I often ask people to change one small thing and then add another only after some time has passed (minimum of 90 days). Diets and fads do not work. We need to commit to a direction that takes us on a healthy path.
The Mental Room
Our thoughts are consciously or unconsciously present. It is said we have 63,000 thoughts per day, yet, we often do not access the chatter that is our constant companion. What are we saying and is this important information?
Our memories connect us with the past and our worries with the future. Yet, we often are unable to focus on the present in a way that is meaningful and effective. Journalizing is a wonderful, noninvasive way to be with our thoughts and feelings. A nonjudgmental, noneditorial writing stream can be a therapeutic and effective means of self-connection. Other activities for mental connection with self include reading, meditation, hobbies, and movies (
The Emotional Room
We often are uncomfortable with our emotions. Feelings are “facts,” and even if lacking in factual content, they are undeniable. Emotional acceptance is paramount in healing processes. Yet this area often is avoided. We think we should not be upset that we are upset.
Interventions for emotional access are journalizing, crying, screaming (into a pillow), punching a punching bag, and talking. Laughter and tears are both very therapeutic. Life causes us to experience the fullness of the emotional spectrum.
Grief has no shelf life. I often work with clients who have traumatic experiences that occurred long ago, and yet their wounds seem fresh. I liken trauma to an iceberg. Only a small portion is above the surface and easily accessible. Yet, if one can work with what is obvious, then awareness can surface from below.
Some of my first work in graduate school was with clients who were grieving. Even though the shock of grief had occurred years earlier, their reactions were frozen. The trauma of grief has a domino effect and can become complex as it touches previous wounds (American Psychiatric Association, 2000).
The Spiritual or Philosophical Room
The spiritual room contains our philosophical meaning or purpose in life. We need to reflect and find a connection here. This may require a time commitment, but even a few quiet moments in a day can have a great impact on quality of life.
Suggestions for access to this area are meditation, prayer, reflection, reading inspirational literature, gardening, spending time in nature, and finding a community of like-minded people. A fellow therapist and mentor told me long ago that without a transcendent purpose, it was difficult to suffer the slings and arrows of life. Some say that philosophy is merely a form of rationalization. But it can be a framework that gives direction and purpose for living. Counseling work for me is very spiritual.
There is quite a distance between religion and spirituality. Religion can be merely dogma unless we give individual meaning to ritual. We are trained to be nonjudgmental as counselors. This is idealistic because we all have formed biases. We need to be clear of our beliefs, however, so that we are integrated and do not need to proselytize in the counseling room. In working with trauma, our philosophy of life must remain intact, as it is often challenged to the limit.
Connecting the Rooms
An interesting aspect of this multifaceted conceptualization of life is that all the rooms are connected by doorways. For example, our physical health can be altered by mental and emotional stress, and thoughts and feelings can be influenced by the state of physical health. Our self-concepts can affect the choices we make for our health, and our healthy choices are affected by the strength of our self-concepts. I have seen people stand in healing lines over and over again, reaching out for solutions to their problems, and wondering if there were some simple physical actions they could execute to improve their maladies. I always search for some feet to place under my prayers.
In addition to the concept of the rooms of our homes, or the facets of our beings, is the idea of floors or levels to the areas of our wellness. Our basement floor is the physical foundation of a home but can also signify the lower or underground, unconscious level of awareness. The upper levels of a home can signify a vertical ascent into consciousness. An attic is usually the highest place in a home and can signify a clear, high state of being. Much as our outer physical home needs cleaning and dusting, surely it is as essential to clean out the debris in all the rooms of our inner beings.
I believe we have an ability to improve our lives. Counseling is truly a high calling. It is an honor to do the work and a responsibility to stay healthy doing it. As traumatic event(s) must be examined across all aspects for healing to occur, so must our lives and dimensions, if we are to stay healthy and strong enough to do this counseling work. If we follow a rubric of life as being composed of facets or pieces of a whole, we can examine and develop ways to thus integrate our life experiences in a self-regulatory manner.
