1

MACMH Annual Conference April 28, 2014

Presenters: Krista Nelson LMFT LICSW

krista.nelson@wilder.org Shawn Schuette LMFT

shawn.schuette@wilder.org The Wilder Foundation

Attachment and Trauma Training Program and Kofi Services

1

Supervising Complex Trauma in Daily Life

Fostering self care, resilience and reflection for staff on the front lines

Goals of Workshop

2

�  Speak to the complexities of supervising front line staff who work with traumatized clients living in unsafe settings. Consider shifts in supervision structure, emphasis and outcomes to reflect trauma’s impact on all

�  Lay out components of trauma informed supervision that is both directive and collaborative as we assume roles of Administrator, Teacher, Coach and Mentor

�  Gain skills in helping supervisees with trauma histories recognize and cope with triggers activated by work with traumatized clients, noting line between supervision and therapy

�  Present and practice tools for this process:, Trauma informed supervision contracts, Reflective Supervision, Mindfulness

�  Apply concepts to your own challenges- What are the essentials of a healing environment in community mental health?

Trauma Informed Supervision “I find that people are hungry for a type of supervision that invites them to inquire into and harmonize the fundamental practices of their professional work with the fundamental values of their personal lives. Look around you, better yet, search your own experience. We work with all kinds of families and a full range of the human experience. But we bring to this work the full history of our own lives as well. … The catalog of human suffering, triumph and their interweaving is endlessly variable yet it unties us all, for in some deep way, it is always the same.” William Schaffer Models and Domains of Supervision and Their Relationship to Professional Development Zero to Three Newsletter November 2007

3

What we typically Do…. (Toward a Common-Factors Approach to Supervision Morgan and Sprenke 2007)

1.  Develop Clinical Skills: intervention strategies, client dynamics, clinical theories….

2.  Guide how supervisee functions as professional within ethical standards and administrative duties….

3.  Elicit personal growth, awareness and emotional management toward autonomy and confidence….

4.  Monitor and evaluate supervisee per agency and licensing board standards….

5.  Balance emphasis on clinical competence with professional competence….

4

Components of Trauma Informed 1.  Explores impact of

trauma on both client functioning and functioning of supervisees and agency

2.  Offers supervisees concepts and tools to work with trauma’s impact

3.  Defines do able tasks and outcomes and re-energizes mission

5

“The Loss of Control is the Central Dynamic of Trauma” “There is a cost to caring for and about traumatized people. It is a transformation in the self of the helper that comes about as a result of engaging empathically with traumatized people and

feeling responsible to help. Its hallmark is disrupted spirituality, or meaning or hope”

What Can Child Welfare Workers Do about Vicarious Trauma- Laurie Ann Perlman in CW360 Secondary Trauma and the Child Welfare Workforce Spring 2012

“Most forms of therapeutic engagement with victims of trauma emphasize the therapeutic relationship. Paradoxically it is empathic immersion that is both necessary and understood to be the portal through which harm can come to the therapist’s inner life.” May Benatar, How conducting

trauma therapy changes the therapist

Scientific American February 26, 2011

6

2

Our Context: Kofi Services in St. Paul Schools

7

�  Our clients demonstrate effects of current and past traumas in coping behaviors that frustrate or threaten school staff and family members.

�  Staff are charged with shifting maladaptive behaviors, mobilizing cultural identity and family as core resource

�  Staff face their own trauma histories

�  Supervision challenges are many…..

Specific Supervision Challenges

8

�  “Is this supervision or therapy?” How do we help contain what staff are witnessing and feeling alongside children and parents in cycles of violence and poverty?

�  How do we help staff gain the skills they need to do the work? �  How do we meet agency mandates to reduce symptoms &

demonstrate skills when clients are still living in unsafe settings? �  How do we buffer stress? How do we create a safe place in

supervision itself , so reflection and learning can occur? �  How do we coach a unifying professionalism in face of trauma as

staff come from different life experiences and cultures?

The Joys of Middle Management

9

Impact of Trauma Work on Staff Trauma and the Organization: Understanding and Addressing Secondary Trauma in Trauma Informed Care Kulkarni and Bell 2012

�  Difficulty leaving work behind �  Lack of resources to do the work i.e. expectations to do

more with less, not enough time in the day �  Caught in need for systems change �  Struggling with service provider-client relationship

dynamics- i.e. not trying to take over client’s life �  Exposure to secondary trauma, suicide, homicide �  Feeling ineffective or powerless to help client �  Not getting enough money �  Different philosophies between staff, departments

10

Shawn’s thoughts �  How have you shifted the

way you do supervision to fit Kofi’s multicultural, community context?

