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A Person-Centered Approach to Clinical SupervisionJamie Marich, Ph.D., LPCC-S, LICDC-CS

+About Your Presenter

LPCC-S, LICDC-CS (Ohio) EMDRIA-Approved Consultant Outcomes-Based Training with the International Center

for Clinical Excellence Author, Qualitative Researcher Thirteen years of experience in a variety of human

services venues Began career as humanitarian aid worker in Bosnia-

Hercegovina (2000-2003)

+What Are Your Needs Today?

+Objectives To identify and discuss common problems in supervising

counselors/clinicians To address these commonly identified problems using a person-

centered approach To explain what the psychotherapeutic professions reveal about

the importance of empathy and therapeutic alliance in treatment (regardless of specific method or model)

To apply these principles of empathy to the practice of clinical supervision

To utilize motivational interviewing approaches with resistant supervisees

To assist others in developing both work plans and self-care plans

+Supervision vs. Consultation

In general, supervision carries more ethical responsibility in terms of licensure boards, legal issues, etc.

Both can involve a gatekeeper function, depending on the nature of the consultation sought

Both have similar approaches in terms of using the person-centered model

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What does empathy mean to you?

+Empathy Coined by the German philosopher Rudolf Lotze in 1858

The German word, Einfühlung, translates as “in” + “feeling”

Derives from the Greek empatheia, meaning “in” + “pathos” (feeling)

Pathos is also the root of “passion” and “pain”

+EmpathyDirect identification with, understanding of, and vicarious experience of another person's situation, feelings, and motives.Stedman’s Medical Dictionary (2002)

+The Rogerian View of Empathy

“Being empathetic reflects an attitude of profound interest in the client’s world of meanings and feelings. The therapist receives these communications and conveys appreciation and understanding, assisting the client to go further or deeper. The notion that this involves nothing more than a repetition of the client’s last words is erroneous. Instead, an interaction occurs in which one person is a warm, sensitive, respectful companion in the typically difficult exploration of another’s emotional world. The therapist’s manner of responding should be individual, natural, and unaffected. When empathy is at its best, the two individuals are participating in a process comparable to that of a couple dancing, with the client leading and the therapist following.”

(Raskin & Rogers, in Corsini, 2000)

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Can this be applied to supervision ?????

+From Irvin Yalom Therapy should not be theory driven, but relationship driven (The Gift of Therapy, 2001)

The Every Day Gets a Little Closer experiment (Yalom & Elkins, 1974)

+Complex PTSD & Therapeutic Alliance According to client experience, the quality of therapeutic alliance between client and clinician is an important mechanism in facilitating meaningful change for clients with complex PTSD (Fosha, 2000; Fosha & Slowiaczek, 1997; Pearlman & Courtois, 2005)

+The Imperative of the Therapeutic Alliance Using a collection of empirical research studies and chapters from the psychotherapeutic professions, Norcross (2002) demonstrated that a combination of the therapy relationship, together with discrete method, is critical to treatment outcomes.

Norcross further concluded that relational skills can be honed by therapists, and that it is the therapist’s responsibility to tailor these skills to the needs of individual clients.

+The Imperative of the Therapeutic Alliance Norcross’ contentions also supported by the massive literature reviews that appear in The Heart and Soul of Change: Delivering What Works in Therapy (Duncan, Miller, Wampold, & Hubbard, 2009)

+The Common Factors

Client & extratherapeutic factors Techniques that engage and inspire the participants The therapeutic alliance The clinician

+The Common Factors The common factors are a listing of four qualities that all successful psychotherapeutic approaches have in common

Developed by psychiatrist Saul Rosenzweig (1936), in response to the numerous philosophies of therapy asserting their superiority in his era

A review of over sixty years of literature on psychotherapy and therapeutic change supports the common factors hypothesis (Duncan, Miller, Wampold, & Hubbard, 2009)

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Can the Common Factors Be Applied to Supervision?

+The Common Factors

Client & extratherapeutic factors Techniques that engage and inspire the participants The therapeutic alliance The clinician

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Do You Struggle with Being Empathetic in Supervision?

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What Were Some of Your Best Experiences with Supervision?

What Were Some of Your Worst?

+Now It’s Your Turn…

Write up a brief case (5-7 traits) :- An actual supervisee- A composite supervisee- A fictional character

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Reactions/Discussion From Guided Imagery Empathy Exercise

+Lessons From My EMDR Supervision Experiences…

+Lessons From My EMDR Supervision Experiences…By the book vs. Go with the flow…depends on who you

ask.

This is what the book says to do…this is what I actually do.

“Imbuing” fear vs. Fostering confidence

Within the context of the relationship, don’t be afraid to ask, “What’s this really about?”