Counseling Implications
Freud (1937/1964) posed the following question and answer: “But where and how is the poor wretch to acquire the ideal qualification which he will need in this profession? The answer is in an analysis of himself, with which his preparation for his future activity begins” (p. 246). Research shows that most therapists have participated in personal therapy at least one time in their careers (Norcross & Guy, 2005). Yet, burnout often creates a resistance to change (Cherniss, 1980). Perhaps this offers a clue as to why the proclamation of “physician heals thyself” may not be practiced as widely as we might like to think among those working in our profession.
Stress and burnout should be studied as a likely occurrence in the profession and not the result of personal limitation (Savicki & Cooley, 1982). Instruction in self-care should be part of graduate studies. In addition, the importance of supervision, especially in trauma work, needs to be emphasized. The unfortunate reality is that supervision is not mandated once professionals are licensed. Yet, the creation of professional relationships that address case study and collaboration is instrumental in counseling work.
Our counseling work is demanding and rewarding. We have been traumatized by its demands and by the idea about whom we think we have to be. Stress comes from a reactivation of our own issues and one-way caring relationships. It is difficult to stay balanced and be fully present when working with others.
Our lives are multifaceted, and holism and wellness are just concepts if we do not systematically integrate meaning into all of our parts. Our clients are upset that they are upset; they cannot integrate their emotional trauma, and instead, they try to stay removed by expending energy and not feeling the pain. Trauma often is multilayered, and its magnitude is daunting to experience and digest. For example, change, loss, illness, death, divorce, unemployment, natural disasters, and acts of terrorism can be mind altering and must be assimilated in small bits and pieces.
Trauma work can encourage the care for self at an extreme level. And self-care is not selfishness. Events in our lives and the lives of our clients are traumatic and traumatizing. The systems in which we work may not be healthy. Powerlessness leads to more stress reactivity. The way out of our dilemma is to find a place within from which to operate and live our lives. Trauma can cause fragmentation, and the work of health, the direction of wholeness, is toward integration. We are complex creatures and the only way to be present in the face of adversity is to have the courage to work on our own issues so that we can be present for and with others.
Conclusion
The challenge of being a therapist is in actually being therapeutic, first to self and then to others. It is possible to preach, without sufficiently practicing what we preach, but the effectiveness of our work and our personal health and balance may be diminished in the process. As mental health professionals, our validation is defined by client progress, and yet we often have little control over outcomes in therapy. We have more dominion over our own growth and investment in the counseling relationship, and the more present we are, the more responsive we can be.
We can become traumatized by our professional engagements as well as the idea of who we think we have to be in facing the enormity of the devastation we see in the lives of others. Or we can be energized by the stimulation of challenge and encouraged to grow as people and professionals as we stand by others and assist in the human repair process, which we have been honored to perform.
APPENDIX 32.1
A Case Study
I would like to elaborate upon the exploration of self-care and wellness dimensions with a case study. My early counseling work began in a medical office with chronically ill patients. I recall one widow who was 70 years old. Her son brought her to me because he had heard that I would help others fight to recover their health.
At our first session, this woman was suffering from leukemia and cancer of her lymph nodes, and medical opinion was that she had only 6 months to live. I began by assessing her life experiences and dimensions. She was recently widowed, after being married 50 years; she had one son; she recently lost a job that she had held for 30 years to a younger person; she was eating only fast foods; she was reading murder mysteries; she was watching soap operas; and she no longer participated in civic organizations.
We explored every room of her life’s world, and I gave her feedback. The interventions were lifestyle changes: better dietary choices, exercise, adjusting reading material, and journalizing. She later told her son that she was overwhelmed with all the changes: “It was too much.” Her beloved son got very quiet and remarked, “Well, Mother, then I guess you are saying you will just die.” Giving her that choice was very powerful. Six months later, her cancer was in remission. She went on to make many lifestyle changes and experienced a full recovery from her disease.
Many years later, I ran into her son who told me she died at the age of 80 (10 years later) from a heart condition. Even though she was suffering from an advanced illness, her depth of self-exploration and ability to make lifestyle changes improved the quality and tenor of her life.
