The Use and Care of Self when Engaging in Rights-Based Clinical Practice
© Springer International Publishing Switzerland 2015S. Megan BertholdHuman Rights-Based Approaches to Clinical Social WorkSpringerBriefs in Rights-Based Approaches to Social Work10.1007/978-3-319-08560-9_5
5. The Use and Care of Self when Engaging in Rights-Based Clinical Practice
School of Social Work, University of Connecticut, West Hartford, Connecticut, USA
S. Megan Berthold
Ellen1 is a 35-year-old clinical social worker and trauma specialist at a nonprofit that offers a wide range of services for women. Many of the women with whom Ellen works have experienced intimate partner violence (IPV), rape, and/or other traumas. Ellen has been providing psychotherapy to these women for the last 10 years. She has difficulty in sleeping and has become increasingly isolated from her old friends, feeling no interest in activities that she used to enjoy doing with them, such as going to movies and dancing. Ellen feels that her old friends cannot understand the pain she feels each day at work when she hears about the traumas of the women she serves. The women’s stories trigger memories from her childhood, when she witnessed her parents fighting and had to go stay at a shelter more than once with her mother and brother. Ellen has started to pick up extra assignments at work, and finds that she cannot stop thinking about the women’s traumas at night. She feels helpless at times, unable to distance herself from the women’s pain or see any solutions to their problems. Ellen does not feel a lot of support within her agency, although she senses that she must not be alone in feeling affected by her work. Already licensed, she receives only occasional supervision and that only to address immediate crisis situations with little follow-up. When she tries to talk to her coworkers about the stressful work, they typically make a joke and avoid having in-depth conversations about the impact of the work on them. Ellen recently was diagnosed with high blood pressure, a surprise to her, since her family members have no history of hypertension.
Have you ever experienced some of the reactions that Ellen has? Do you sometimes have trouble sleeping or find yourself thinking about the traumatic experiences of those you work with after work hours? Are not social workers supposed to be able to remain strong in the face of anything we encounter at work? Is it a sign of weakness to acknowledge our vulnerabilities? If we find ourselves affected by the experiences of the survivors we work with, does it mean that we should not be social workers? Are you already doing things to take care of yourself? If so, what works for you? Is self-care consonant with a rights-based approach to clinical social work? If no, why not? Is self-care a luxury? Do any human rights instruments support our right to self-care? Do we have a right to have support for our well-being from our employer? If so, what form(s) should that take?
Social work practitioners use themselves as a tool and medium in their practice with diverse individuals, including with those who have experienced or are at risk of experiencing human rights violations. Like Ellen, many clinical social workers have experienced some traumas in their lives, sometimes similar in nature to aspects of the life experiences of those who they provide therapy to. Social workers also tend to have (or hopefully have) strong capacities for and inclination toward empathy. Both of these phenomena can put social workers at risk for having difficulty maintaining professional distance, having unhelpful countertransference reactions (CTRs), and for being negatively affected by their work with people in distress (Wilson & Thomas, 2004). These challenges can also arise even if the clinician has not experienced significant trauma himself or herself. In the absence of effective tools to prevent and manage these effects, clinical social workers may find their abilities to provide appropriate services and safeguard the rights of those they serve to be compromised. In addition, social workers may find that they leave work exhausted, with little time or energy to devote to their own interests or taking care of themselves. Rights-based clinicians may feel overwhelmed with not enough time or sufficient resources for addressing the enormity of the problems they face in their work. In comparison to the human rights violations they are dedicated to combat, taking care of themselves may seem less important, selfish, or impossible.
This chapter identifies human rights instruments that support all persons’ (including social workers’) right to leisure, health, and well-being. It examines the use of self by social workers engaged in rights-based practice. The practitioner’s ethical duty to remain deeply self-reflective and aware of the impact of his or her work and approach on self and those they work with is also highlighted. Application of cultural humility and other core principles of a rights-based approach to practice are infused throughout this chapter. The vital need for social workers to deepen their skills of self-awareness and continually reflect on their own values, biases, assumptions, and prejudices is promoted in order to safeguard and realize the rights of those they serve. Individuals, families, and groups served by clinical practitioners frequently are in distress when they seek or are mandated to receive services from social workers and may have a significant trauma history, including sometimes trauma as a result of seeking or obtaining services from social workers or other service providers not operating from a rights framework. The impact of rights-based practice on the social work practitioner is explored. It is essential that every clinician working with trauma survivors develops and nurtures ongoing self-awareness and the ability to manage his or her own reactions to the person’s trauma material in order to minimize the risk of retraumatizing the survivors they work with (Piwowarczyk, Moreno, & Grodin, 2000; Wilson & Lindy, 1994). If not aware of their secondary traumatic stress, clinical social workers may do harm to the survivors they serve, even unintentionally. Attention to assessing, preventing, and attending to the practitioner’s vicarious or secondary trauma and the impact of CTRs on the therapeutic relationship is included, and readers are introduced to the concept of vicarious resilience. Recommendations are presented to advance self-care and the clinical practitioner’s ability to engage with the pain, distress, and trauma of those they serve in a therapeutic fashion in keeping with a rights-based approach to practice. Finally, a call for the importance of creating an organizational culture of self-care is made.