�  How do you buffer staff from client stress or agency mandates to create a spot for reflection?

�  How do you structure supervision so it is both collaborative and directive when needed

�  How do you build trust with staff who distrust large systems or have language or education barriers to meeting agency mandates?

11

Outsider Ally Characteristics

� Ally: A member of a majority or dominant social group who takes a stand against social injustice directed at members of an oppressed or non-dominant group

� Comfortable about own identity � Take responsibility for learning � Listen and respect different perspectives � Acknowledge unearned privilege � Unlearn oppressive beliefs

3

Recognizing Historical Trauma �  The legacy of numerous, cataclysmic events a community

experiences over generations and encompasses the psychological and social responses and adaptive learning to such events. (Brave Heart 1999, Evans-Campbell 2008)

�  Trauma and emotional wounding is held personally and collectively and transmitted over generations as descendants continue to identify emotionally with ancestral suffering and apply trauma adaptations in present life.

�  “Soul wound” – cumulative effect of historical trauma brought on by centuries of colonialism, genocide and oppression.

13

“The lived experience of discussion differences and conflicts within the supervisory relationship is one of the most valued sources of mutual growth and development for supervisor and supervisee” A Practical Guide to Reflective Supervision Heller and Gilderson c. 2009

14

Supervision Roles We Take “Good supervision is ability to work from within multiple supervisory roles, using which role best meets the changing demands” Morgan and Sprenkle- Journal of Marriage and Family Therapy January 2007

Clinical Competence Professional Competence

15

Ø  Coach Clinical competence, therapeutic goals and relationship, critical feedback on clinical work

Ø  Mentor Personal/professional development of supervisee, self as therapist, strengths-limitations, member of professional community

Ø Teacher Acquisition of knowledge about clinical work, skills, theories, system concepts, client context: culture, socioeconomic status, assessment/diagnosis

Ø Administrator Ethical, legal standards, ensuring standards being met, protecting clients, supervisees, agency, profession, clinical documentation, resolving ethical dilemmas, agency policies, evaluation of performance

Small Groups

1.  Pick two roles as a group. List examples of each role. 2.  Can or do you move fluidly between roles? 3.  What are the barriers to doing so at your setting? 4.  Why might finding a balance between the roles be

essential for supervising work with trauma clients? 5.  What does the term “developing a colleague through

supervision ” mean to you?

16

Discussion How are we blending these roles and meeting these challenges? Can we create protective structures so learning can occur? Can agency mandates mesh with realities front line staff face? 17

Applying Roles in Context of Front Lines Complex Trauma � Without maps of the Teacher, we lose our way-- � Without reflection of the Coach, we forfeit the

best supervision and therapy tool we have, ourselves-----

� Without an “eye on the prize” of the Administrator as to what makes a difference, we become hopeless and give up----

� Without clear ways for rejuvenation of spirit and purpose of the Mentor,, we lose capacity to empower families in trauma--- 18

4

Teacher Role- Training staff for front lines �  Provide foundational understanding of impact of trauma on

domains of developmental and neurological delays and on family functioning

�  Provide map for trauma therapy, despite technique, that

reinforces connection and coping for families in face of persistent stress. Assess skill development in delivery

�  Show examples of “seeable goals” for children that

jumpstart development in five domains �  Address agency mandate for seeing change through outcomes

19

TF CBT?, EMDR? ACT?

What do we Teach? q Trauma is not a diagnosis but a universal human experience q Circles us back to stories of resilience, feeling alive in the

midst of hardship the world over q How people respond to traumatic events is more important

than the events themselves q Connection to others – attachment is our primary

protection, our way of moving on q Can’t extract trauma like a bullet- can’t “fix” it q Can facilitate change by facing fear, walking in and through it,

grow a healthier skin around it

Lifetime Consequences

�  Understanding Trauma’s Impact - Client to Community: Helping Keep a Neuro-Bio-Social Perspective on “ACEs Too High”

Essential Components of Complex Trauma Treatment (B. van de Kolk 2005) �  Creating Safety �  Regulating Overwhelming Stress �  Promoting Reflective Thinking �  Trauma witnessing- telling of the story in treatment goals,

plans and documenting outcome �  Setting up supportive structures and relationships �  Practicing competence in a stress filled world

