Addressing Burnout, Secondary Traumatic Stress & Vicarious Trauma CEU

I'd like to welcome everybody to today's presentation on addressing secondary traumatic stress and vicarious trauma. I'm your host, Dr. Donnisee Snipes. Today, we're going to distinguish secondary traumatic stress, vicarious trauma, and burnout. Burnout is not the same thing. Interestingly enough, we use those terms interchangeably, but they're not necessarily the same thing. We'll identify sources of secondary traumatic stress and vicarious trauma for clients, significant others, and therapists and identify risk factors for vicarious trauma and then obviously what to do about it. Burnout is a condition that results from occupational strain. When your job is just pulling you six different directions, making unreasonable demands, giving you case loads that are just incredibly difficult that can lead to burnout. However, we need to remember that people don't exist in a vacuum. So, what constitutes occupational strain? What constitutes a really difficult work environment for one person is different than what constitutes occupational strain for another person partly based on how much stress they've got going on in the rest of their life. Going back to that stress bucket, the person who has a relatively empty stress bucket can handle more crap at work than somebody whose stress bucket is already half full. Trauma is the direct experience or witnessing of a traumatic event. Traumatic stress is the stress response to a direct trauma. Traumatic injury refers to the ways the traumatic stress continues to negatively impact any piece of your life. People can experience a trauma and have traumatic stress and resolve that stress without developing additional um traumatic injury symptoms like flashbacks and nightmares and depersonalization. I do like to separate that out because a lot of people assume that when you have been exposed to trauma that you're naturally going to have acute stress disorder, PTSD, what have you. And that's not true. Vicarious trauma and secondary traumatic stress are often used interchangeably in the literature. Okay, that's fine. However, when we get down to literal definitions, vicarious trauma occurs when the person experiences the trauma through empathetic connection. We are connecting with our patients in session and we are getting into the well with them so deeply so to speak that we start experiencing distress. And I have talked about empathy and sympathy before, but for those of you who haven't heard the analogy, um, empathy is when you see somebody down in a dark, cold well, they're scared and, you know, they just really want help. You can't get them out. But what you can do possibly is strap on some repelling gear and go down into the well to sit with them. What's the difference? You can pull yourself out before you get overwhelmed. You can pull yourself out before you get hypothermic. You have the ability to pull yourself out before you start experiencing significant traumatic stress and possibly traumatic injury. But vicarious trauma comes from empathetic connection. Secondary traumatic stress is the stress response resulting from knowing about a traumatizing event experienced by another. And again, see, you can see how these can overlap. If you're empathizing, then you obviously know about it. But you can also know about a traumatic event such as um the survivors of Hurricane Katrina or Hurricane Harvey or you know name a disaster. We saw it on television. We saw the people. We saw the suffering. And some people really were impacted internally by seeing that distress. they could put themselves in that person's position. So, they were kind of empathizing, but it wasn't like you were interacting with the person. Ultimately, we're kind of splitting hairs here, but I did want to clarify the definitions. Compassion fatigue. Oops, I'm sorry. Secondary traumatic stress occurs in approximately 11.29% of people. It's not an uncommon thing to happen. And so one out of every 10 peopleish may experience secondary traumatic stress. Think back to 9/11. Think back to Katrina. Think back to some other disaster. Um even the hurricane and of course I blocked it out of my mind. Uh the name of the hurricane that hit North Carolina and Tennessee. Seeing the suffering and feeling helpless to do anything to improve or help relieve the suffering can be maddening, especially because we were trained, we went into this field because we wanted to relieve suffering. And it can be devastating to feel like you're stuck on the sidelines. Vicarious traumatization can be measured sort of by the vicarious traumatization questionnaire which assesses the person's current level of secondary traumatic stress. See, I told you these words get kind of lumped together. The VTQ measures physical and behavioral responses, emotional responses, cognitive responses, and life beliefs. That's great. It doesn't measure interpersonal and in intrapersonal behaviors such as withdrawal. Environmental and spiritual impacts of the trauma are also not measured. I think that's important that we consider, but the VTQ is currently the preeminent assessment for vicarious trauma. I did look for over an hour, maybe longer than that, to try to find a PDF of the VTQ and I could not find it. It is used regularly in the research, so it exists, but you're probably not going to run into it. Um, my point in including it is to let you know that