Jewel Jones
     

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Not Knowing

“Not knowing” is challenging. Ask anyone who is waiting for nasty medical test or exam results when the outcome could be significantly negative and even change the course of one’s life. The kind of not knowing which is preoccupying me at the moment is the indecision and vacant space that takes up residence in my being when I am sitting with a client or supervisee, waiting for inspiration to pay a visit. It always happens when I least need vacancy and impotence. Not-knowing seems to occur when knowing is critical, necessary and desperately wanted.

If I “knew” what to think, what to say, what to do, then I would be flying! I’d see myself as a brilliant counsellor, in charge, full of insight and wisdom; perhaps the client would see me that way too. Why, together we would move mountains. Oh the places we would go! (With thanks to Dr Seuss). 

My Personal Philosophy of Counselling Supervision

 

 Three moments in Supervision

 
 
My views about supervision have been strongly shaped by my own very rich, positive experiences as a supervisee, as well as by my own experience as a client. So I want to record here some key moments in my own development as a counsellor in supervision. (Daniel Stern , in The Present Moment In Psychotherapy and Everyday Life  (2004)elaborates on this notion of present moments upon which therapeutic process depends.)These are all pivotal moments for me, as clear as a full-screen, digitalised movie with panoramic sound and all the accompanying emotional charge. Each is a personally experienced, transformative moment that have informed my choice of frameworks for supervision. My models were slowly being co-constructed in my supervision experiences.
 
 

Moment one:

 
I had probably completed 40 hours’ clinical work. My supervisor had put in a tape of her supervision of me to her supervisor for on-going accountability. I was in Stage 2 of Kaslow’s developmental model: insecure, idealising my supervisor, double-checking many of my interventions, and constantly looking for affirmation or direction. (Handout 5, Interrelate Supervision Training Notes, 2009.)
 
 During the tape, as supervisee, I was exploring some counter-transference reactions to something that had taken place with a client in session, and because I had done significant personal therapy in my own life, went fairly deeply into the supervisory exploration process. I then emerged at the end of the supervision with a deeper understanding of the issues that had triggered me, and some possible alternative responses. But I was not sure if such exploration meant I was too broken to be a counsellor...Was such exploration ok? Was I too “out there” because I had been triggered? I was anxious that her supervisor would see that I was not ok, or that I had caused my supervisor to step out of the boundaries of “proper” supervision.
 
The moment?
 
Supervisor: My supervisor had some feedback about your work as an aside, and I thought you might like to hear it?
 
Me: Yes... ..I would.
 
Supervisor: She said, ‘This one’s got it! She’s really got it.’
 
As we discussed what was meant by this it became clear to me that what this observer was feeding back was that my emotional work was not only ok in supervision, but that it was an indicator of an ”x” factor, something I did not quite get with my head, but my gut ‘got it’. Working in this way was an asset to my work, to my clients, and there was no shame in bringing all of me to supervision. A psycho-dynamic, strengths-based, process-oriented model of supervision was beginning to form in me.
 
 

Moment Two:

 
I had about another hundred hours’ experience, and had recently been moved to another supervisor who happened to be my boss. I had built fairly deep trust with this supervisor by this time. By then I was in Stage 3 and, I suspect now, being nudged by this supervisor to move to a new stage. Something had happened in my professional and personal interactions with other clinicians that were confronting me with differences in models and approaches, in ways of being with people, and in potential abuses of clients by these senior clinicians. I was shocked, but had no language for my knowing, felt unsure of my opinions, and rather embarrassed to be actually having opinions about such matters when I was still a trainee. My ethical radar was on maximum alert. Confusion coated every word, and I was doubly concerned because I was expressing these taboo ideas to my boss!
 
This moment presents itself to me now as a sped up, almost comical Charlie-Chaplin-style scene. I was scrawling all over the whiteboard, enraged. Shaking. Whispering for fear of ‘them’ hearing the ‘heresy’ I was spitting out into the room.
 
S: Heresy. So will you be burned at the stake?
 
Me: What?
 
S:You said you were a heretic, and heretics get burned.....
 
