Portfolio Piece: TOUCH by Becky Blanton

TOUCH

SWPRN.COM MAY 2014

A QUARTERLY JOURNAL FOR SOCIAL WORKERS WHO TOUCH PEOPLE’S LIVES

Boundary Setting For

SocialWorkers

The Situational Narcissist • What to Do After a Client Suicide • When Trauma Occurs on Your Caseload • Understanding Military Sexual Trauma •

Welcome to Touch, Touch is a new kind of newsletter for SWPRN social workers and those who work with them. Social workers encourage, support, praise, challenge, push, pull, worry, celebrate, mourn, grieve and...

Care.

Social Workers touch lives and Touch is here to help them with tips, case studies, workshops and stories that also encourage, support, praise, challenge, push, pull and to show SWPRN appreciates and CARES for them as well.

Touch

A Quarterly Journal for Social Workers

Publisher Robert Plotkin Pres. & CEO, Social Work p.r.n. of Philadelphia Deputy Editor and Coordinator Joann Poole Director of Operations, Social Work p.r.n. of Philadelphia Creative Director and Editor-in-Chief Becky Blanton Marketing Consultant Bob Poole The Poole Consulting Group Social Work p.r.n. of Philadelphia is a social work owned and operated franchise company and was built as a social work business that could integrate these values and serve as a resource for both settings and social workers. Core values include: • • • • • • •

Businesses are built on relationships Relationship-building is paramount to the success of our business People, specifically, our employees and affiliate staff, are our most valuable resource Consistent validation of a person’s contributions helps a person feel valued “Growing people” is both good for persons and for the organizations for which they labor Persons are entitled to be “whole people” with “whole lives” even though they work at jobs, AND…. The concept of “fit”. The concept holds that the relationship between the employer and the worker helps to meet the needs of both parties and the mutuality of the fit is vital in placing workers into jobs.

Questions, comments or suggestions? Contact: joann@swprn.com bobpoole@bobpoole.com

7241 Hollywood Road Fort Washington, PA 19034 t: 215-641-2311 f: 215-641-2313

Dear Social Workers, Employers and Contractors, Welcome to the premiere edition of TOUCH, our new newsletter/magazine. Each edition of Touch will focus on a theme. Our first edition is focusing on boundaries. As we all know, our professional and personal reputations are built on a foundation of respect, relationships and growing people into all they can be. That begins with healthy boundaries. Spring and summer are, unfortunately, when suicides and accidents peak. More teens are killed, or kill themselves, during the spring and summer than any other time of the year. So we’ve also included articles on what to do in the aftermath of a client suicide, as well as how to cope with death on your caseload, the topic of a recent SWPRN workshop. I hope you enjoy our new newsletter format. We would love any feedback you have, positive or otherwise, regarding the content, layout, idea and especially the Q&A section. We hope to expand that area each issue to deal with the various questions and concerns of social workers, employees and those who read TOUCH. Thank you and look forward to more to come!

Rob Plotkin 5

In This Issue Client Suicide: 9 Things to Do in the Aftermath of a Client Suicide

PAGE 38

One in four therapists and half of all psychiatrists will experience a client suicide during their career. Doing these nine things in the aftermath may help you or a colleague cope with the emotional, social and legal aftermath of what experts call the “most devastating event in a therapist’s career.”

Work Boundaries 101 It’s one thing to set and enforce boundaries with clients, but what about your boss? Learn how to create, communicate and enforce boundaries with co-workers, your boss, vendors and supervisors.

PAGE 22 Upcoming Workshops PAGE 60

Check the SWPRN.com website for updates and changes.

April 14, 2014 When Trauma or Death Occurs on the Caseload Page 48 May 2, 2014 Putting the Pieces Together: Supportive Supervision Page 54 May 16, 2014 Helping Medical Patients Cope: A Problem Solving Therapy Approach Page 60

PAGE 54 6

PAGE 62

September 26, 2014 Understanding PTSD & Military Sexual Trauma Among OIF & OEF Female Veterans Page 62

Have a Question? Get an Answer. Q&A is like “Dear Abby,” only for Social Workers. If you have a professional, personal or client question, email us at QandA@swprn. You will remain anonymous unless you request otherwise. Look for the answers in the next issue, or on our Facebook page. Page 20

ActionAIDS: Featured SWPRN Employer!..........................................8 Fun Facts Social Workers On the Job!.............................................12 Situational Narcissism!......................................................................14 Q&A!...................................................................................................20 Boundaries 101!.................................................................................22 Client Suicide: 9 Things to do in the Aftermath!..............................38 Death on the Caseload!....................................................................48 Supportive Supervision!....................................................................52 Understanding Military Sexual Trauma!...........................................62 Recommended Books!.....................................................................68

TOUCH Magazine is copyrighted by The Poole Consulting Group LLC and may not be reproduced by any means, electronic or otherwise, without the express, written permission of Robert Poole, President - The Poole Consulting Group. The magazine is a quarterly publication offered in both print and digital format. Social Work p.r.n. of Philadelphia.

