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The Supervision Quarterly

Spring 2014

Welcome
Welcome to the Spring newsletter.  This edition is a reflection on some of the discussions in supervision and experiences in teaching I have had over the past few months. I’ve been busy running workshops on clinical supervision and family systems therapy and it is interesting to reflect on the experiences shared with me from participants who have attended training.
In this newsletter I will address supervision of trauma informed practice, ways to increase self-awareness of possible vicarious traumatization and the role of self-care in helping clinicians minimise the ‘negative effects of caring about the caring for others’. 

I am interested to hear from you if you would like anything specific covered in future newsletters, or if you would like to comment on any aspect of the material covered. I hope you enjoy the Spring edition of the Supervision Quarterly.

Christine Senediak

Supervision of 
trauma-informed practice

Traumatic events unfortunately occur all too often and clinicians are at the forefront to help clients manage the impact of these events. Fifty percent of professionals who work with trauma clients report feeling distressed as a result of their work and of these 30% report experiencing ‘extreme distress.’ Of these, 30% have experienced personal trauma in the past. 

There is a growing awareness of the importance to enhance organisations and care systems to be more trauma-informed, even when trauma per se may not be the main focus of the service.  For supervisors there are particular challenges to supervising clinicians learning and executing trauma-informed work.  
These include helping clinicians identify appropriate self-care, managing personal attitudes that might impact on working with traumatised clients and possible agency/organisational restraints such as lack of resources and policies. 

There is a growing recognition of the value of supervision in being a major protective factor and buffer against the development of vicarious trauma for clinicians. Because it protects trauma reactions being triggered in clinicians who work with traumatised clients, supervision should be an integral part of all clinical work. 

I provide supervision to many clinicians, some who work in specialist trauma contexts (e.g. child protection, victims of crime, domestic violence, drug and alcohol, mental health and sexual abuse services) and others in mainstream services, who in the course of a typical working day will hear repeated ‘trauma’ and ‘abuse’ stories. For many, organisational structures simply are unable to provide a safe level of protection to adequately manage the stresses clinicians commonly face when working with such high pressured clinical presentations.
Common signs of vicarious trauma
 
Feelings Thoughts Behaviour
Feeling overwhelmed Over identification with client Distancing, numbing
Feeling angry or sad about the client’s issues Loss of hope, cynicism May experience similar symptoms to client
Overly involved emotionally with client Question competence Impact on personal relationships
Feeling isolated or detached form colleagues Low job satisfaction Heightened overall genial distress
Feelings of self- doubt, Heightened sense of vulnerability Overextend self and assimilate client’s trauma material
Experience of bystander guilt or shame Poor self-worth Difficulty to maintain professional boundaries
 
Supervision can offer the ‘normative and supportive’ functions of providing a safe context for clinicians to explore their clinical work, and professional - client relationships. Supervision that combines both knowledge about trauma and supervision, provides a focus on the characteristics of the interrelationship between the trauma, the clinician and the helping relationship within the context that the work in being provided. 
With increased knowledge and awareness of vicarious trauma reactions, clinicians can become resilient and develop a practice of ‘trauma stewardship’ to counterbalance the harmful effects of trauma.  Effective clinical supervision within a trauma context provides the following:
  1. Exploration of the transformative relationship processes that exist between client-clinician and within their respective systemic contexts.
  2. Promotion of quality therapeutic relationships contributing to repair emotional supports.
  3. Educational components which empower the clinician to help the client.
  4. Education and promotion of affect regulation and emotional processing.
Essentially supervision for trauma-informed practice includes the sharing of theoretical and clinical knowledge that oversee clinical judgements made by clinicians, alongside assessing the clinician’s vulnerabilities and resilience relative to trauma content.  A supervisor needs to help the clinicians address job-related stress and challenges and exercise self-care within the context of their work practice. Supervision needs to be provided in an environment that feels structurally safe (private, neutral, physical set up etc.,) AND emotionally safe (consistent day/time for supervision).  The challenge for the supervisor is to ensure that all aspects of the supervisory relationship provide this safety to allow for open discussion and reflection of the impact of trauma work.  