there is a questionnaire out there and, you know, you might be able to find it. when we talk about burnout. Um, and this can also apply to secondary traumatic stress. It's important to recognize it doesn't happen overnight. And this model was taken from the police trauma stress disorder literature. and which was kind of neat because I got to go back into my dissertation from 2000 to pull out some research and you know uh but with law enforcement they start out as a rookie. They are optimistic. They're going to save the world. Obviously they went in to help people. After a little while they start feeling like what they're doing is not doing any good. So they tighten down and they become the John Wayne. They become badgeheavy adrenaline junkies as they say. Um when that doesn't work because there's always going to be crime. There's always going to be stuff going on. Some of them get to the point where they feel like they're not making a difference and they move into professional control or what we sometimes call retired on duty. They just do the job. They respond to the calls. They do what they got to do and they move on. They are often emotionally divorced from it. After a while, they move into burnout because it's just day after day of same stuff, different day, not making a difference. What's the point? And oh, by the way, um we don't get a lot of appreciation and we're not paid very well. Okay, so that's the police trauma stress disorder model. Let's look at it in terms of counseling. The new clinician, those of you who've worked with interns or people who are working on their postmasters hours, they are optimistic. They are eager. They are excited. They think they can help everybody. And when they realize that that's not necessarily the case, then they may devolve into what I labeled the rescuer. They start trying to fix people. Instead of allowing people to fix themselves, they start trying to take more control, try to fix people, try to make it work. When that doesn't work, they uh for everybody or enough people, they move on to just doing the job. And this is especially true if they've got high case loads, especially high intensity case loads. Eventually, it's just like I I just I don't have the energy to deal with 15 people that have PTSD and borderline personality. I just don't have it in me. So, they move into just doing the job. I'm showing up. I'm doing my groups. I'm doing my individuals and my notes and I'm going home. Over time, that's still exhausting. They're still exposed to hearing about trauma. They're still exposed to the stresses at work. They're still exposed. And it erodess their energy and their optimism and can lead to secondary trauma. And we want to recognize where we're at. I remember and I think a lot of us can think back and remember when we were that new clinician. We were we thought we knew everything and we were going to change the world and then very quickly we found out uh-uh especially if you worked in addictions in my opinion um it seems like that can be sort of a more a rder awakening in some cases because you see people relapse and come back through a month later, three months later. I know I took that personally and I started to get really down and my supervisor in in one of our sessions we were talking about it and he said, "All right, what are your expectations?" And I said, "Uh, I'm expecting to help them move into recovery and stop using." and he sat back and put his hands across his belly and kind of shook his head and laughed and said, "That's part of your problem. You're working with people who are often in pre-contemplation or contemplation, and you're expecting not only to move them into action, but through action and into maintenance in 30 days. That's not possible. You need to adjust your expectations." That helped a lot for me to reduce my stress and reduce my feelings of failure when people would relapse. um we would take it as a learning experience and helped me a lot to I think to not progress further in that burnout secondary traumatic stress uh whatever we're going to call it. So let's talk about domains of impairment and most of us can probably check these off. sleep disturbances. You lay down, you start thinking about a client, be pondering it, ruminating on it, or you wake up in the middle of the night thinking about a particularly difficult case, worrying about if somebody is safe. Um, so we start having increased sleep disturbances and part of it is recognizing and setting boundaries and recognizing the client's autonomy to make certain decisions. Uh, increased pain. The more stressed we are, the more we actually feel pain. our nosioceptive, our pain receptors become more sensitive and we actually feel more pain. Our gut m microbiome gets disrupted. Those little critters in your gut do not like stress and as the pH in your gut changes, so do the microbes. There's possible alterations in your thyroid and gonatal hormones. So you may have less energy, you may have lower libido, hypervigilance may increase and this is later in the process for a lot of people. Um but hearing about traumas, hearing about uh dangers that people have experienced or traumas that people have experienced may make you hypervigilant. Maybe you start becoming more protective, more of a helicopter parent over your elementary age child because you're worried about their safety. You start changing your beliefs about the goodness of human