Me: Oh yeah. (Still trembling)
 
S: Who is this ‘them’ you mentioned who might hear you utter heresy?........ (and so on)
 
And so entered a new sometimes recurring theme of my supervision: the congregation of all the experienced, skilful therapists out there who I was sure would hiss in my ear their doctrines of perfection in my moments of vulnerability. Simultaneously, I slid across the line to owning my own theoretical frameworks, my ethics, my ability to stand against this invisible shaming ‘other’. And I moved to a new developmental stage: I had my own identity as a counsellor. Also, I was developing a sense that I could and would become a senior clinician, and that I was already critically reflecting on the context within which I was practicing; that is, the therapeutic milieu.
 

Moment three:

 
Same supervisor. Not seen for years and maybe a thousand client hours, but the experience of moment two beckoned me to return to this person. We had been meeting for a few months when moment three emerged.
 
Me: Oh...it’s sooo clunky and rough sometimes when I’m counselling; there are times I feel like I don’t have a clue what I’m doing.
 
S: So that’s what it’s like when your work with clients feels clunky.....Tell me, what’s it like when the work is going well?
 
Me: (on guard immediately...unfamiliar turf here...visibly frozen, resisting) What do you mean?
 
S: Well, what’s the experience like inside you when it’s really good between you and a client?
 
SILENCE.
 
..........waiting..................
 
Me: .....Well......(feeling some panic at this unexpected chance to reflect on the good stuff)
 
S: Yes?
 
Me: Well   It’s a .... It’s a ................................ (and then I breathed out a single resonant musical note) It’s a HUUMMMMMMMMMMM....(Hide face)
 
I don’t remember his response but I know it was a perfect matching, an elaboration, one of those ‘hum’ moments! Resonance, in tune, a union of minds. My shame, awkwardness and the felt sacredness of this self- disclosure was seen and transformed into collegiality, and we moved into and through the felt experience together.
 
And we theorised about the musical theme I’d introduced into the room, and I drew together my reading that I didn’t even know I’d absorbed, and expressed ideas I didn’t know I had formed about the work I was doing. To be drawn forward, or coaxed, to a place of equality and competence, and to be seen and met in that moment of being seen transformed me – and my work with clients. It was, in John Rowan’s terms, a transpersonal experience, beyond relationship between us and deeply accessing soul. (Rowan and Jacobs.....)
  

Summary:

 All three moments recorded here have shaped my views that supervision needs to be a profoundly safe place to explore potentially shaming material. If this safety is not consciously built from the first moment, there is a strong risk the therapist will avoid bringing to supervision those issues that might be damaging to clients if left unattended. Supervision without deep safety is no longer going to deal with the real issues that are taking place in the therapy room, and ethical, legal and personal risks will be amplified. The paper which follows assumes these presuppositions.
 
 

My Personal Philosophy of Supervision 

More than education, counselling, monitoring or consultation (Bernard & Goodyear, 1992), supervision for me is the process of one counsellor facilitating and evaluating another practitioner’s overall work and presence when with clients, with the overall goal of maximising effective counselling interventions and client safety.  (Interrelate Workbook, 2009) In my experience, the outworking of this definition has many shapes and colours, varying according to the counsellor’s needs, the clients’ needs, and the strengths and passions of the supervisor.
 
My views of supervision are strongly shaped by experiences such as those recounted in the preamble. And they are also deeply shaped by my reading about psychotherapy and counselling, and my reflections on what counselling is about. The following quotes sums up my overall philosophy, which is largely shaped by the well-documented view that it is not model, skill or training that is most helpful to clients, but it is our selves, and our relationship with the client that is most likely to make a difference (Spinelli, 2002).
 
Supervision that is to encourage the therapeutic use of self by the counsellor will emphasise attention given to the person of the counsellor as he or she lives in relationship with the client....will focus primarily on the counsellor’s own dynamics and reactions to clients.....case discussion, analysis of client problems, case work management....skills and techniques...will need to take precedence on occasion (But)as a rule the counsellor will be principally encouraged to examine their own needs, drives, motivations and personal responses to clients as a way of developing their internal supervisor...and enhancing their use of self.
 
- Wosket, Val (P209, 1999)
 
This is the real task of supervision: to penetrate the celluloid respectability of therapy and explore the often brutal , destructive and mad forces operating within and among the patient (sic),  therapist and supervisor.
 