Principles for
trauma-focused supervision

  1. Understand the impact of trauma on the client AND clinician.
  2. Adjust supervision of the clinician to support the client’s coping capacity.  What else might the clinician need to know or do to be in a position to help the client emotionally, behaviourally and cognitively?  What resources can they call upon?  Do you as supervisor need to provide further knowledge or skills?
  3. Allow a safe place for self-reflective practice. Supportive reflective supervision is a predictor of lower levels of vicarious trauma.  By doing so supervisees are better able to manage their trauma symptoms and better able to minimise the likelihood of burnout.
  4.  Allow for countertransference reactions – being able to recognise and talk about what the clinician is feeling is the first step to being able to ‘let go’ of the empathic strain felt from listening to the trauma story.
  5. Allow time to process and allow recovery time within the clinical and supervisory contexts.  Be aware that vicarious trauma can be cumulative and if it is not dealt with appropriately can impact on the clinician’s personal well-being and capacity to help others.
  6. Ensure that the clinician maintains a balanced case load, including pacing and sequencing particularly difficult clients (don’t overload on difficult clients all in one day if possible).
  7. Encourage the clinician to seek and maintain helpful and healthy connections with others (e.g. colleagues, team leader, supervisor)
  8. Allow for time out within the working day – ensure the clinician takes breaks to recharge.
  9. Where appropriate, allow for ongoing reflective practice to examine how trauma work impacts on the self within their work context with a focus on empowerment (offer validation and consistent feedback).
  10. Ensure that the clinician has opportunities for choice in their clinical work: as the supervisor, help the clinician to choose the best possible intervention.

The fine line between
therapy and supervision

There is a fine line between providing good quality professional supervision and providing therapy.  Within trauma focused work however, it may be necessary to help the supervisee address personal trauma experiences, at least in the context of raising awareness of the possible impact this might have on their ability to work with trauma clients. Personal experience has a powerful influence on the way in which the clinician might approach their traumatised clients so a conversation about this is important. 
For example, a clinician who themselves might have experienced a similar event to the client might influence them not to ask about the event, for fear that it might reactivate their own reactions. Or it might work the opposite way. By talking about such events, the supervisor can respectfully help the clinician recognise a ‘red light’ or’ no-go’ trigger, which would need some work.  The decision then can be made about what is appropriate for supervision discussion, vs. what is more appropriate for discussion in a counselling context elsewhere.  If the goal is for protection of both the clinician and client, then the supervisor must sensitively address this issue.

Emotional safety is paramount and addressing transference and countertransference issues positively aids professional and personal growth.  Combining reflective practice within the supervisory context and encouraging ongoing introspection outside supervision will provide opportunities for safe exploration of self in the therapeutic contexts. 
 
There are a number of tools that you might find helpful to use in your clinical and supervisory contexts.  You might want to consider giving your supervisee one of these questionnaires as a way to open up or begin a discussion about how they are travelling, what they are experiencing in the workplace and areas that they might want to change.
Measures to assess 
stress and trauma
Traumatic Stress Inventory (TSI-BSL) Pearlman, 1996
Traumatic Stress Inventory Life Event Questionnaire (LEQ) Pearlman, 1996
Compassion Fatigue Self-Test Figley, 1995
Maslach Burnout Inventory Maslach, 1996
Secondary Trauma Questionnaire Motta et al., 1999
Professional Quality of Life Scale (ProQOL) Stamm, 2004
Self-report Posttraumatic Stress Disorder Scale (PSS-SR) Foa et al., 1993
You might be interested to have a look at these questionnaires…….
1.Compassion Satisfaction/Fatigue Self-Test for Helpers http://casat.unr.edu/docs/testa-smith.mary_ya.wa_08.pdf
2.Burnout self-test http://www.mindtools.com/pages/article/newTCS_08.htm
3.Stress and Burnout Questionnaire http://msd.org.au/wp-content/uploads/2010/03/Stress-Inventories.pdf