Crafting Realistic Case Plans Administrator Role Regulating Environments Regulating Relationships � Shows small steps of hope that can be experienced � Repeats important examples of client’s resilience � Gives a picture of what it looks like when it is better � Prioritizes client’s choice for what she/he wants to see grow � Organizes hard stuff into a story- beginning, middle, end � Shows client is not alone- mobilizes resources � Showcases client’s competence and coping

23

Administrator Role- Ethical Dilemmas on Front Lines �  Culture/class similarities and or differences in supervisee

that impact ethical judgments with clients? �  Front line staff can see documentation requirements as

unnecessarily controlling? �  Performance evaluation- an ongoing discussion �  Clarifying professional boundaries �  Safeguard therapy as place where traumatized clients are

protected enough to risk shifting patterns of survival? “ As a therapist, you are something like an athlete, who must stay in

shape to be ready for whatever comes at you during the game. You must have a team on your side who supports you, challenges you

and tells you when you are in danger of screwing up” Mary Jo Barrett- Ethics in Therapy: Defining Professional Boundaries 2014

24

5

To Active Vitality in the Face of Trauma- Make Room for the Coach Role

�  Prepare for inevitable Secondary Traumatic Stress on staff

�  Create enough relational trust to explore impact of staff’s own traumatic history or impact of historical trauma on decision making

�  Make this explicit in supervision contract

�  Tend to vital skill of self care

25

Secondary Traumatic Stress (STS) �  The effect of working with people who have experienced

trauma and of being exposed to the difficult stories they share.

�  An occupational hazard of providing direct services to traumatized populations: we are all vulnerable to STS.

�  Secondary stress because it is experienced indirectly, through the process of being a witness to another person’s trauma. (A. Norwood & A Beckman MN Center for Victims of Torture)

�  Compassion Fatigue- extreme state of tension or preoccupation with the suffering of those being helped to the degree that is traumatizing for the helper (Figley)

�  Empathic Distress-getting so wrecked by what we see that we can no longer help (Joan Halifax)

26

Impact We See as Supervisors

�  Emotional: anger, sadness, grief, guilt, depression, hopelessness, numbing, overwhelmed, feeling bored, distant, distracted or overly fearful,

�  Physical: headaches, stomach aches, chronic exhaustion, or hyper-arousal, illness, sleep problems

�  Personal: isolation, cynicism, irritability, moody, withdrawn, increased risk for alcohol or substance use, negativity, pessimism, guilt for own blessings

�  Workplace: avoidance, minimizing, unmotivated, diminished creativity, job dissatisfaction, inability to empathize, grandiosity, disliking clients, can’t embrace complexity, or can never do enough 27 28

Implications for supervisors at front lines of trauma treatment? �  Secondary Traumatic Stress needs to be a focus of frequent

supervision content and process. Studies show that from 6 to 26% of therapists working with traumatized populations and up to 50% of child welfare workers are at high risk for STS

�  Cannot be passive or reactive to this reality. Client care can be compromised when staff is emotionally depleted and cognitively affected.

�  2006 study found that action oriented rather than emotion oriented or passive support from supervisors was most helpful in preventing or reducing STS, as well as specific qualities vs quantity of supervision (Bride and Jones- International Journal of Social Work Education)

29

“Put on your own mask before assisting others” � Be in attachment

terms a “Secure Base” for supervisees. Hold and regulate their stress so they can sort and reflect.

•  Regulating…. •  Mentalizing…..

30

6

Supervision or Therapy?

�  Good supervision always involved some elements of therapy �  If responsible supervision is recognizing activation of personal,

secondary or historic trauma in supervisees and consequent emotions, thoughts or actions toward clients, then supervision must go beyond monitoring tasks and teaching good technique: use of self as therapist/worker focus is a must.

�  Critical skill: monitoring own automatic internal and behavioral reactions to client’s presence, words and actions. Supervisee practices how to be sensitive to nuance of own states and thoughts with guidance of supervisor.

�  Distinguish from therapy through Informed Consent- explicit contract of goals and responsibilities –Supervisor and Supervisee

31

Dual Quality not Dual Relationship Supervision Therapy �  Help supervisee improve

professional functioning. �  No responsibility for

helping supervisee function better in personal life.