ActionAIDS Friends for Life

SWPRN employees work with some of the best, the brightest and the most life changing agencies, organizations and corporations in the state. Each issue we feature one of those SWPRN employers and highlight their organization and their mission. If you have a suggestion for an agency or organization to feature, let us know. 8

“No One Should Ever have to face AIDS ALONE.” ActionAIDS is a member of United Way & funded by The Philadelphia Department of Public Health, AIDS Activities Coordinating Office (AACO)

When a gay man with AIDS is fired by his law firm because of his condition, he hires a homophobic small time lawyer as the only willing advocate for a wrongful dismissal suit. He wins. That’s the plot for the 1997 Oscar winning movie, Philadelphia. It’s the kind of story that sparked the founding of ActionAIDS by 86 buddies and volunteers more than a decade before the award-winning film touched millions of viewers and helped change the way people saw people with HIV/ AIDS. It’s a testament to the organization’s impact that many of the scenes in the Philadelphia movie were actually filmed on the fourth floor of their offices. “All of our clients have HIV disease,” said Beth Hagen, the Deputy Executive Director for ActionAIDS. “We provide medical case management, and help the financially disenfranchised client with HIV and/or AIDs. Our goal is to remove barriers to allow people to get the services they need, from housing to medical care, to support. “Volunteers have a really special place for us. We were founded in 1986 by a group of volunteers, so we have a large footprint of volunteers throughout all of our programs,” she said. As the largest AIDS and HIV service organization in the state, ActionAIDS currently serves over 4,000 clients a year in five offices (four in Philadelphia and one in Delaware County) through the efforts of over 350 dedicated volunteers and 84 professional staff. “We try to link people with any services that are going to let them get into medical care and sustain treatment, including helping them get insurance, welfare, social security and link them to medical providers, take care of transportation issues and follow them throughout the process.

“We make sure they understand what HIV disease is and the importance of taking care of themselves and taking their meds. Affordable housing is a big issue. One of our new initiatives is partnering with Pathways to Housing around the housing first model, where there’s no requirement for people to stop using drugs or alcohol or to be in mental health treatment and provide really intensive support to help them succeed.” Some of the many programs ActionAIDS offers include:

are tailored to meet the changing needs of the youth population, which includes an educational and support approach to managing HIV disease. Their Medical Case Managers work with youth to establish and develop a professional relationship to help remove barriers to accessing primary medical care. Those services may include support groups, transportation, assistance with accessing medications, and assistance and support for treatment adherence.

BUDDY PROGRAM ActionAIDS Buddy Program is now one of the oldest and largest buddy programs in the United States. They serve over 250 individuals and families each year. ActionAIDS has become a national model for volunteer programs. Trained volunteer buddies work closely with case managers to prevent isolation by providing emotional and practical supports through regular calls, visits, and help with the tasks of daily living.

FREE HIV TESTING Taking an HIV test is the only way to know if you are at risk for AIDS. ActionAIDS offers Free Rapid HIV Tests, in Center City Philadelphia. Rapid testing eliminates the wait for HIV test results. Know your status in only 20 minutes. The test uses an oral swab (no blood is drawn).

SUPPORT GROUPS Support groups are facilitated by volunteers and staff who are supervised by mental health professionals. ActionAIDS holds weekly meetings for HIV/AIDS clients, their family members and loved ones. Attendees are able to discuss the daily challenges of living with HIV & AIDS in a supportive and confidential environment. ActionAIDS groups are tailored to create a safe and comfortable environment for people of many backgrounds. YOUTH FORWARD ActionAIDS Youth Forward Program provides specialty Medical Case Management and Prevention services for adolescents and young adults. Services