beings. Exhaustion. Well, sleep disturbances, increased pain, altered thyroid. Yeah, those are all going to contribute to exhaustion. It just it does. And when you are ruminating, your brain uses a lot of energy. When your brain is constantly on, that doesn't allow it to shut down to activate deep sleep. So, when people are stressed, especially if they're hypervigilant, they often have disrupted sleep architecture and they're not clearing out those toxins. And some people may turn to substance or behavioral addictions. Substance use or misuse is obvious, I guess, but other people may choose more socially acceptable addictions such as shopping or scrolling online, um getting on Tik Tok and staying on there for 4 hours, playing games on their mobile device for hours on end to avoid having to think, to avoid having to connect with other people because they just don't have it left in them. Interpersonally, we may see over involvement with the survivor, with the client, or sometimes under involvement. Sometimes the clinician will want to help. They'll want to fix it. They'll get all up in that client's business to try to help them fix it instead of empowering them to take the steps themselves instead of promoting autonomy. Under involvement often again comes later in the process when the therapist just doesn't have the energy and you know I'll hand you a list of resources, call them if you want, whatever. Good luck. The reduced ability to trust others and questioning the goodness of humanity. Impatience. Well, if we're in pain, if we're hypervigilant, it's hard to be patient. It's hard to hear a client say, "Yeah, I know I was supposed to blah blah blah, but I didn't." And therapists can start feeling irritable and impatient with clients for failing or for being resistant. Again, behavior is communication. Why are they not engaging in that behavior? Um, that's a whole different class. and they may withdraw from peers. [snorts] Most of the time when people start experiencing secondary traumatic stress, they don't want to hear about other people's cases. They don't want to hear about what's going on at another agency or what have you. It's just I'm overloaded with what I've got to do to do my work right now. Intrapersonally, there's reduced self-efficacy when therapists are regularly hearing about trauma, especially if they are not feeling like they're making a difference or not a a big enough difference, they may have reduced self-efficacy. Even if they are making a difference with every single one of their clients, just the neverending litany of people coming in with trauma, it feels like we can't make a dent in improving the health and well-being of society, which a lot of us have set as one of those goals. Possible obsession with regaining control intrapersonally. thinking about how to fix somebody's PTSD and reduced self-esteem. When a person doesn't feel like they are accomplishing what they set out to accomplish, they may and when they start withdrawing from others, not having energy to spend with their kids, feeling like they're not doing what they need to do or could do at work anymore. That self-esteem may go down. Emotionally, we often see anger and irritability devolve into depersonalization and emotional numbing. Cognitively, problem solving difficulties. Well, yes. Stress. When people are experiencing secondary traumatic stress or burnout, which is a form of stress, what do we know? When the stress response is active, the energy and resources necessary to think clearly are being shunted from the preffrontal cortex to other areas of the body to help us fight or flee. So, yeah, we're going to have executive dysfunction and problem solving difficulties. We're going to have difficulty paying attention and concentrating in session. Even if the client is doing everything right, we may have difficulty focusing. But especially if the client is not doing everything we want them to do. You know, they're not letting us control them like puppets, we may start to get frustrated and check out. We start ruminating on our own frustration. Well, if you would have done what I told you, if we notice we're saying that to ourselves in session, we need to check it. Pessimism. Cognitively, people as they become more burnt out become more pessimistic. Everybody has trauma. You know, instead of thinking, you know, maybe everybody on my case load has trauma. people start feeling like everybody in the world must have trauma because that's all I see every day. And intrusive thoughts and images when you've heard details of traumas um sometimes intimate details of traumas. It's not unusual for you to at some point have intrusive images. you can actually visualize that traumatic event happening. Um, if you saw it on TV, obviously you can visualize that happening. And those intrusive thoughts can become overwhelming. They increase our stress. They make us feel unsafe in our own head. I mean, it's a PTSD symptom. We know this. Environmentally, people often experience a reduced sense of safety. Again, hearing about all this trauma, it feels like the world is wildly unsafe. Spiritually, and we don't often talk about spiritually here, but spiritually, as clinicians, we may experience a loss of meaning and purpose for the job. Why am I doing this? How is this contributing to me being who I want to be? How is what's the purpose of me working going to work and doing this? How am I making a difference? And