Resources
The following resources may be helpful to students, clinicians, and instructors who are interested in trauma and self-care.
Websites
Curtis Graf, PhD
Person-centered counseling (http://www.person-centered.org/counseling.html)
Peggy Natiello, PhD
Person-centered counseling (http://www.person-centered.com/)
SAMHSA . Serious psychological distress and receipt of mental health services.SAMHSA’s 2007 National Survey on Drug Use and Health (http://www.oas.samhsa.gov/2k8/SPDtx/SPDtx.htm)
Publications
Chodron, P. (2002). When things fall apart. Boston, MA: Shambhala.
Hesse, H. (1922). Siddhartha. New York, NY: New Directions.
Hesse, H. (1923). Demian. New York, NY: Harper Classics.
Tolle, E. (1999). The power of now. Novato, CA: New World Library.
Travis, J., & Ryan, R. (1988). Wellness workbook (2nd ed.). Berkeley, CA: Ten Speed Press.
West, W. (2004). Spiritual issues in therapy. New York, NY: Palgrave Macmillan.
Woodman, M. (2000). Bone: Dying into life. New York, NY: Viking.
References
- Allen J. G. (2005). Coping with trauma: A guide to self-understanding. Washington, DC: American Psychiatric Press.
- American Counseling Association. (2005). ACA code of ethics. Retrieved from http://www.counseling.org/files/fd.ashx?guid=ab7c1272-71c4-46cf-848c-f98489937dda
- American Counseling Association. (n.d.). ACA taskforce on counselor wellness and impairment. Retrieved from http://www.counseling.org/wellness_taskforce/index.htm
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
- Brady J. L., Healy F. L., Norcross J. C., & Guy J. D. (1995). Stress in counselors: An integrative research review. In Dryded W. (Ed.), Stress in counseling in action (pp. 1–27). Newbury Park, CA: Sage.
- Bride B. E., Hatcher S. S., & Humble M. N. (2009). Trauma training, trauma practices, and secondary traumatic stress among substance abuse counselors. Traumatology, 15(2), 96–105.
- Cherniss C. (1980). Professional burnout in human service organizations. New York, NY: Praeger.
- Erikson E. H. (1950). Childhood and society. New York: Norton.
- Evans Y. A., & Payne M. A. (2008). Support and self-care: Professional reflections of six New Zealand high school counsellors. British Journal of Guidance and Counseling, 36(3), 317–330.
- Farrenkopf T. (1992).What happens to therapists who work with sex offenders? Journal of Offender Rehabilitation, 18(3–4), 217–224.
- Figley C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner/Mazel.
- Freud S. (1933). Fragment of an analysis of a case in hysteria. In Collected papers of Sigmund Freud (Vol. 3). London: Hogarth. (Original work published 1905).
- Freud S. (1955). Beyond the pleasure principle. In Strachey J. (Ed. & Trans.). Standard edition of the complete psychological works of Sigmund Freud (Vol. 18, pp. 1–65). London, United Kingdom: Hogarth Press. (Original work published 1920)
- Freud S. (1959). Further recommendations in the treatment of psychoanalysis: On beginning the treatment. In Collected papers of Sigmund Freud (Vol. 2). New York: Basic Books
- Freud S. (1964). Analysis terminable and interminable. In Strachey J. (Ed. & Trans.), Standard edition of the complete psychological works of Sigmund Freud (Vol. 23, pp. 209–253). London, United Kingdom: Hogarth Press. (Original work published 1937)
- Hettler B. (1984). Wellness: Encouraging a lifetime pursuit of excellence. Health Values: Achieving high level wellness, 8(4), 13–17.
- Johansen K. H. (1993). Countertransference and divorce of the therapist. In Gold J. H. & Nemiah J. C. (Eds.), Beyond transference: When the therapist’s real life intrudes (pp. 87–108). Washington, D. C.: American Psychiatric Press.
- Jung C. (1961). Memories, dreams, reflections. New York, NY: Random House.