Social work and allied professions increasingly are preparing their practitioners to engage in what is referred to as “self-care.” While it is vital for clinical social workers to develop the awareness, skills, and commitment to take care of themselves, this does not take away from the obligation of organizations and governmental authorities to ensure their rights to health and leisure are protected and realized. New Tactics in Human Rights (2010), a global community of human rights defenders, defines self-care as the “ability to engage in human rights work without sacrificing other important parts of one life …. Self-care can also be understood as a practitioner’s right to be well, safe, and fulfilled” (para. 4). Rather than framing self-care as an individual endeavor, a goal that does not fit culturally for many, identifying self-care as a collective concern of the individual, the organization he or she works for, and his or her community is recommended (New Tactics in Human Rights, 2010). Ensuring the well-being of the practitioner is consistent with the human right to leisure and health.
Relevant Human Rights Instruments
Various international human rights instruments affirm the rights of all humans to leisure, health, and well-being. The Universal Declaration of Human Rights (UDHR) states that “Everyone has the right to rest and leisure, including reasonable limitation of working hours and periodic holidays with pay” (UN General Assembly, 1948, Article 24). The right to health is also set forth in the UDHR: “Everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing, and medical care and necessary social services” (UN General Assembly, 1948, Article 25.1). The right to health is also supported by the International Covenant on Economic, Social and Cultural Rights (UN General Assembly, 1966) that holds, “Everyone has the right to the enjoyment of the highest attainable standard of physical and mental health” (Article 12.1). The United Nations’ Committee on Economic, Social and Cultural Rights, in its General Comment 14 (2000) stresses that the highest standard of health is something that every human is entitled to and that this indispensable right supports the ability of human beings to live in dignity and to exercise their other human rights. States are obligated to fulfill and implement the right to health and the United Nations has appointed a special rapporteur to examine and report on the implementation of this right and violations by State parties. The codes of ethics adopted by the International Federation of Social Workers and the National Association of Social Workers in the United States also affirm these rights. This body of instruments and ethical codes supports the right of social workers to leisure, health, and well-being. In practice, many factors contribute to making the realization of these rights challenging.
Use of Self and Self-Awareness
Clinical social workers enter into professional relationships with the people and communities they serve. In the process, they seek to become change agents, using themselves (in part) to effect positive change and growth in those they work with. For decades, social workers have spoken about the key role of the use of self in their work, and that the social worker himself or herself becomes the instrument of change through the development of an effective therapeutic relationship (Chapman, Oppenheim, Shibusawa, & Jackson, 2003; Heydt & Sherman, 2005). By this, social workers mean that they deliberately and determinedly interact with those they serve to facilitate change using his or her abilities, energy, and enthusiasm (Sheafor & Horejsi, 2003; Heydt & Sherman, 2005). Sometimes, this means containing distress through the social worker’s demeanor and interventions. This can be particularly challenging when the social worker finds that he or she becomes distressed in the session himself or herself (a topic addressed later in this chapter).
Social workers must remain aware of and in control of their feelings and motivations in their work, and be attentive to how they are perceived (Neuman & Friedman, 1997). Postgraduate training and ongoing clinical supervision by a seasoned licensed clinician with relevant experience is strongly recommended to develop one’s ability to do this and monitor and address challenges as they emerge in practice. Chapman et al. (2003) teach MSW students a model of peer supervision given the reality that many public organizations do not have the resources to provide as in-depth and frequent clinical supervision as is needed. Self-knowledge and awareness are essential in order for social workers to discern the countertransference, transference, and other key dynamics in their relationships such that they can engage in effective helping relationships at both the micro and macro levels (Jacobson, 2001).
At times, the way the person seeking services perceives and reacts toward his or her social worker (the person’s transference) may be hard for the social worker to tolerate or know how to respond to. Sometimes the situation may become volatile.