when you lose meaning and purpose, you often develop a sense of hopelessness. And obviously, most people are not going to have every symptom. Some people are going to have one or two symptoms that are really intense. Some people may have 10 symptoms that are moderate. We're not um competing here. What's important is to recognize when your job, what you're doing, your interactions with other people through your job are negatively impacting you. all pe any or all pieces of your life. Risk factors for secondary traumatic stress. If you've got a personal history of trauma, they've shown that it is much more likely that you may develop secondary traumatic stress. And there's some neurobiology behind it regarding the priming of the amygdala and all that other stuff. We're not going to go into that right now, but suffice it to say, and a lot of us do have a personal history of trauma, makes us more vulnerable. It doesn't mean we can't do the job, but we need to recognize that we may need to give ourselves a little more self-care. A personal history of mental illness or addiction. When you're hearing about other people's mental illnesses, traumas, addictions, it may be more triggering for you. Current stress load. If that stress bucket is already filled up or mostly filled up, then it doesn't take hearing about much trauma. It doesn't take much organizational stress to make your bucket overflow. close identification with the victim. And this one makes sense, but we don't talk about it a lot. If you are working with somebody who has a child who, heaven forbid, drowned in their swimming pool and that child was 5 years old and you've got a fouryear-old at home, it is much easier for you to empathize. is you can envision your own child in that position. And sometimes those intrusive thoughts, you hear about it from your client, but then you start having intrusive thoughts about it happening to your own child and you're you're superimposing, which is super stressful. I mean, you see your own kids struggling or suffering and, you know, it triggers every mama bear hormone that you've got or papa bear hormone. Um, proximity to home or safe spaces. A lot of times we like to think that bad things happen to them and the the trauma stays over there, the violence stays over there, bad things happen to them. But if your client is talking about something that rings true um or hits close to home, as they say, then you're at greater risk for secondary traumatic stress. For example, um when I was at the University of Florida, I always thought that colleges were safe and you know, 9 10 o'clock at night, I was out jogging with my headphones on, whatever. my my uh sophomore year, we had a serial killer and on campus and it was terrifying because that was supposed to be something that happened out there, not on our campuses. Um, when you hear about somebody who is very similar to you in some way, maybe they're a parent, maybe they're a therapist, maybe they live in a neighborhood that's similar to yours, uh, m like if you live in a gated community and they live in a gated community and they're they experience a home invasion, then it can trigger more of a stress response because you feel more kinship with them in some ways being aware of this that's okay you know knowing and separating I'm safe my house is safe that's not happening now obviously if something happens to your neighbor yeah that's really hitting close to home that is actually your home space but again recognizing what aspects are different between you and your house and your neighbor. Another interesting one, if you have high empathy, which I think a lot of us do, and perspective taking with personal affective distress and and this is one of those interesting things that has to do with sort of that repelling gear, high empathy and perspective taking. you go down in that well, you're feeling the cold, you're in the dark, but you know you can get out. So, the personal emotional distress is a lot lower. But for somebody who actually puts themselves into the shoes of the person, um, sort of without the repelling gear, it can be a lot more impactful. And recognizing how much affective distress you have during and after a session is important. Some of them are going to hit closer to home and it's and trouble you more effectively in which case you know you're really working that stress response system. It's going to be important to downregulate and to take greater steps in self-care in the short term. recognizing that you burn through a whole lot of energy, empathizing, and through your own distress. And it's going to be important to allow yourself to recover. Think of it like running a marathon. You wouldn't run a marathon and get up the next day and think that you're going to feel great and everything's going to be hunky dory. Disruption of social support. Another risk factor. If you don't have social support, your spouse doesn't want to hear about it. You know, even, you know, avoiding PHI, your spouse just isn't interested in your job. You don't have friends at work that you can decompress with. You don't have adequate supervision where you can decompress or um downregulate, it starts to be a problem. And we do need to have people that we can call, other clinicians that we can call and run stuff by. Again, we don't have to give out PHI, but saying, "I do have this client and I'm going through this right now. I'm feeling really stuck." Or what