PRISON Case managers also help people with HIV/AIDS who are in the Philadelphia County Jail. They make sure they’re engaged in medical services while they’re in prison and then help them obtain additional services when they’re discharged from prison. PERINATAL PROGRAM The Perinatal Program is funded by the AIDS Activities Coordinating Office (AACO) and provides case management to pregnant women living with HIV and AIDS. While specialized Case Managers are linked to the prenatal clinics at HUP, Temple, Einstein, Pennsylvania Hospital, Hahnemann and Jefferson, perinatal case management is available for any pregnant client regardless of where she receives care. Perinatal Medical Case Managers will work with clients throughout their pregnancy and up to twelve months

postpartum. Perinatal Medical Case Managers (PMCM) are trained in the specific needs of pregnant women and are aware of the resources available to this population. Some of the services include: • assessing medical/medication adherence and client readiness • monitoring CD4 and viral load as it relates to reducing the risk of mother-to-child (MTC) transmission • screening for safety and intimate partner violence • securing medical insurance for mother and infant • referrals for baby equipment/clothing • education around formula feeding and not breastfeeding • linking infant to pediatric HIV Specialist • education on AZT for baby postpartum • risk reduction counseling HOUSING Lack of housing and homelessness are the most critical threats facing people living with HIV today. ActionAIDS has six counselors who serve more than

600 individuals and families each year. The program works to prevent homelessness and promote economic and social self-reliance among individuals with HIV. Services provided by agency Housing Specialists include but are not limited to: working with clients to identify housing needs through a comprehensive assessment and frequent contact, negotiating housing services with clients, providing training and advocacy to clients in regards to tenants' rights and responsibilities, providing information, referral and linkages to subsidized housing programs and working closely with other agency staff to ensure that all goals outlined in an annual service care plan are being met. EMPLOYMENT ActionAIDS provides employment and educational services to people living with HIV & AIDS. Learn more about our employment services, and share this page with people. Our staff is working hard to ensure that people know about the employment and educational opportunities available in and around the city of Philadelphia. ActionAIDS helps individuals build their resumes, apply for jobs online and find who is hiring.

OTHER SERVICES • • • • • • •

Buddy Program (one of the nation’s oldest and largest) Medical case management Outreach Housing Counseling Housing at Casa Nueva Vida Positive Living HIV Testing

• • • • • • • •

Prevention & Education Counseling Prison Linkage Program Family/Perinatal Program Youth Forward Program Positive Action Employment Services Support Groups Advocacy

FUN FACTS Facts obtained from helpstartshere.org

According to the Bureau of Labor Statistics, the need for social workers is expected to grow twice as fast as any other occupation, especially in gerontology, home healthcare, substance abuse, private social service agencies, and school social work. 12

Professional social workers are the nation’s largest providers of mental health services. According to government sources, more than 60 percent of mental health treatment is delivered by social workers.

Ever wonder if you picked the right profession? You did! Social workers help people in all stages of life, from children to the elderly, and from all situations from adoption to hospice care. This means the opportunity to find your dream job is greater than in almost any other profession. Social workers are found in almost every workplace, from fire departments, veterinary clinics, hospitals, ranches, the military, outdoor- and sports-oriented companies; to anywhere people need someone with people skills, listening skills and the ability and training to help people. According to the Bureau of Labor Statistics, the need for social workers is expected to grow twice as fast as any other occupation.

Social Workers

On the Job More than 650,000 people currently hold Social Work degrees in the USA, including more than 170 social workers in national, state, and local elected office, including two U.S. Senators and four U.S. Representatives.

The Veteran’s Administration employs more than 3,800 MSW’s to assist veterans and their families with individual and family counseling, patient education, end of life planning, substance abuse treatment, crisis intervention, and other services. 13

Situational Narcissism When Circumstances Bring Out the Worst

By Betsy Wuebker

Have you ever been blindsided by a sudden, explosive change in a previously stable friend, client or co-worker’s behavior? Maybe someone's "inner drama queen" let loose in a completely inappropriate response to a stressful situation. Or, perhaps during an investigation you became a target of extreme behavior designed to throw you off track. These are all indicators for situational narcissism in a person whose negative behaviors have mostly been under wraps, until now. In this article, “situational narcissist” is a chosen term used to describe a person whose previously covert narcissistic behavior has been triggered by a change in circumstances. The narcissist may previously have had relationship dynamics under control with steady, reliable narcissistic supply occurring in the family unit or professional circles. Suddenly, there is a disruption. Now the narcissist perceives a threat to their carefully nurtured status quo. This disruptive, trigger event may come in different forms. Health issues in self or family member (not necessarily the narcissistic supply source), perceived or actual change in professional circumstances, or developments that affect social