The importance of outcomes & seeking feedback

Repair the ruptures (Dworkin & Errebo, 2010)

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The “Resistant” Supervisee or Consultee

+Motivational Interviewing (Miller & Rollnick, 2002) Collaboration- Counseling involves a partnership

that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conductive rather than coercive to change.

Evocation- The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals, and values.

Autonomy- The counselor affirms the client’s right and capacity for self-direction and facilitates informed choice.

+Motivational Interviewing: 4 Principles (Miller & Rollnick, 2002)

Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy

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What is the Application to Clinical Supervision?

+General Proverbs That Go Along Way…

Meet them where they’re at

Do unto others as you would have them do unto you

Remember what it was like

Please Return by 1:00pm

“The problem with winning the rat race is that even if you win,

you’re still a rat.”-Lilly Tomlin

+Stress vs. Burnout

How would you define stress?

How would you define burnout?

+Stress vs. Burnout

STRESS BURNOUTCharacterized by over-engagement Characterized by disengagement

Emotions are over-reactive Emotions are blunted

Produces urgency and hyperactivity Produces helplessness and hopelessness

Loss of energy Loss of motivation, ideals, and hope

Leads to anxiety disorders Leads to detachment and depression

Primary damage is physical Primary damage is emotional

May kill you prematurely May make life seem not worth living

SOURCE: Stress and Burnout in Ministry (Croucher, n.d.)

+Stress vs. Burnout

Burnout is most common in the workplace. You may be flirting with burnout if:

Every day on the job is a bad one. Caring about work seems like a total waste of energy. The majority of your day is spent on tasks you find

either mind-numbingly dull or unpleasant. Nothing you do appears to make a difference in a

workplace full of bullying, clueless, or ungrateful supervisors, colleagues, and clients.

SOURCE: Helpguide.org

+Common Signs and Symptoms of Burnout

Powerlessness Hopelessness Emotional exhaustion Detachment Isolation Irritability Frustration Being trapped Failure Despair Cynicism Apathy

SOURCE: Helpguide.org

+An Important Point to Remember

Workplace burnout isn’t the same as workplace stress. When you’re stressed, you care too much, but when you’re burned out, you don’t see any hope of improvement.

Dealing with stressors may be a preventative measure against burnout.

+Causes of Burnout

While some careers have higher rates of burnout, it’s present in every occupation.

Those most at risk are employees who feel underpaid, underappreciated, or criticized for matters beyond their control.

Service professionals who spend their work lives attending to the needs of others, especially if their work puts them in frequent contact with the dark or tragic side of human experience, are also at high risk.

SOURCE: Helpguide.org

+Causes of Burnout

Setting unrealistic goals for yourself or having them imposed upon you.

Being expected to be too many things to too many people. Working under rules that seem unreasonably coercive or

punitive. Doing work that frequently causes you to violate your

personal values. Boredom from doing work that never changes or doesn’t

challenge you. Feeling trapped for economic reasons by a job that fits any

of the scenarios above. SOURCE: Helpguide.org

+Causes of Stress and Burnout

The information on the following slides is presented by the National Institute for Occupational Safety and Health (NIOSH).

A booklet by this organization, Stress at Work, is an excellent resource that you may consider adding to your personal library.

Follow along as these scenarios are presented; make mental notes or check off which scenarios may apply to you and your workplace.

+Job Conditions That May Lead to Stress The Design of Tasks. Heavy workload, infrequent rest

breaks, long work hours and shiftwork; hectic and routine tasks that have little inherent meaning, do not utilize workers' skills, and provide little sense of control.

Example: David works to the point of exhaustion. Theresa is tied to the computer, allowing little room for flexibility, self-initiative, or rest.

SOURCE: National Institute for Occupational Safety and Health

+Job Conditions That May Lead to Stress Management Style. Lack of participation by workers

in decision- making, poor communication in the organization, lack of family-friendly policies.

Example: Theresa needs to get the boss's approval for everything, and the company is insensitive to her family needs.

SOURCE: National Institute for Occupational Safety and Health

+Job Conditions That May Lead to Stress Interpersonal Relationships. Poor social

environment and lack of support or help from coworkers and supervisors.

Example: Theresa's physical isolation reduces her opportunities to interact with other workers or receive help from them.

SOURCE: National Institute for Occupational Safety and Health

+Job Conditions That May Lead to Stress Work Roles. Conflicting or uncertain job expectations,

too much responsibility, too many "hats to wear." Example: Theresa is often caught in a difficult

situation trying to satisfy both the customer's needs and the company's expectations.

SOURCE: National Institute for Occupational Safety and Health

+Job Conditions That May Lead to Stress Career Concerns. Job insecurity and lack of

opportunity for growth, advancement, or promotion; rapid changes for which workers are unprepared.