have you, you'd be amazed at how much it helps to have another therapist go, "I think you're doing everything you can." or you know when you see them next, I wonder what would happen if you tried this. And that can spark an aha moment and give you a little bit of hope when you're feeling stuck. People with low psychological resilience obviously are at greater risk. If you're already worn down and exhausted and having difficulty bouncing back from life, then you're going to be at greater risk. Regret and denial are also risk factors. If you regret things that you said or do with a client or if you deny how much the uh interactions are impacting you, it's going to sneak up and bite you in the butt. Burnout can also increase susceptibility to secondary traumatic stress due to cognitive inflexibility and resource depletion. If your work environment is intense, nice euphemism, intense, unsupportive, uh, etc. If your work environment is one that would stress anybody out, and you're also seeing high acuity clients, then it's a recipe for disaster. the burnout work environment already fills your stress bucket up quite a bit than hearing the traumas having to think because I mean it's not counseling is not easy we don't just sit in there and listen and go along to get along we're thinking we're processing we're connecting we're exploring and that takes a lot of energy and if you've already expended your energy getting upset over some stupid policy change, then you don't have energy left and you're going to start feeling even more vulnerable. things that can cause burnout. High trauma case loads and these are structural or organizational issues. High trauma case loads, lack of social or organizational support, excess work, long hours, night or rotating shifts. And night shifts work against our natural circadian rhythms, which means the person's if they keep that schedule seven days a week, they're still fighting their natural rhythms. Little bit easier on them. But if they work night shift and then on their days off they're keeping normal hours and then they go back to working night shift, their circadian rhythms are constantly screwed up and that increases stress on the body. It increases inflammation. It disrupts sleep architecture. It does all kinds of stuff to deplete your energy and your resources and make you more vulnerable. Rotating shifts aren't much better. Your body likes a a steady routine. Even if you are a spontaneous person, your body likes to know when it's going to work, when it's going to sleep, when it's going to wake up. Uh if you are working the 8 to four shift three days and the 4 to 12 shift two days, your body's like, "Okay, we were, you know, by 10:00 when you're at work, your body's like, "Okay, we were supposed to be in bed already." Um unclear scope of work or role ambiguity. At my old place of work, we had something called PODS, performing other duties as assigned. And I think PODS took up about 60% of our time and 40% was spent on like actual counseling and documentation. Um when that happens, when you've got um creep and other things start creeping in that you're expected to do, you're expected to write grants, you're expected to do this, that or the other, it can start taking up a lot of time and then you're exhausted. You know, you're stressed all the time. There's always stuff in the inbox. you don't feel like you can get everything done. You don't feel like you're giving enough energy and time to your clients, which is the whole reason you're there. And it starts to wear on people. Um, dissonance between ethics, expectations, and actual policies. um you're in an organization that says every person that you assess will have a diagnosis and will be assigned to some sort of treatment even if it's just adjustment disorder. Now ethically that that's not not um and we need to be able to rectify that. We need to be able to address it with human resources, with whomever to point out the disparity between what the policy is and what our ethical obligations are. an absence of secondary traumatic stress informed organizational activities, self-care days, wellness fairs, um downregulation groups. Some organizations actually encourage therapists to get together once a week for an hour and just decompress and process what's been going on. Adequate supervision. Um, every place I've worked, I wish I could say that was an exaggeration, but no. Every place I worked has lacked supervision. Even when I was working on my postmasters hours, if I needed Well, when I needed my weekly supervision, I would have to go track down my supervisor and basically wrangle him in order to get my hour. not because he was, you know, incompetent or irresponsible, but because he had an unclear scope, role ambiguity, and too much to do already. Uh, for a lot of people, the supervisory stuff um especially super supervision of, uh, postmasters interns is something that falls under other duties as assigned. And to do that right takes a lot of time. And a lack of job satisfaction. This was number one in some studies. Even if it's a relatively decently working workplace, if the individual is not experiencing job satisfaction, if they're not deriving meaning from it, if they're going to work and saying, "Why am I here?" they are at much greater risk for secondary traumatic stress. So, let's talk about protective factors. What do we do? Because this is what you're interested in. The earlier