standing can all cause closeted narcissistic behaviors to emerge. If you haven't recognized an individual as narcissistic before this happens, you'll be surprised and unprepared. Note: Acquired Situational Narcissism is a separate concept, where an individual's narcissistic traits become induced by the onset of wealth or celebrity. What is it with Narcissism anyway? Clinical and social psychologists differ in their assessments of narcissism. Clinicians believe narcissism should be treated as a discrete disorder; social psychologists treat narcissism on a continuum, as a personality trait. Others describe narcissism using a behavior spectrum, with "full-blown" Narcissistic Personality Disorder (NPD) being pathological in severity. Narcissistic persons are most concerned with how they are perceived. They need admiration and recognition. They use these as a coping strategy against their underlying feelings of worthlessness, and they self-protect by avoiding attachment. Narcissists also tend to “overreact when they perceive others are setting limits…” See Narcissistic Personality Disorder: Rethinking What We Know.1 Because narcissists are “empathy-impaired,” they are unable to respond appropriately to another person's feelings, even though they may feel as 15

Whenstressbecomes

TOO though they do. They may even describe themselves as empathetic when they really aren't. People with NPD are not particularly self-aware, in that they fail to identify their own behavioral triggers, needs and motivations. As such, some psychiatric theory points to empathy as being a risk for a narcissist: they need others to validate them, not vice versa. When others are hurting or require attention, a narcissist feels as though he is being deprived of energy that “belongs” to himself.

Narcissistic behaviors will often trigger compensating behaviors in the supply source, as well as any enablers in the narcissist's orbit. The CEO's husband may neglect or defer decisions on his mother's behalf, the abusive parent's children may refuse responsibility, alienated children may engage in protective alignment behaviors, and admirers may defend the narcissist to others.

What happens when a covert narcissist's supply is threatened?

How is situational or covert narcissism relevant to my professional caseload?

The narcissist may have had it all together up until now: stable family life, adoring spouse, professional recognition and accomplishments, good reputation in the community. But, the secret part of a covert narcissist's life is the relationship with narcissistic supply. This supply comes from someone the narcissist views as an underling: a romantic partner, child, sibling, employee, colleague, or friend.

Your job is to identify vulnerabilities and provide assistance with the appropriate service referrals. Narcissistic behavior may distract or mask the realities of a situation, leading to ineffective interventions. If this type of dysfunction appears frequently in your caseload, you as a social worker may even come to feel intimidated, gaslighted, or abused. Obviously, these behaviors can compromise your professional assessments.

When narcissistic supply is interrupted or under threat, the narcissist acts out. So, the CEO rages at her husband for tending to his mother's medical issues, an elderly person becomes more verbally abusive with infirmity, or the divorced parent alienates the children against the other parent who has had the audacity to remarry.

Narcissistic behavior elevates conflict. The narcissist's need to re-establish control will spill over into the case. They may attempt to manipulate the speed at which a case progresses or resolves, divert perceptions away from difficult truths, and influence decision-makers in their favor. In escalating or highconflict scenarios, narcissists will employ a variety

much of sophisticated tactics designed to restabilize the world according to their needs: triangulation, innuendo, projection, deception, mirroring the real victim, responsibility deflection/shifting, scapegoating and more. Narcissists take advantage of ambiguity in the legal and social service systems. Unless you are prepared (or even able) to cherry-pick your caseload in favor of less complex or demanding situations, you may be dismayed that your ability to provide the appropriate advocacy is systemically constrained. Managing your cases appropriately means understanding and recognizing narcissistic behavior in order to contravene its effects in families, legal systems and professional circumstances. You need this knowledge in order to do a good job. What are some clues that I might be dealing with a heretofore covert narcissist? In healthy relationships, people communicate openly. Conflict is managed by cooperation and problem-solving. In dysfunctional relationships, there is a power structure which inhibits this healthy interaction. Narcissists, who are

heavily invested in the false facade they present to the world, will continue playing their “public” role. Yet, you will see certain clues that indicate not all is perfect in their world. 17

“A narcissist wants to dominate a situation; their strength lies in persuading and influencing others for destructive purposes.As such, they can be very comfortable within the legal and social services process. They will complicate a case by using their rights as an adversarial advantage.”