Example: Since the reorganization at David's plant, everyone is worried about their future with the company and what will happen next.

SOURCE: National Institute for Occupational Safety and Health

+Job Conditions That May Lead to Stress Environmental Conditions. Unpleasant or dangerous

physical conditions such as crowding, noise, air pollution, or ergonomic problems.

Example: David is exposed to constant noise at work.

SOURCE: National Institute for Occupational Safety and Health

+Personal Susceptibility to

Stress or Burnout: 7 DomainsAssess the Extent of Your Risk Factors

1.) The nature of the stressorStressors that involve central aspects of your life (your marriage, your job) or are chronic issues (a physical handicap, living from paycheck to paycheck) are more likely to cause severe distress.

2.) A crisis experienceSudden, intense crisis situations (being raped, robbed at gunpoint, or attacked by a dog) are understandably overwhelming. Without immediate intervention and treatment, debilitating stress symptoms are common.

3.) Multiple stressors or life changesStressors are cumulative, so the more life changes or daily hassles you're dealing with at any one time, the more intense the symptoms of stress.

4.) Your perception of the stressorThe same stressor can have very different effects on different people. For example, public speaking stresses many out, but others thrive on it. Additionally, if you’re able to see some benefit to the situation—the silver lining or a hard lesson learned—the stressor is easier to swallow.

5.) Your knowledge and preparationThe more you know about a stressful situation, including how long it will last and what to expect, the better able you’ll be to face it. For example, if you go into surgery with a realistic picture of what to expect post-op, a painful recovery will be less traumatic than if you were expecting to bounce back immediately.

6.) Your stress toleranceSome people roll with the punches, while others crumble at the slightest obstacle or frustration. The more confidence you have in yourself and your ability to persevere, the better able you’ll be to take a stressful situation in stride.

7.) Your support networkA strong network of supportive friends and family members is an enormous buffer against life’s stressors. But the more lonely or isolated you are, the higher your risk of stress.

+Costs of Stress and BurnoutThere is a clear connection between workplace stress and physical

and emotional problems. According to the National Institute for Occupational Safety and health, early warning signs of job stress include:

Headache Sleep disturbance Upset stomach Difficulty concentrating Irritability Low morale Poor relations with family and friends

SOURCE: Helpguide.org

+Costs of Stress and Burnout

Evidence suggests that workplace stress plays an important role in several types of ongoing health problems, especially:

Cardiovascular disease Musculoskeletal conditions Psychological disorders Workplace injury

SOURCE: Helpguide.org

+Costs of Stress and Burnout

According to the Journal of Occupational and Environmental Medicine, health care expenditures are nearly 50% greater for workers who report high levels of stress.

SOURCE: National Institute for Occupational Safety and Health

+Costs of Stress and Burnout

According to the St. Paul Fire and Marine Insurance Company, problems at work are more strongly associated with health complaints than are any other life stressor-more so than even financial problems or family problems.

SOURCE: National Institute for Occupational Safety and Health

+Costs of Stress and Burnout

Studies show that stressful working conditions are associated with increased absenteeism, tardiness, and intentions by workers to quit their jobs-all of which have a negative effect on productivity and a company’s bottom line.

SOURCE: National Institute for Occupational Safety and Health

+ If You are a Supervisor or “Boss”

Much of the Stress at Work booklet is geared towards you and what your organization can do to promote a healthier work environment.

Pay special attention to the material from Page 12 onward in the Stress at Work booklet.

If procedural or organizational change is something that you have a desire to bring about, you will find the suggestions in this booklet helpful.

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SOURCE: National Institute for Occupational Safety and Health

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Compassion Satisfaction and Fatigue Test (1996)

+Small Group Activity

What are some ways that a working individual can go about taking care of himself/herself to reduce stress and to minimize

the development of burnout?

Are there any issues or strategies specific to your profession that need to be considered?

You have 15 minutes to consider these questions in your group; share your experiences if you are willing

+Strategies for Developing a

Self-Care Plan

What did you come up with in your small group

discussions?

+ Recovering Professionals

What makes people in recovery enter the helping professions?

What are some special pitfalls for risk that recovering professionals may face?

Can anything be shared based on your experience or small group discussions?

+Break Time (15 Minutes)

+ Strategies for Developing a Self-Care Plan

Go for a walk. Spend time in nature. Talk to a supportive friend. Sweat out tension with a good workout. Write in your journal. Take a long bath. Play with a pet. Work in your garden. Get a massage. Curl up with a good book. Take a yoga class. Listen to music. Watch a comedy.