stuff was to help you recognize some of the symptoms as well as identify some of the risk factors that you may not be aware of. All of this, I think, is super important for your postmasters interns because I can tell you most of them are probably not getting this information when they are in graduate school. And a lot of my uh supervises very quickly start feeling completely overwhelmed. They're like, I can't know everything I need to know. I can't I don't feel like I'm ever prepared to work with a client because I don't know all the techniques to handle anything that they throw at me. And you know, backing it up and reminding them 80% of progress is from the relationship, not from the techniques that can help with down reggulation. But you have to have a a supervisor there to say that. um and and encouraging supervisees to be aware. Having a history of trauma or depression or anxiety or addiction, that's not a deal breakaker at all. In some ways it can make you able to empathize more but it's important that when you empathize you still maintain that boundary and you don't over empathize with them or take on so much that it starts triggering those issues again. So anyway protective factors resolution acceptance is protective. Well that sounds good but what in the world does that mean? radical acceptance. Accepting that you've done the best you can. You are you've provided the client the tools and resources they need to the best of your ability and you are empowering them to take the next steps recognizing that you cannot control them. We're not paternalistic. We're not going to tell them what to do. We're not going to do it for them. We we need to resolve in our own mind that we've provided them the resources and tools and the stuff they need and accept their choices. That's hard. That is really hard for me when I first started out and I would be working with a client and they'd be doing really well in their in their sobriety and then they would relapse. I would feel like it was my fault, like I failed them somehow. And again, we go back to my supervisor who said who would say, you know, tell me what you did with them. You know, what tools did you give them? What things did you process? Let's look at your progress notes. and recognizing encourage me encouraging me to recognize that I was working with adults who were mentally competent and I had to accept choices they made even if they had all the resources and information to point them in a different direction. That can be protective. Being able to step back and go, I did my God's honest best. Emotion regulation, super important. Being able to slow your breathing. Remember I said those who who are more effectively burdened by empathy tend to be at higher risk for secondary traumatic stress. If you can regulate your emotions in session, that's super helpful. But definitely if you feel really overwhelmed and distraught after session, being able to take a break and downregulate, you've got to turn that stress response down. If you go into your next session and your stress response is up here, you're not going to think clearly. You're not going to concentrate as effectively. You're not going to problem solve as effectively. you may end up feeling more ineffective and you're just burning out, burning through all that energy. Taking that extra time to go to the bathroom or go to the breakroom, go outside even even better if you can go outside. We used to have squirrels um on the campus that I worked at and I would go outside and feed the squirrels. that made me happy and helped me downregulate and refocus. Self-compassion can blunt the effect at high exposure levels. Not telling yourself, I shouldn't be this upset about this or I should just let this go. What would you tell a client who was shoulding themselves? That's not going to help. having compassion for yourself that you're a human being and you're noticing and recognizing the suffering of another human being and that's natural. It can feel overwhelming. It can suck sometimes but it is a natural response and you have the ability you have the skills to downregulate and process through. Sometimes we have to process through and I think I'm getting ahead of myself but process through our own grief about we we hear these things and we have to grieve sometimes for the client sometimes it changes our worldview and we have to grieve the loss of our own worldview. But self-compassion tells us that that's okay. Self-compassion tells us it's okay to grieve. It's okay to be angry. um it's what you're going to do with it that can be helpful or problematic. Being mindful of your personal needs, limits, and resources at any given time. What your needs, resources, and limits are today may be different a month from now. You know, we talked in other classes. Most of you know that I went through a a a spate where we had two animals die in close succession. And my animals are near and dear to my heart. And I was done. I was devastated. I kind of walked around in a fog for about six weeks. And knowing that my needs, limits, and resources were com, you know, very different then than they are today was really important. So I didn't push myself too hard and overstep over overflow my stress bucket. Hardiness, one of my favorite tools, proposed by Kabasa in 1978, um encourages us to focus every day, maybe multiple times a day, on all of the things that are important to our rich and meaningful