In the family unit, be aware when you observe submissive behavior. Are the children afraid or subdued? Is a spouse quiet or guarded? Are someone's answers just a little too pat, or is almost everybody using the exact same words in their responses, as though they've been coached? In the face of constructive criticism, does someone come out swinging? Do others justify poor behavior on someone's behalf? Is a person continually acting as the peacemaker? Do people in the situation feel powerless when dealing with someone? In personal or professional circumstances, the narcissist will often be a micromanager in the relationship. Perhaps there is a perfectionist in the mix whose standards must always be met by others in the face of extreme consequences if they are not. Maybe it seems a little too important to an individual that you view them in a positive or admiring way. Sometimes this comes out in the form of a personal story that is meant to evoke sympathy or pity. Do you observe that someone feels inappropriately obligated to another? Is there a kind of "circling the wagons" when secrets like addiction, mental illness, lapses in ethics or law breaking might come to light?

How do I handle a narcissist in the context of my case? A narcissist wants to dominate a situation; their strength lies in persuading and influencing others for destructive purposes. As such, they can be very comfortable within the legal and social services process. They will complicate a case by using their rights as an adversarial advantage. Courts and social service agencies often unwittingly strengthen the narcissist with favorable decisions based upon incorrect perceptions. Don't be fooled by unreliable information. You may not be getting the "whole truth" from individual family members or members of other dysfunctional groups. These people tend to protect themselves by defending the existing dynamic. Bill Eddy of the High Conflict Institute tells us that children will align with the more powerful and disturbed parent, spouses may be afraid to leave the abuser, or families may scapegoat the most functional individual. As such, legal and social advocates are prevented from getting at the truth, and faulty decisions follow. Look at behaviors. Zoom out from individual issues and observe the whole. Is there a discernible behavior pattern? Eddy recommends a team approach which will correct individual biases and

“Bill Eddy of the High Conflict Institute tells us that children will align with the more powerful and disturbed parent, spouses may be afraid to leave the abuser, or families may scapegoat the most functional individual.”

misinformation in assessments. Get more training to develop your skills in detecting tell-tale behavior patterns associated with disordered behavior and dysfunction.

1 http://www.psychiatrictimes.com/personality-

disorders/narcissistic-personality-disorderrethinking-what-we-know FURTHER READING:

What's the overall takeaway here? Know that covert narcissism can be triggered on a situational basis. When a narcissistic individual perceives that loss of supply is imminent, behaviors will escalate proportionally. If a narcissist has a history of inappropriate behaviors - verbal abuse, disregarding court orders, physical threats, for example - they will fall back on these when faced with new situational threats. Looks can be deceiving. Know that the narcissist up to this point may have been quite skillful at managing the relationships in their orbit. They may appear quite charming, accomplished, and charismatic. The picture they present to outsiders can be quite false. Dig a little deeper. Be aware that the presence of a covert narcissist in your case will most likely complicate and prolong it. Be prepared to identify and forestall their tactics from harming the process and causing further injury to vulnerable parties.

The High Conflict Institute — New Ways for Families — Professional Information http:// www.highconflictinstitute.com/new-ways-forfamilies/new-ways-for-families-professionalinformation Not To People Like Us: Hidden Domestic Violence in Upscale Families http:// www.nottopeoplelikeus.com/ weitzmanCenterSWNArticle.pdf What Borderlines and Narcissists Fear Most: Part A http://www.psychologytoday.com/blog/stopwalking-eggshells/201110/what-borderlines-andnarcissists-fear-most-part

Betsy Wuebker, writer and researcher, has coauthored two books on the subject of narcissism, The Narcissist: A User’s Guide and The Narcissist at Work.

Q&A is like “Dear Abby,” only for Social Workers. If you have a professional, personal or client question, email us at QandA@swprn. You will remain anonymous unless you request otherwise. Look for the answers in the next issue, or on our Facebook page.

What type of agencies does SWPRN work with?

This is probably the most asked question SWPRN gets each month. If you’re not familar with Social Work p.r.n. (SWPRN) we’re a social work owned and operated franchise company. We work with many social service agencies, including schools, hospital both medical and psychiatric, long term care to managed care and employee assistance programs. A social worker can wear many hats. They are called clinicians, therapist, counselors, case managers and coordinators. So, any agency that would utilize a social worker, no matter what the job title is, we can assist with staffing a professional social worker.