Some reflective questions regarding 
trauma related
 
clinical practice

  1. How am I doing?
  2. What would I like to change in the way I am working?
  3. What worries me most?
  4. Have I changed since beginning this kind of work?  If so, in what way both positively and negatively?
  5. Am I experiencing any signs of vicarious trauma?
  6. What is my sense of achievement in the work that I do?
  7. How do I take care of myself?  What might I need to change to take better care of myself?
  8. What supports do I need and what can I draw on from my workplace/colleagues, social supports/supervisor?
  9. What might be the first step I can take in order to access supports?
  10. Is there anything else I need to know about (theory) or skills, that I might need that would help me better manage the work that I do?  Where might I access this?
  11. Are there any personal issues that I need to address?
  12. Do these issues impact on my therapeutic work?
  13. How do I create a balance between caring too little and too much?  What is the right balance?
  14. How can I continue my professional and personal growth in order to allow me to continue the work that I do with my clients?

Simple steps for self-care in

trauma informed practice
  1. Become alert to signs of initial vicarious traumatization.  Notice your emotional temperature reading and chart when you approach the ‘red’ zone,
  2. Engage in self-care behaviours within the workplace such as brief mindful breathing between clients and taking breaks,
  3. Develop a ritual for the transition between work and home…..leave work in the office,
  4. Engage in positive activities that nurture physical and mental well-being,
  5. Set realistic expectations within the work that you do with clients.  Know your limitations and recruit other support services,
  6. Remind yourself that this is the client’s journey and you are not in a position to take responsibility for their healing.  There will be times that you are not able to ‘fix it’
  7. Balance your caseload and workload,
  8. Respectfully use your emotions within the therapeutic context as this makes meaning  of the therapeutic process for clients,
  9. Monitor your personal limits,
  10. Seek collegial support and supervision.
 
"At every moment, by our actions, we are choosing who we are being.
Our existence is never fixed or finished,
every one of our actions represents a fresh choice"
 


Jean-Paul Sartre.
I hope that you have found this newsletter interesting and relevant to your work.  Please don’t forget to let others know about the newsletter and pass it on if you think they might find it helpful.  As always, I would be interested to hear from anyone who would like me to cover anything specific in my next newsletter.
Christine
References

Bell, H., Kulkarni, S., & Dalton, L. 2003.  Organizational Prevention of Vicarious Trauma, Families in society: The Journal of Contemporary human Services, 463 – 469.
Berger, R., & Quiros, L. 2014. Supervision for Trauma-Informed Practice. Traumatology: An International Journal,
Bertrando, P., & Arcelloni, T. 2014. Emotions in the Practice of systemic Therapy, Australian and New Zealand Journal of Family Therapy, 35, 123 – 135.
Etherington, K. 2009.  Supervising helpers who work with the trauma of sexual abuse, British Journal of Guidance & Counselling, 37, 179 – 194.
Harrison, R., & Westwood, M. 2009.  Preventing Vicarious Traumatization of Mental Health Therapists: Identifying Protective Practices, Psychotherapy Theory, Research, Practice, Training, 2009, 203 – 219.
Meichenbaum, D. 2006.  Resilience and posttraumatic growth: A constructive narrative perspective. In L. Calhoum & R. Mahwah, (Ed.)., Handbook of posttraumatic growth : Research and practice, (P: 355- 368). NJ. Lawrence Erlbaum Associates.
Patsiopoulos, A., & Buchanan, M. 2011.  The Practice of Self-Compassion in Counselling: A narrative Inquiry, Professional Psychology: Research and Practice, 42, 301 – 307.
Pross, C. 2006.  Burnout, vicarious traumatization and its prevention, Torture, 16, 1 – 9.
Van Berckelaer, B. Using Reflective supervision to Support Trauma- Informed Systems for Children, A white paper developed for the Multiplying Connections Initiative, http://www.multiplyingconnections.org/sites/default/files/RS%20White%20Paper%20(Rev%206--11)_0.pdf
The Supervision Quarterly is brought to you by
Christine Senediak of Clinical Supervision Services (CSS).

Email: clinicalsupervisionservices@gmail.com
Web: www.clinicalsupervisionservices.com.au
All articles by Christine Senediak. Copyright Clinical Supervision Services 2014
Copyright © 2014 Clinical Supervision Services, All rights reserved.


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