Nguyen2, a 46-year-old South Vietnamese former officer, who had been detained and tortured for more than 5 years in North Vietnam by the military after the fall of Saigon, was seen by a therapist in the United States for his depression and post-traumatic stress disorder (PTSD). As Nguyen walked with the therapist toward her office when they first met, he swore loudly at the therapist over and over, so all in the clinic could hear. Once in the office, he refused to sit down for most of the session, clenching his fist as he expressed anger toward the therapist. He was livid that he had come to a clinic specialized in treating Southeast Asians, but had been assigned to the only non-Southeast Asian clinician. Nguyen identified (correctly) the therapist as American and a feminist (although she did not confirm this later assumption on his part). He did sit down eventually that first day. Over time, Nguyen revealed to his therapist that his torture had begun when he was “abandoned” by the American military forces he was fighting alongside. His wife was now divorcing him. She had arrived in the United States long before he did, while he was still detained. She had adopted “feminist ideas” in the United States and he feared that his female American therapist would take the side of his wife. Nonetheless, Nguyen engaged in therapy with this therapist for several years. The therapist had to have strong skills and self-awareness in order to contain the situation and build a positive therapeutic relationship over time with Nguyen. Ultimately, the very things about the therapist that triggered a negative reaction in Nguyen appeared to become, over time, key ingredients in his healing process.
The interactional social work practice theory of Shulman (1999) relates to the clinical social worker’s skilled use of self to create a therapeutic relationship and positively influence the outcomes of his or her interventions. Chapman et al. (2003) explicate the key features of a course designed to teach MSW students in their final semester how to effectively, ethically, and professionally use themselves in their practice. Social work students are taught to deeply understand the difference between conscious and unconscious use of self (Chapman et al., 2003; Heydt & Sherman, 2005). Through experiential activities, they are guided to examine how their personal characteristics and history serve as the basis of their emotional reactions to those they provide therapy to (countertransference) and affect their work together (Chapman et al., 2003). Some may have had little exposure in their coursework to process-oriented training and, in contrast, may have encountered media images of therapists such as in the films Good Will Hunting and The Prince of Tides that depict unethical and sometimes dangerous clinicians who violate ethical boundaries, yet the people they work with get better (Chapman et al., 2003). Social workers who rely on their gut to guide their clinical interventions, no matter how well intentioned and desirous of being helpful, are not acting professionally (Heydt & Sherman, 2005). They may well violate the rights of those they serve in doing so. Lacking self-awareness, a social worker may engage in behaviors or display emotions that are harmful to the very people they are trying to assist (Cournoyer, 2000). A Jamaican social work educator describes how student prejudices toward and perceptions of marginalized populations (e.g., individuals who are LGBTQ, disabled, living in severe poverty, and/or living with HIV/AIDS) shaped by what she calls anti-rights socialization in society, can be confronted and transformed in the curriculum (Chadwick-Parkes, 2014). If left unexamined, the social worker may be at risk for having his or her personal beliefs, attitudes, interactional patterns, values, and prejudices affect his or her ability to be helpful or sustain a therapeutic relationship. Enhanced and conscious awareness of these factors enable social workers to make effective use of self as an instrument of positive change (Heydt & Sherman, 2005).
Ellen, the social worker in the opening vignette in the chapter, might be at risk of engaging in a nontherapeutic fashion with the women she serves if she does not make conscious use of herself. For example, suppose that she still feels fragile about the severing of her relationship with her father, as a result of the long-term violence she witnessed him inflicting on her mother, when she was a child. Imagine that Ellen continues to have nightmares about the times she and her mom and brother spent in the shelter. If Ellen is not fully aware of these continued impacts of her own traumatic childhood, she may be in danger of imposing her own choices on the women she works with. She may, for example, try to persuade them not to go to a shelter rather than ensuring that the women are fully aware of their rights and full range of choices and supporting their self-determination.
Since clinical social workers cannot avoid using themselves in their work (as described above), it is vital that they work to make it a priority to continually enhance their self-awareness throughout their career. The potential risks for the people they serve of not doing this, or not doing it effectively, are great. Among the various factors that may impede the development of a therapeutic relationship, particularly if the social worker is not aware of them, are behaviors and attitudes that are degrading or devaluing of others and personal issues (Sheafor & Horejsi, 2003). Personal issues may include such matters as dealing with one’s own or a family member’s mental or physical health problem or addiction; going through a divorce and child custody issues; healing from a rape or other assault; experiencing financial stress; undergoing a spiritual or religious transformation in one’s own life and trying to impose one’s own beliefs and values on others; and a tendency to become defensive about one’s own views with an inability to hear or consider the perspectives of others.