The business started in 1988 under the company name, Joan Upshaw & Associates. In 1992, we trademarked the name Social Work p.r.n. “PRN” is Latin for pro re nata or “under the circumstances.” Hence, our name Social Work “as needed.” For more information and other locations, please visit the corporate website at www.socialworkprn.com. Franchising opportunities exist throughout the United States, so come on and join the team! Believing that social work and business ideas make a great meld, Joan K. Upshaw, LCSW, developed Social Work p.r.n. as a demonstration project for the social work profession. Our core values include:

• Businesses are built on relationships • Relationship-building is paramount to the success of our business • People, specifically, our employees and affiliate staff, are our most valuable resource • Consistent validation of a person’s contributions helps a person feel valued • “Growing people” is both good for persons and for the organizations for which they labor • Persons are entitled to be “whole people” with “whole lives” even though they work at jobs, AND…. • The concept of “fit”. The concept holds that the relationship between the employer and the worker • 20

helps to meet the needs of both parties and the mutuality of the fit is vital in placing workers into jobs. Social Work p.r.n. and Social Work p.r.n. of Philadelphia were built as a social work business that could integrate these values and serve as a resource for both settings and social workers.

Seeking EAP service providers Arcadian Telehealth provides telemental health service to EAPs. We are currently looking for providers in your state to provide EAP services to our customers.

You must be a clinically licensed, master level clinician and have EAP experience. All services are provided via HIPAA compliant video conferencing. If you would like to forward your resume/ CV for our review, it would be appreciated. Please include the state in which you are licensed and any specialties you may have. Also, include your available time for providing this service.

ARCADIAN telehealth Please contact Dr. Elly Engel at 215-641-2525 for more information or submit your CV to elly@arcadiantelehealth.com.

7241 Hollywood Road Fort Washington, PA 19034 215-641-2525 www.arcadiantelehealth.com 21

Boundaries 101 Why You, “Don’t Get No Respect”

In the wild, gorillas, chimpanzees and monkeys do something called a “monkey dance,” where they threaten, scream, jump around, shake sticks or their fists and act angry in order to intimidate other members of their group in order to get their way. The sad thing is, a lot of people do the same thing.

Boundaries aren’t just a sign of a healthy relationship with others; they’re a sign of self respect. The more you respect yourself, the more others will too. The better your boundaries are, the better (and more respected) a social worker, a person, a spouse, a partner and a friend you will be — but more importantly, the more you’ll respect yourself. It’s true. So how good are your boundaries? • • •

Do you ever feel like people take advantage of you? Is your nickname (if only in your own mind) “doormat?” Do you feel like the adult in a room of grown up kids, constantly having to “save” people close to you and fix their problems?

• • •

•

Do you feel angry, frustrated and resentful when people ask you for favors? Do you spend too much time getting sucked into pointless fights or debates? Do you find people constantly using your emotions (guilt, desire to please, etc.) for their own gain? Are you the one people go to first to cover a shift, collate photocopies, run errands, host or oversee the company potluck, or volunteer for mostly undesirable jobs, projects and tasks? Do you find yourself waaaaay more invested or attracted to a person than you should be for how long you’ve known them? Do you find it hard or impossible to say “no” to friends, family and co-workers, even when you really hate the idea of saying “yes?”

“People tend to respect people who have strong boundaries and disrespect those who don’t.”

•

Does your marriage or relationship feel like things are always either amazing or horrible, with no in-between? Or perhaps you even go through the break-up/reunion pattern every few months? Do you lie awake at night, scheming about ways to avoid people so you don’t get “tricked” into agreeing to something you don’t want to do?

•

Do you feign illness, other obligations or spouse disapproval rather than simply saying, “Thanks, but no thanks” to requests from others? Do you tell people how much you hate drama but seem to always be stuck in the middle of it? Do you have a poor sense or disregard of personal space? Can you sense or do you know

“If you don’t respect yourself by having and enforcing personal boundaries, how can you expect others to respect you and honor your boundaries?”

• • • • • • •

•

how physically close you should be in relation to another person? Do you disregard your personal values in order to please others? Do you fall in love with someone on a first date? Do you ignore another person’s display of poor boundaries or invasion of your boundaries? Do you share too much personal information with someone you don’t know well? Do you accept food, gifts, touch, invitations or sex that you don’t want? Do you give or take gifts excessively? Do you think obsessively about another person for any reason, as in you can’t get them out of your mind for good or bad reasons? Do you allow others to describe your reality — in other words, tell you what you like or don’t like, what you should or should not do, how you should dress, decorate, eat, exercise or look? Do you act on your first sexual impulse or are you sexual for your partner and not for yourself?