- Embelton , Gary  (P120, McMahon & Patton, 2002)
 
 
I take these quotes as my starting place, although I wish to add some caveats. Such an approach needs to keep in mind the developmental stage of the counsellor at all times. ( In addition, an anchor needs to be provided by the use of a tool such as Daphne Hewson’s triangle so that there is a grounding of any supervisory work that emphasises working with the self (Hewson in McMahon & Patten, 2002). Hewson’s  model calls me back to the whole, reminding me that even as I work with a focus on self, selves, selves in relationship and self-in-relationship- with self, I need to maintain a focus on the multiple context s which are shaping and being shaped by the therapeutic work at all levels.
 
Having established some broad caveats, I wish to focus on exploring what it means to be adopting a model of supervision which has as its primary focus the use of the therapist’s self, and how that impacts on the work with the client.
 
I am drawn to existential approaches to therapy (Spinelli, 1994), self-psychology (Kahn, 1997), and those approaches that are broadly referred to as ‘relational’ (Kahn,1997) , or intersubjective. (Driver & Martin, 2002; Kahn, 1997; Farber, 2006) The notion of ‘wounded healer’ (Driver & Martin, 2002; Farber, 2006; Wosket, 1999) is probably central to all of these approaches, in that our own brokenness is seen not just as ok, but potentially very useful in our work with clients. Thus the supervisory process needs to work actively with relationship in the here and now (Stern, 2004), with intersubjective moments (Driver & Martin, 2002; Stern, 2004), and with frank acknowledgement of personal wounds and their multi-faceted impact on the client. (Driver & Martin, 2002; Wosket, 1999).  Thus, I would agree with Christine Driver when she says: ‘supervision should itself be therapeutic’ meaning ‘that the work should engage the inner worlds of the supervisor, supervisee and the patient.’ (p9 , Driver & Martin, 2002)
 
At all times, of course, I see the processes taking place in supervision as information, resources and clues about what is happening in the room with the client. It is not self-reflection in the same way as personal therapy might be; it is far more focussed on growing the counsellor to a deeper understanding of how their ‘self’ and their experiences, assumptions, and interpretations or judgements are participating in the interactive dance they are doing with the client.
 
I have named some of this ‘you-me’ stuff: i.e. the intersubjective real relationship that develops with clients. In the room there is the therapist or counsellor, the client, the ‘us or we’of both, and the ‘space between’. And all of this is reflected or mirrored in the supervisory relationship. The we/us and the space between are as important in supervision as it is in the counselling room. Together, as human beings, we co-create a new context, a new relationship and ultimately, new selves. The process has the potential to be transformative, not just for the client, but also for the supervisee, and even the supervisor.
 
And all of this you-me stuff  is about providing the best possible interventions and outcomes for the client. Growth and shifting in supervision unclogs the workings in the room with the client, partly through a positive use of parallel process, and partly because growth and transformation in the supervisee can result in new interventions with the client. Certainly, at the very least, a greater sense of awareness will contribute to better outcomes in the counselling rooms.
 
The boundaries around the processes that take place in such supervision need to be clearly delineated and agreed to at the beginning contracting by the counsellor and the supervisor. It is not therapy, even though in all likelihood therapeutic moments will occur. The focus is to be firmly agreed upon: the client, and processes relating to the client, is the focus and the purpose of supervision. Of course, in this initial contracting it is imperative that legal, moral and ethical boundaries be spelt out. Discussions about how they would deal with potential difficulties would all need to be discussed, and agreed to. These moments are already building the you/me relationship between supervisor and counsellor, as well as building in safety and accountability for professional practice.
 
As a counsellor in Private Practice, these parameters are imperative: I do not have the legal protection that I might have if I was counselling for an agency. This only reiterates for me the stance I need to take, especially if I am working within an intersubjective/relational framework. We are not having a chat. We are not doing coffee. And we are not doing therapy. There is still an evaluative and educational element in the relationship...not fluffy, not soft.....just a more relational model which has some extra demands if there is to be real relating as well as real accountability!
  
In conclusion, I come back to the place where I started. Safety to enable the therapist to self-disclose, to take risks and to grow in supervision is foundational. And I see the relationship that is formed within clear ethical and professional frameworks as the building itself. Skills, theorising, case management, administration, professional identity and all the systems that are involved then have a place to reside, to shelter and to grow within a strong building built on a secure foundation.
 

References

 
Bernard, Janine M. & Goodyear, Rodney K . (1992). Fundamentals of Clinical Supervision. Needham Heights: Allyn & Bacon.
 