life. The things that we're committed to in our life, our family, our health, our job, our clients, you know, whatever. Focusing on what is important in our rich and meaningful life. That's what we're committed to. Identifying what aspects of those things we can control and using our energy, investing our energy in the things we can control, not the things we can't control. That includes nurturing the positive, not just ameliorating the negative. And viewing obstacles as challenges. Problems come up, they're going to come up. viewing it as a challenge. I have this client right now that is seems to be on a plateau and they don't see they seem to be very resistant. Hate the word going to use it. Uh resistant to doing anything to change their situation. I feel stuck. Okay, that's a challenge. Now, how do I use my energy to address that in a way that helps me move toward what's important in my rich and meaningful life? For me, what I would do in that situation is talk to the client about what's going on that's causing their resistance? Do they not believe in the process? Do they not see a problem? Do they not have the skills? [cough] Do they just not have the internal capacity to do one more thing right now? Um, do they not know where to start? Or do they not have the self confidence that even if they did start, it would do any good? Connection to self, others, and something greater was cited in the literature. And not all of you have faith in a higher power and I can respect that. Um, however, connection to your rich and meaningful life if nothing else is important because that's where you want to go. Those are the things that are important and connection to that. Everything you do uses your energy to either move you toward that and the things that are meaningful or away from that. [snorts] varied work activities. This is something your occ your job can do. Some days you're doing assessment, some days individual psychoeducational groups, administrative work. I find for me that I lose effectiveness in my ability to focus after about four hours of individual. I need to do something else. I can do a group and then I can go back to doing individual or what have you. But if I do more than four hours of individual straight, my brain is fried. Same thing is true for assessments because I really try to understand what's going on in the assessment. It's not just paperwork. And I find that I need to finish out the day with something else. If your organization can arrange that or can allow you to arrange that, that is super helpful. Um, veagal control and mini breaks are really important. Working on developing skills where you can actually trigger your vag nerve and downregulate. Mini breaks are those breaks you take throughout the day. Um, I usually do them every time I go make a cup of coffee while the water's warming up in the microwave. I will practice slow breathing or I will massage my tragus in order to activate my vagus nerve and I will notice how my heart rate goes down. Going out into nature, they've shown reduces cortisol and alters blood pressure and everything else. That's another thing that I do when the weather's a little bit nicer. But taking these mini breaks throughout the day allows your nervous system to downregulate. Think about driving a car. And if you're driving a car and you know, pedal to the metal for eight solid hours, that engine block is going to get pretty hot. Um, if you periodically take breaks to allow everything to cool down, you know, it's easier on the car, you're not stressing it quite as much. develop specialized skills such as EMDR or IFS, internal family systems theory, to address some of the issues that your clients bring to you that are heavy. Um, that way you feel like you are more equipped to address some of those heavy issues. Set realistic goals. And that goes back to what I was talking about earlier. Don't think that somebody is going to come to you and in three weeks they're going to be skipping down the sidewalk. It ain't going to happen. Uh set realistic goals. Not only does this help you and your own sense of self-efficacy and mental health, but it helps the clients. If you work with clients and you're setting a treatment plan that is unrealistic, they are going to feel unsuccessful, defeated, hopeless. What is realistic for this client and you to expect to change? What how much progress is realistic to expect in the next four weeks? and really set those realistic goals and not expect perfection, not expect fixed. Actively use consultation, support, and debriefing. if your um organization isn't about having those meetings where people can get together and debrief. Okay. Um there there are a couple organizations I've heard of that actually have a uh debriefing line where clinicians any any staff member um but including clinicians can call in and talk to a peer um anonymously and debrief what's going on. still talking to somebody in the organization so you don't have all kinds of HIPPA issues, but um that has been helpful for some. Increase awareness of and address the grief that you're experiencing. And remember, grief is denial, anger, sometimes bargaining, depression, and acceptance. And for some of us, we deny the problems really. We deny that what the client's talking about is really bothering us. You know, it's just I deal with this every day. It's not that big of a deal. Once you move past denial and realize that, you know what? I'm