•

Do you expect others to anticipate and fulfill your needs? If you answered yes to four or more of these questions, chances are your boundary skills (or lack of them) could use some help. More important than the fact you’re not experiencing the life you could have, a lack of boundaries, or poor enforcement of the boundaries you do have, is the reason for the respect you’re not getting. More than anything else boundaries do for you, they increase the amount of respect people have for you. What!? All this time you thought being nice and giving everyone everything they wanted would earn you stars and respect? Wrong. Oddly enough it seemed to work when you were being abused, or were in unhealthy relationships. Giving up what you wanted, thought or needed may have convinced your abuser to leave you alone or stop verbally or mentally abusing you, but that’s not the same as having and enforcing a boundary. It’s not the same as getting respect and being treated like you deserve and want to be treated.

If you don’t respect yourself by having and enforcing boundaries, you can’t expect others to respect you and honor your boundaries. To get respect, give respect. Not everyone will respond in kind, but they don’t have to. Healthy people’s emotions and reactions are not dependent on the emotions and actions of others. Even if you feel anger, resentment or even rage, don’t express it. The reality is, we attract people like ourselves. If you are attracting drama, abuse and inappropriate people, you probably have some issues around boundaries in those areas. You teach people how to treat you by what you allow others to do to you and how you react or respond when someone violates your boundary. Get the Respect You Deserve Few of us get the respect we want and deserve from people even when we’re behaving and acting professional and respectful. That’s why it’s important not to engage in an argument when there’s no respect from another person. If someone attacks you, don’t engage in a debate or argument with them. Emotions are not a choice, but your actions are. You can respond, “When you yell at me/criticize me/ respond sarcastically/berate me (pick one), I feel defensive. I’d be willing to discuss this if we can do so calmly and respectfully.” If the person is mocking, rude or abusive in an office setting, restaurant, movie or anywhere in public, respond as quickly as you feel able. Say: “When you say that, I feel uncomfortable/sad/ angry/ and feel like leaving. Please don’t do that.” Chances are you’re going to get some pushback because the person may not respect you. If they do respect you, they’ll apologize and stop, respecting your boundary. If the abuse or boundary violation continues, it’s important to be willing to calmly leave the situation—whether it’s a job, a friendship, a marriage or whatever the relationship, for hours, days or even permanently. That person, boss, coworker, spouse or friend has demonstrated they

don’t respect you. Public humiliation demands an immediate response. Staying in a relationship where you aren’t respected breeds more disrespect. Enforcing boundaries means they’re more likely to be respected and you’re less likely to have them trampled again in the future. Limit your interaction with people who drain your energy and mental or emotional resources. We’ve all experienced the friend with a bottomless well of conversation—often about nothing, or all about gossip. Limit intrusive and draining phone calls and conversations, particularly if the person wants to complain, vent or gossip. Appropriate responses include: •Unfortunately, I have to get going. Talk to you soon. •“Hi. I only have a minute.” One minute later, say: I have to go. Bye! •I’m expecting a call so I can’t talk right now. •I’m on my way to a meeting, what did you need to talk about? Maybe we can schedule something later. •I’m working on a deadline right now, so I don’t have time to talk. Can you send me an email? I have 15 minutes to chat on Friday; will that work for you? I love connecting with you, but I like to keep conversations positive and uplifting. I need to be alone right now. Perhaps another time? I’m preoccupied with something else. I don’t think I have the energy to refocus right now.

“You don’t have to attend every fight, battle, cause or drama you’re invited to.” • • • •

Playing “hard to get” is more than a teenaged dating strategy. It’s the foundation of healthy boundaries. Don’t over share. Limit access to yourself when meeting new people or making new friends. Open up with 10 or 20 percent of yourself, not 75 or 90 percent. That way you have a chance to see if the person is safe, or is someone who will or does