�  Supervisee may discuss aspect of personal history or circumstances as when reactions to clients parallel ones in own life. Is never mandatory or pressured.

�  Help client resolve distress they are experiencing in personal life

�  Therapist assumes some responsibility for helping clients find way to function better.

�  Strongly encouraged when supervisee’s personal life is impairing their clinical work.

32

Coach Role – Reflective Supervision q Do not just stay in Administrative and Teacher Roles, despite

lack of time and resources- “Process Problem Solving” q Make room in sup hour for guiding staff to take a “10

thousand feet view” of self interacting with client q Is not therapy- focus is on what is happening between self and

client using Regularity, Reflection, Collaboration q Safe place to explore, “what is snagging me?” q “Slice it thinner” Use silence Let hour move from “reporting

events” to impact of client on staff and staff on client q Note staff’s struggle, themes, hold their pain, help them see

next steps – q Use beginning and ending ritual to preserve this time, space 33

Phases of an RF Session 1.  Preparation: Clear your mind, create a protected environment

for you and your staff. Orient thoughts to this staff’s needs and strengths.

2.  Greeting and Reconnecting: Evoke relationship briefly 3.  Opening the Dialogue and Finding the Agenda: Ritual

to begin, listen, see what staff wants to focus on. 4.  Telling your Story and Focusing on the Details: What

exactly happened, What was said and not said? What was observed? Don’t seek solutions yet. Help staff become aware of own reactions as he tells his story.

34

5. Understanding Perspectives and Generating Hypotheses: Both of you share hunches about what is going on. Wonder about client’s perspective, staff’s perspective. “ I wonder if…” 6. Considering Next Steps: After clarify uncertainties, and issues, guide consideration of next steps. “Given all you shared, how do you want to approach your next visit.” 7. Closing: - Appreciate staff’s engagement in work and continuation of next supervision contract 8. Post Supervision Reflection: Record key themes, affect expressed, level of engagement and comfort with session

35

RF- “Safe Base” holding of client trauma/staff trauma

36

Respect each supervisee’s pace and readiness to learn

}  Strengthen supervisee’s observation and listening skills }  Suspend harsh or critical judgment }  Invite sharing of details of client’s particular strengths, behaviors, interactions,

concerns, }  Listen for emotional experiences that supervisee is describing in response to

work: anger, impatience, sorrow, confusion etc. }  Invite supervisee to have and talk about feelings awakened in the presence of

the client }  Wonder about, name and respond to those feelings with appropriate empathy }  Maintain a shared balance of attention on client and supervisee }  Reflect on supervision in preparation for next meeting

7

RF tools – from A Practice Guide to Reflective Supervision

�  Timelines or Genograms of past supervisory experiences �  A basket full of questions: Ø  Talk about a child who reminds you of… Ø  Talk about a parent who is difficult to get along with Ø  Describe a good day at work- a bad day Ø  What helps you when you feel stressed.. �  Earliest memory interview �  Watching movies without sounds or “Velveteen Rabbit” �  Nine Dot Problem (that only can be solved by going outside

the box)

37

Small Groups

1.  Think about one supervisee with whom you work whom you believe is experiencing secondary traumatic stress and or vicarious traumatization.

2.  How are you addressing it now in supervision: as teacher, mentor, coach or guide?

3.  How do deal with differences between you in culture, in lived experiences, in ways of dealing with pain and loss?

4.  How do you help your staff identify what might be tripping him up from trauma responses and what helps him cope?

5.  What can you do as a supervisor to make supervision a place where staff can explore this?

38

Mentor Role Compassion Satisfaction

Making Meaningful Contributions

“ It is not stress that kills us. It is effective adaptation to stress that permits us to live.”

Resilience is the ability to respond adaptively to

challenge, strengthened by tie to at least one other

39

The Resilience Alliance Project ACS-NYU Children’s Trauma Institute- New York City Child Protection Three core skills to be taught, coached and mentored in supervision:

§ Cautious Optimism - ability to reframe events and focus on best outcome with clients, with self as professional healer

§ Mastery – ability to regulate own stress and do self care

§ Collaboration- ability to not isolate despite pull toward “survivor mode” and use mutual support in workplace

40

Mentoring Optimism �  Does supervisee intensify

or dampen own internal experience or what hear?

�  Supervisee can choose how she engages, holds and thinks about material

�  Help with Role Clarification- where can I have best impact?