Driver, Christine & Martin, Edward (Eds.), (2002). Supervising Psychotherapy: Psychoanalytic and Psychodynamic Perspectives. London: Sage.
 
Embelton, Gary (2002). Dangerous liaisons and shifting boundaries in psychoanalytic perspectives on supervision, in McMahon, Mary & Patton , Wendy (Eds.), Supervision in the Helping Professions: A Practical Approach (pp119-130). French’s Forest: Pearson Education.
 
Farber, Barry A. (2006). Self-Disclosure in Psychotherapy. New York: The Guilford press.
 
Hewson, Daphne (2002). Supervision of psychologists: A supervision triangle, in McMahon , Mary & Patton, Wendy (Eds.), Supervision in the Helping Professions: A Practical Approach (pp197-210). French’s Forest: Pearson Education.
 
Interrelate Supervision Training Course Notes, 2009.
 
Kahn, Michael (2001). Between Therapist and Client: The new Relationship, Revised Edition. New York: WH Freeman.
 
Rowan, John & Jacobs, Michael (2002). The Therapist’s Use of Self. Maidenhead: Open University Press.
 
Spinelli, Ernesto (1994). Demystifying Therapy. London: Constable.
 
Wosket,Val (1999). The Therapeutic Use of Self: Counselling Practice, Research and Supervision. London: Routledge.
 
Stern, Daniel N. (2004). The Present Moment In Psychotherapy and Everyday Life. New York: WWNorton & Company.
 
 
 
 

 

 

Self-Care: Reflections on how to avoid people burn-out as a health provider

Professional Articles (For Counsellors)
Self-Care: Reflections on how to avoid people burn-out as a health provider
 
Working with clients/patients can expose workers to unexpected self-disclosure. When taking a case history, you may hear about neglect, physical and sexual abuse, or domestic violence which has impacted on the patient’s well-being. This confronts you with a range of emotions. This can be draining, exhilarating, confronting and even scary. It can be dangerous if you do not have basic awareness of vicarious traumatisation. All forms of emotional/sexual/ abusive trauma is contagious. You may “catch” trauma as the worker.
 
Just the day to day stress and demands of caring for others, being as fully present as you can, showing restraint and patience, can lead to burn-out.
Therefore workers need to be aware of the need to take care of themselves. Such self-care will take different forms for different people.
 
 
What is burn out?
Jerald S. Greenberg, in Comprehensive Stress Management defines it thus:
An adverse work stress reaction with psychological, psychophysiological, and behavioural components.
 
Symptoms can include:
Losing your sense of humour
Skipping rest and meal breaks
Increased working hours/not taking holidays
Increased physical complaints
Social withdrawal
Decreased job performance
Self-medication, possibly including alcohol
Emotional exhaustion, loss of self-esteem, depression, frustration, feeling trapped
Difficulty making/explaining decisions, pessimism, loneliness
 
The 5 Stages of burn-out:
  • Stage one: Worker is satisfied, enthusiastic and then gradually senses loss of energy/enthusiasm 
     
  • Stage two: Fatigue sets in. May sleep poorly, abuse drugs.
     
  • Stage three: Constant exhaustion, susceptibility to disease, anger, depression.
  • Stage four: Actual illness can develop, time off work, home life affected, self-doubt, pessimism, obsessing about problems.
     
  • Stage five: Severe illness, career may be threatened
 
 
How can you treat or prevent Burn-out?
 
Work out who you are and what you want.
 
Why are you working?
What things are most important to you?
Then you can make choices about what to let go of. Talking with someone to get this clarity may help, or writing it down, drawing, or mind-mapping.
 
 
Actively care for yourself
What are your ways of caring for yourself?
  • Physical, embodied: hot bath, walk, gym, sleep, snooze, stretch, swim, massage, healthy diet
  • Talk/relational/ friends/family/inter-personal support (eg. Peer supervision, professional debrief/supervision)
  • Distraction/changing the focus/doing something engrossing/ hobbies
  • Balance activities: joy/fun/unwind/scream/cry/laugh/play play play....
  • Spiritual, inner replenishment: prayer, meditation, walks in the bush, journal, reading

Barriers to self-care:

  • The first one may be complete denial. We may believe that it is unprofessional to have feelings, or to be impacted by another’s story. So we bury our real response, rather than giving ourselves an opportunity to move through the feelings.
  • Many of these were learnt as we grew up as children. Our families/environment/experiences taught us to “suck it in”.
  • Some barriers to self-care will be based on beliefs that we carry in us that tell us we don’t deserve to be nourished, that we are “spoiling” ourselves and that is not OK.
  • Some people experience guilt if they stop and re-fuel. Or if they say no.
  • Sometimes the depth and extent of another’s pain may trigger us into running to avoid the feelings that brings up for us.
  • Not being sure of what we feel/need/want. Finding it difficult to tune inside ourselves.
  • A belief that others’ needs must always come first.
Remember: You cannot be truly there for others if you are not truly there for yourself.
 