freaking angry that this happened to this person or that this could happen to any person. Okay? Recognize it. Process it. Depression. I feel hopeless and helpless to change the world. I can't prevent this from happening to everybody. What can I do? Increasing your awareness of how clients issues are impacting you and sometimes organizational issues are impacting you and using your energy to address the threats, address the problems in a way that's meaningful. What aspects of it can you control? Now, organizations are notoriously difficult to change or to control. However, you can potentially make a suggestion to human resources and make one small change that could start the ball rolling. For example, engage in advocacy activities. if you're working with a lot of um trauma victims. When I when I was much younger, I worked for um the child advocacy center and we had a grant for child victims of crime and every client that I had on my case load was a child victim of usually sexual abuse, but sometimes physical abuse. and you know that that takes a toll. Um, engaging in advocacy activities for child welfare helped me feel like I was doing something to address the bigger issue, not just the the person, the child that was right in front of me. Work with your organization to ensure that clear, reasonable, and stable expectations are provided. You don't want the goals to be on goal uh the goalpost to be moving all the time. You want it to be this is the number of billable hours you have to have. These are the things you're expected to do, what have you. If it seems like those change, it's important to address it with your supervisor. A good middle manager works as an advocate for you between line works as an advocate between line staff and senior management. Maintain or try to encourage the organization to maintain reasonable case loads based on intensity and acuity. When I was assigning clients to people in my residential program, I wouldn't give all of the trauma cases to one person because that would have been overwhelming and they probably wouldn't have been able to provide adequate treatment to all of them. So, I would break it up. Everybody would have a couple trauma clients. Everybody would have a couple of things. If I had a client that I knew was particularly intense, that clinician's case load may be reduced. Instead of having 15 on their case load, I may drop them down to 10 so they had the time to address it and maintain their own mental health. Work for environmental safety and acceptance. Educate everybody in the organization, not just the clinicians, about vicarious trauma and signs of burnout because this impacts the front desk staff. It impacts medical records and impacts nursing staff. It impacts everybody. Ensure staff has access to training and consultation and is appropriately trained. They have to start out at a base level of training that is adequate. Identify and address sources of employee dissatisfaction. Suggestion boxes can be really helpful. Promote a flow of clear communication both ways between li line staff and seuite. Often goes through the middle manager, but that's okay. Ensure feedback is delivered in a constructive manner, not a punitive or critical manner. Encourage the practice of self-care among all staff and ensure access to traumainformed employee employee assistance. Evaluate employee deficits through a traumainformed lens. If Jon is not getting his paperwork done or maybe Jon is spending too much time doing counseling, not enough time doing administration, that's usually one of the bigger problems. Why is this? And it could be that John clinician is feeling helpless, feeling traumatized and is getting over involved with the clients um which is keeping him from doing his work. So we need to use a trauma-informed lens and recognize that this work can be traumatizing and use care in case assignments for employees that are at risk. If you have somebody who's going through a messy divorce or when my when my husband um or when my son was born, he was in the neonatal intensive care unit for a couple of months and it was a godsend that his supervisor said, "You know what? You've got a lot going on. Do what you need to do. Take the time you need." and really cut back on his assignments some during that time. That went a long way to helping us cope with what was going on. Counseling and social work can vicariously expose people to trauma on a regular basis. Clinicians who are already experiencing burnout are at greater risk of secondary traumatic stress and injury. Burnout and secondary traumatic stress both contribute to turnover and worse patient outcomes. Prevention and intervention must be a joint effort between the clinical staff and the organization. Are there any questions? Simply me, you're very right. Overloading the senior therapists or the more skilled therapists and underloading or giving the newer therapists the easier quote unquote case load just burns out the senior therapists. What we need to do is have the acuity spread across and the intensity spread across therapists so the senior therapists can mentor the newer or less experienced therapists. And you're right, Courtney, it is extremely hard to hear what some clients are going through or have gone through. Um just imagining and empathizing can be traumatic. Everybody have a fabulous rest of your week. Remember those mini breaks and self-care and I will see you next Wednesday.