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+ Strategies for Developing a Self-Care Plan

Logistical issues:Clarify job descriptionDevelop a work plan Ask for new duties

+ Strategies for Developing a Self-Care Plan

The common sense things we often overlook:Take time offResist perfectionismFlip negative thinkingPrioritize/ “To Do” ListsTalk it outFind humor in a situationLearn how to say “no”

+ Strategies for Developing a Self-Care Plan

On nurturing yourself; remember, it is a necessity, not a luxury:

Set aside relaxation time. Include rest and relaxation in your daily schedule. Don’t allow other obligations to encroach. This is your time to take a break from all responsibilities and recharge your batteries.

Connect with others. Spend time with positive people who enhance your life. A strong support system will buffer you from the negative effects of stress.

Do something you enjoy every day. Make time for leisure activities that bring you joy, whether it be stargazing, playing the piano, or working on your bike.

Keep your sense of humor. This includes the ability to laugh at yourself. The act of laughing helps your body fight stress in a number of ways.

SOURCE: Helpguide.org

+ Strategies for Developing a Self-Care Plan

On adopting a healthy lifestyle:

Exercise regularly. Eat a healthy diet. Reduce caffeine and sugar. Avoid alcohol, cigarettes, and drugs. Get enough sleep.

+ Strategies for Developing a Self-Care Plan

On unhealthy ways of coping with stress: Smoking Self-medicating with alcohol or drugs Using sleeping pills or tranquilizers to relax Overeating or eating too little Sleeping too much Procrastinating Withdrawing from friends, family, and activities Filling up every minute of the day to avoid facing problems

SOURCE: Helpguide.org

+ Strategies for Developing a Self-Care Plan

Suggestion from the National Institute for Occupational Safety and Health:

Balance between work and family or personal life A support network of friends and coworkers A relaxed and positive outlook

SOURCE: National Institute for Occupational Safety and Health

+ Strategies for Developing a Self-Care Plan

Suggestions from the Presenter:• If you have a spiritual belief system, use it to help you deal

with stress.• Always make time for your hobby or activities that you enjoy;

even when your time is minimal, you may experiences greater consequences later if you don’t keep doing at least one thing for yourself that you enjoy

• Seek outside help if necessary: EAPs, support groups, helping professionals

• Use healthy boundaries in the workplace when it comes to your personal life

+ Small Group Exercise

Get into your original groups. Take about 5-10 minutes and write down a plan for self-

care based on information that you learned today or based on strategies that you have already implemented in your life for self care.

Write out at least five points of your plan using “I will” statements (e.g., “I will go ballroom dancing at least twice a week,”“I will refrain from talking with my boss about politics”).

Share what items you are willing to share with other group members.

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How Can You Work With Supervisees to Develop Their Work & Self-Care Plans?

+References

Courtois, C.A., & Pearlman, L.A. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18(5), 449-459.

Croucher, R. (n.d.). Stress and burnout in ministry. Retrieved March 20, 2008, from www.helpguide.org/mental/burnout_signs_symptoms.htm

Dworkin, M., & Errebo, N. (2010). Rupture and repair in the EMDR client/clinician relationship: Now moments and moments of meeting. Journal of EMDR Practice and Research, 4(3), 113-123.

empathy. (2002). Stedman’s Medical Dictionary. Retrieved February 18, 2012, from Dictionary.com website http://dictionary.reference.com/browse/empathy

Figley, C.R. & Stamm, B.H. (1996). Psychometric Review of Compassion Fatigue Self Test. In B.H. Stamm (Ed.), Measurement of Stress, Trauma and Adaptation. Lutherville, MD: Sidran Press.

Fosha, D. (2000). The transforming power of affect: A model for accelerated change. New York: Basic Books. Fosha, D., & Slowiaczek, M.I. (1997). Techniques to accelerate dynamic psychotherapy. American Journal of Psychotherapy, 51(2), 229-251.Helpguide.org. (2008). Preventing burnout: Signs, symptoms, and strategies to avoid it. Retrieved March 20, 2008, from http://www.helpguide.org/mental/burnout_signs_symptoms.htm

+References

Marich, J. (2011). EMDR made simple: Four approaches for using EMDR with every client. Eau Claire, WI: Premiere Education & Media.

Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: W.W. Norton & Co.

National Institute for Occupational Safety and Health. (n.d.). Stress at work. Cincinnati, OH: U.S. Department of Health and Human Services.

Norcross, J. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.

Yalom, I. (1973). Every day gets a little closer: A twice-told therapy. New York: Basic Books.

Yalom, I. (2001). The gift of therapy: Reflections on being a therapist. London: Piatkus Books.

To contact today’s presenter:

Jamie Marich, Ph.D., LPCC-S, LICDC-CSMindful Ohio

jamie@jamiemarich.comwww.mindfulohio.comwww.jamiemarich.comwww.drjamiemarich.comwww.dancingmindfulness.com www.TraumaTwelve.com

Phone: 330-881-2944