Self-Care and Boundaries/Limits
One of the biggest challenges for some health workers is facing their own limits in that role, or the limits put on them by the “contract” of the patient/worker role.
 
 Setting appropriate boundaries is the core of the work of helping others, in many ways. It is the emotional/spiritual/relational core of the caring role.
 
What are Boundaries?
 
o   A boundary is an invisible, symbolic “fence”, usually with a gate, that we have around our SELF. It defines where you begin and end.
 
o   Boundaries define you in relation to others; they are about relationship. Our boundaries need to be made visible to others and communicated to them in relationship. Boundaries vary according to the nature of the relationship we are in. Some are closer, some are more permeable. Some are rigid.
 
 
o   Boundary violations can have immense personal, social, spiritual and legal consequences.
 
o   We have many boundary problems because of relational fears. Fears of guilt, not being liked, loss of love, loss of connection, loss of approval, receiving anger, being known, and so on. In the helping field we can be triggered into inappropriate boundaries by the immensity of the client’s needs and pain.
 
 
o   Good boundaries give clear limits. In the helping context, they give safety and clarity for all parties. They protect the worker from burnout, unethical conduct, or dual relationships which can unravel very quickly if things go wrong.
 
o   Sometimes others will feel hurt or challenged when we set a boundary. Then we need to look after our feelings that are generated by this response. We only have power over our own boundaries: what we will and will not allow, or do. We cannot control another’s choices.
 
 
o   We have the freedom to set our own boundaries, and the responsibility to respect others’ boundaries. Our concern should not be “Are they doing what I would do or what I want them to do?” but “Are they really making a free choice?” When we accept others’ freedom, we don’t get angry, feel guilty, or withdraw our love when they set boundaries with us. When we accept others’ freedom, we feel better about our own. (Cloud & Townsend, Boundaries)
 
Questions about Boundaries and your professional context:
·         What boundaries does the professional role give you? (time/tasks/personal)
 
·         What boundaries will be your own responsibility as a health-care provider?
 
·         What are the areas of vulnerability for you personally in terms of boundaries? (Where might you find yourself stressed by setting or maintaining boundaries?)
 
·         What warning signs will you look for in these vulnerable areas? And what will you do to care for yourself and the relationship with the client?
 
We need to be clear about why we are offering to help others. If we are doing it to fill unmet needs from the past, we may find strong feelings are triggered when we are asked in a helping context to set and maintain firm boundaries. We may find ourselves “driven” to do more and more, wanting to “fix” or help beyond the contracted boundary.
If our boundaries are not communicated and exposed directly, they will be communicated indirectly or through manipulation.
 
Boundaries as Health Providers
·         In a professional context, the organisation/modality you represent sets some boundaries for you. These are part of the contract you agree to when you become a health-care provider.
·         Context, the type of relationship, defines appropriate closeness and distance in a relationship. Touching people can lead to deep levels of trust and self-disclosure.
·         Confidentiality is a boundary that is paramount in caring. (Exception being mandatory reporting)
·         Dual relationships (ie. Being in a relationship beyond the client/worker role) often lead to pain and distress for the carer and the client. This principle needs to be honoured.
·         Certain roles carry rank or power. If one person is the therapist/health worker, the other the client, the provider is seen to be the one responsible for caring for/ setting/ protecting the boundaries in the relationship. That is the responsibility and privilege you are given.
·         The sexual boundary must never be violated. This means excluding talking inappropriately about sexual things, off-colour jokes, or inappropriate touch.

You can download a copy of "Self-Care: Reflections on how to avoid people burn-out as a health provider" here.

PDF Downloads for Counselling Professionals

Professional Articles (For Counsellors)

In addition to my articles on this site, here are some of my articles in a downloadable Adobe Acrobat (PDF) format:

Healthcare Workers Self Care Article