The imperative of self-awareness as a clinical social worker, including in relation to one’s own stereotypes and biases “about self and self in relationship to other cultures” (Ortega & Faller, 2011, p. 34), is also a part of what is required in approaching one’s work with cultural humility (one of the core principles of a rights-based approach to practice). Self-awareness not only promotes connectedness with oneself but also with others, including the people one works with (Ortega & Faller, 2011). Social workers “must assess the barriers their own attitudes and behaviors present to learning from others about others since personal knowledge alone will not sustain new insights, awareness, and behavioral change” (Ortega & Faller, 2011, p. 34).
Rights-based practitioners are encouraged to engage in therapy of their own, even if they do not have pressing or significant issues to address, in order to enhance their self-awareness. Becoming aware of one’s vulnerabilities or unhealthy behaviors without becoming defensive, and remembering and revisiting painful events from the past can be stressful and emotional experiences. These issues are more appropriately addressed in depth in therapy than in supervision. Engaging in one’s personal therapy may also be helpful in addressing the impact of intense clinical work with those who have had their rights violated. Crenshaw (2008) stresses that a therapist’s self-awareness and healing of his or her own vulnerabilities is:
… not an isolated task undertaken for a relatively brief period of personal therapy but rather a life long journey in which self-monitoring, personal therapy, supervision, consultation with colleagues, and continuing training and education are vital …. We can’t afford to undertake this work with blind spots, unhealed damage, or unresolved trauma. (pp. 123 & 124)
Social workers must attend to their own healing to be able to serve others effectively.
Therapist’s self-awareness can also extend to the somatic and emotional sensations the therapist experiences as he or she hears a story of trauma or sits with someone in great distress in his or her office. Consciously being aware of and transforming these sensations can be helpful to the therapist in containing his or her own distress while also enabling him or her to remain present and available to attend to the distress of the person they are conducting therapy with. The example of Rose, below, illustrates a piece of this work.
Rose, an adolescent torture survivor from a country in West Africa, experienced a dissociative flashback in her therapist’s office as she recounted searching through a pit of dead bodies looking for her father. Rose began to hyperventilate. The therapist split her awareness, remaining attentive to Rose while bringing a portion of her awareness to her own body. The therapist became aware that her stomach was tightening up and that her breathing was more rapid and shallow than usual. This gave the therapist the opportunity to consciously deepen and slow down her breath, while at the same time, grounding and orienting Rose back to the safe environment of the therapy room with her, half way around the world from the pit and those who tortured her and killed her father. The therapist also gently but firmly encouraged Rose to slow her breathing and match the therapist’s breath—in and out … in and out. Then the therapist added a visualization of a safe place that she and Rose had developed together in an earlier session prior to doing any trauma work. Rose was gradually able to regain her equilibrium and return to being present with the therapist, no longer hyperventilating or flooded with images and sensations of her trauma.
Rose’s therapist found that her training in meditation was a powerful and valuable tool that enabled her to navigate this challenging moment in therapy.
Given the important influence the social worker can exert on the person he or she is engaged in psychotherapy with, positive or negative or mixed, it is essential that the social worker strive to be continuously and consciously self-aware. For example, a trauma survivor may shut down or stop sharing important details or feelings if the clinician starts to grimace or gasp (or otherwise become visibly distressed) when the survivor reveals a particularly sensitive or gruesome part of his or her experience. That is not to say that the clinician should sit with a blank expression on his or her face or smile throughout the session, as that would also not be therapeutic. Acknowledging and validating the pain and rights violation (verbally and nonverbally) is essential, yet maintaining one’s empathic engagement and professional demeanor will facilitate the exploration of difficult aspects of the survivor’s experience.
Trauma survivors often utilize avoidance strategies (e.g., substance abuse and dissociation) in order to cope with trauma memories and associated emotional distress (Briere, Hodges, & Godbout, 2010). A therapist may also consciously or unconsciously seek to avoid hearing about or processing the traumatic experiences of survivors they provide psychotherapy to. Awareness of this response and the development of skills and abilities by the therapist so that they are not avoidant are essential. While such avoidance may be a protective response, it can hinder the positive aspects of treatment survivors may derive from exposure to and working through the traumatic memories, and consequently, interfere with recovery (Briere & Lanktree, 2013; Briere, Scott, & Weathers, 2005; Polusny, Rosenthal, Aban, & Follette, 2004).
Vicarious or Secondary Trauma
Clinical social workers, exposed at high rates to the trauma material of others, are at risk for developing vicarious traumatic stress (also known as secondary traumatic stress) (Bride, 2007). Rights-based clinical social workers must be able to engage empathically with the trauma material of those they serve. In doing so, their inner experience is transformed and in the absence of appropriate boundaries, they may be at risk for developing vicarious trauma (Saakvitne, Pearlman, & Staff of TSI/CAAP, 1996