�  Discussing choice around how one makes meaning

�  See trauma triggers as a gift- bit of self still working it through so can see trauma, own, client’s, with larger lens- expand narrative

�  See defensive (jackets) that protect us: avoiding, pleasing, numbing, fighting and choice about when to use

41

Mastery Work- Active Regulation Practice in Mindful Supervision �  Respectfully activate dopamine (the “oh shit” hormone) to

risk facing fears within supervisory discussion �  Assess stress level, give it a size, a number, a picture in the

mind as begin and end �  Paying attention together through observation of emotional

and physical reactions as discuss client’s story �  Sitting together for two minutes in silence �  Active wise mind orientation- “you are doing the best you

can and you can always learn something new”

42

8

Collaboration How well does your workplace…

�  Allow staff to bring items of comfort into one’s space- personal photos, art, reminders of nature to give staff places to reconnect with own body, spirit, purpose?

�  Have ways staff can monitor own stress levels and do something to regulate stress within trauma work- a meditation place, walking spaces, yoga, a place to breathe?

�  Gather staff together to laugh, play or spill- such as “crap sessions” every Friday afternoon for “dumping the bucket” of traumatic stress piled up each week

CW360 Secondary Trauma and the Child Welfare Workplace

Spring 2012 University of Minnesota 43

Supervisors –We Are Vital Tending to our own“Mindsight” Is Vital

44

}  “Lack of clinical supervision is a potential drain on the best leadership skills and commitment of our most capable managers and supervisors. They need support as they support those who bear witness to the chronic pain and need of others”

}  Supervision must prioritize time for reflection and self care,

most vital in this line of therapy, despite administrative demands

}  Supervisors too must find a way to be “held” professionally so that they can continue to hold and nurture a program and staff”

}  “When I distance myself from the tragedies that happen at work, I put myself at risk. If I do not protect myself, I risk the program”.

Tying it All Together Trauma Resilient Practice �  Do we take time to recognize impact of traumatic stress on

client behavior and goals we set in treatment, with an eye to resilience and building of supportive relationships?

�  Do we take the time to do this with staff and in our organizations? Is supervision a “holding space”?

�  Can we move fluidly between roles of administrator, teacher, coach and mentor?

�  Can we draw from therapy models of trauma resilience whatever our specific treatment methods?

�  Can we use elements of Mindfulness and Reflective Supervision to recognize trauma’s impact on self and keep fresh in the relational work? 45

Personal Resilience Plan The pleasure we derive from being able to do our work well

�  How can we look forward to Monday’s next supervision meeting?

�  What creates stress in my work?

�  What helps me stay balanced physically and emotionally?

�  What helps me to manage my energy?

�  What helps me to quiet my mind and calm my emotions?

�  Who can I connect with for support and a sense of belonging?

46

“Life will break you. Nobody can protect you from that, and living alone won’t either, for solitude will also break you with its yearning. You have to love. You have to feel. It is the reason you are here on earth. You are here to risk your heart. You are here to be swallowed up. And when it happens that you are broken, or betrayed, or left, or hurt, or death brushes near, let yourself sit by an apple tree and listen to the apples falling all around you in heaps, wasting their sweetness. Tell yourself that you tasted as many as you could. Louise Erdich- The Painted Drum

References-- �  A Practical Guide to Reflective Supervision, edited by

Sherryl Scott Heller and Linda Gilderson Zero to Three c. 2009

�  Work Discussion: Learning from Reflective Practice in Work with Children and Families, edited by Margaret Rustin and Jonathan Bradly, The Tavistock Clinic Series

�  Treating Complex Trauma: A Relational Blueprint for Collaboration and Change, Mary Jo Barrett, Routledge Psychological Stress Series c. May 2014

�  Traumatic Stress: Effects of Overwhelming Experiences on Mind, Body and Society, Bessel van de Kolk, McFarlane &Wesearth c. 2009

48

9

References-- �  The Reasonably Complete Systemic Supervisor Resource

Guide Storm and Todd, c. 20002 �  Trauma and the Organization: Understanding and

Addressing Secondary Trauma in a Trauma Informed System Shanti Kulkarni and Holly Bell April 2012

�  Trauma Stewardship: Everyday Guide to Caring for Self While Carrying for Others Laura van Dermoot Lipsky c. 2009

�  Inside Compassion: Edge States, Contemplative Intervention, Neuroscience, Joan Halifax

49