- Jung C. (1985). The psychology of the transference. In The practice of psychotherapy: Collected works (Vol. 16, pp. 163–22). Princeton, NJ: Princeton University Press. (Original work published 1954)
- Lawson G., & Venart B. (2005). Preventing counselor impairment: Vulnerability, wellness, and resilience. In Walz G. R. & Yep R. (Eds.), Vistas: Perspectives on counseling 2005 (pp. 243–246). Alexandria, VA: American Counseling Association.
- Lee S. M., Cho S. H., Kissinger D., & Ogle N. (2010). A typology of burnout in professional counselors. Journal of Counseling and Development, 88(2), 131–138.
- Mahoney M. (1997). Psychotherapists’ personal problems and self-care patterns. Professional Psychology: Research and Practice, Vol. 28.
- Maslach C., Schaufeli W. B., & Leiter M. P. (2001). Job burnout. Annual Review of Psychology, 52, 397–422.
- McAdams C. R., & Keener H. J. (2008). Preparation, action, recovery: A conceptual framework for counselor preparation and response in client crises. Journal of Counseling and Development, 86(4), 388–398.
- Myers J. E., & Sweeney T. J. (2008). Wellness counseling: The evidence base for practice. Journal of Counseling and Development, 86(4), 482–493.
- Myers J. E., Sweeney T. J., & Witmer J. M. (2000). The wheel of wellness counseling: A holistic model for treatment planning. Journal of Counseling and Development, 78(3), 251–266.
- Newsome S., Christopher J. C., Dahlen P., & Christopher S. (2006). Teaching counseling self-care through mindfulness practices. Teacher’s College Record, 108(9), 1881–1900.
- Norcross J. C., & Brown R. A. (2000). Psychotherapist self-care: Practitioner tested, research informed strategies. Professional Psychology: Research and Practice, 31(6), 710–713.
- Norcross J. C., & Guy J. D. (2005). The prevalence and parameters of personal therapy in the United States. In Geller J. D., Norcross J. C., & Orlinshy D. E. (Eds.), The psychotherapists’ own psychotherapy. New York, NY: Oxford University Press.
- O’Halloran T. M., & Linton J. M. (2000). Stress on the job: Self-care resources for counselors. Journal of Mental Health Counseling, 22(4), 354–364.
- Osborn C. J. (2004). Seven salutary suggestions for counselor stamina. Journal of Counseling and Development, 8(3), 319–328.
- Rogers C. (1995). A way of being. Boston, MA: Houghton-Mifflin.
- Rotter J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80(1), 1–28.
- Saakvitne K. W., Pearlman L. A., & Staff of TSI/CAAP. (1996). Transforming the pain: A workbook on vicarious traumatization. New York, NY: Norton.
- Savicki V., & Cooley E. (1982). Implications of burnout research and theory for counselor educators. Personnel and Guidance Journal, 60(7), 415–417.
- Schwarzbaum S. (2010, February). Counselors don’t necessarily make good clients. Counseling Today, 48–49.
- Siegel D. (2010, January/February). The complexity choir: The eight domains of self-integration. Psychotherapy Networker, 46–61.
- Skovholt T. M., Grier T. L., & Hanson M. R. (2001). Career counseling for longevity: Self-care and burn-out prevention strategies for counselor resilience. Journal of Career Development, 27(3), 167–176.
- Smith C. D. (1990). A study of the relationship between selected personality attributes and allergic symptomatology. Unpublished doctoral dissertation, University of Akron.
- Stebnicki M. (2008). Empathy fatigue: Healing the mind, body and spirit of professional counselors. New York, NY: Springer Publishing.
- Substance Abuse and Mental Health Services Administration. (2008). National survey on drug use and health. Retrieved from http://www.oas.samhsa.gov/2k8/SPDtx/SPDtx.htm
- U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General—executive summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/home.html
- Witmer J. M., & Sweeney T. J. (1992). A holistic model for wellness prevention over the lifespan. Journal of Counseling and Development, 71(2), 140–148.