respect your boundaries. You also won’t feel so vulnerable if they aren’t respectful and you realize you’ve just shared your most vulnerable secrets with them. Acknowledge your own needs, desires and wants. If you know what makes you uncomfortable you’re more likely to recognize and address the discomfort before it becomes too pronounced. You’re also more likely to see a boundary trespasser coming and take evasive action as well. Learn to control your energy. We’ve all experienced a feeling of warmth, coolness or downright frigid energy from people. By subtly withdrawing your energy, interest and warmth it’s easy to signal to another person that their remarks or behaviors are inappropriate or unwelcome. If being subtle doesn’t work, then verbalize your boundaries. Say, “I’m sorry, I need to speak with the hostess,” or “I need to take a break,” or even, “I need to go to the ladies room.” You don’t owe someone comfort at the risk or lack of your own comfort and needs, no matter how “right” it might feel or seem. You can choose to put your own needs second, but recognize that is your choice and not because they are owed it. If a person seems well-intentioned, but clueless and unskilled at social cues, withdraw gently, but cleanly. “I’m here with my husband/ partner/friend/co-worker. I need to spend time with them.” or, “Thanks for your time and input, but I’ve got a meeting to get to.” Be less reactive. You don’t have to attend every fight, battle, cause or drama you’re invited to. It’s okay to keep your mouth shut and your opinions to yourself, even if asked what you think. If you do choose to respond, do so from a place of neutrality, without being attached to the outcome, or the understanding or approval of the other person. Having boundaries means not needing other people’s approval or permission to go after what

you want, or to express what you think. Don’t demand respect, command it. If you find yourself demanding respect, or whining or complaining about not getting it, chances are your problem is poor boundaries. Instead of demanding respect, command it. Commanding respect means people naturally respond to you with respect because of how they perceive you. You don’t have to ask for it; it just happens. We all know people who just walk into a room and people stop what they’re doing to listen. We’ve all encountered natural leaders, people who seem to have the attention and respect of everyone from the moment they shake a person’s hand. This is commanding respect. It comes from a high level of self-esteem, confidence, body language, personality and respect of others. Speak confidently, slowly—but not too slowly. Look people in the eye. Be polite. Show respect and honor other people’s boundaries. Leaders get respect because they’ve earned it, and you can too. Influence, don’t manipulate, people. Influence requires others to “buy-in” to your idea because it benefits them as well. Include others, don’t exclude them. Back up your opinions, particularly unpopular or controversial ones, with facts. Don’t be a hypocrite. Keep your word and your promises. Never ever refer to others in a derogatory way. You may think someone is inept and awkward, but it’s better to say, “I think Joe could use some mentoring or help with XYZ,” rather than, “Joe is so clueless when it comes to XYZ.” When people hear you talk negatively about others they wonder what you say about them when they’re not around. Keep your negative opinions to yourself, or couch them in appropriately neutral language. Walk the walk and talk the talk. If you wouldn’t do something yourself, don’t ask others to do it either. Provide a positive example.

“If you don’t practice it, you shouldn’t be preaching it.”

Nice people violate boundaries too! Enforcing your boundaries has nothing to do with how nice, well-meaning or well-intentioned a person is. It has everything to do with how you want, and expect, to be treated. In healthy relationships and encounters other people respect your “No,” and your boundaries. People who continue to push for an answer, or a diﬀerent answer, or who trample clearly expressed boundaries may be great people, but they’re being inappropriate. Allowing them to continue to push, trample or ignore your boundaries is doing them and you a disservice. Strong boundaries, like strong fences, make for good neighbors, good friends and good working relationships.

How to Deal With People Who By Becky Blanton Elizabeth’s new co-worker Tom stopped by her office about 10 minutes before quitting time. “Hi,” he said. “I liked what you had to say in the meeting this afternoon. I’d like to hear more. Do you have time to get a drink or cup of coffee after work?” Elizabeth was flattered. She’d worked hard on her presentation and needed to convince at least two co-workers to help her implement the program. Tom might be one of those since he was showing an early interest. “Thanks Tom,” she said. “I’d love to talk more about the program. I already have plans today, but next week looks good. How about

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Monday?” Tom frowned. “I don’t think it would take more than a half hour. Can we do it before, or after, whatever you have going on after work?” Elizabeth stopped for a moment. It was important to get volunteers, but this was also her night out with her teenaged daughter and she didn’t want to cancel or change her plans. “I’m sorry, Tom,” she said. “I really don’t have time today.” She picked up her briefcase and purse and smiled at him. “It’s Friday and I have plans. Monday is the earliest I can get together with you.” “Well,” he said, “I wouldn’t mind a call on Saturday. Maybe lunch?” Now he was just being annoying and ridiculous, Elizabeth thought.

sh “That’s not an option either, Tom. I don’t work weekends unless it’s scheduled. Nothing is going to happen or change in two days. Let’s plan on meeting Monday around 9 a.m.” Tom was not to be deterred. “We can just talk on the phone if you don’t want to get together.” Elizabeth sighed. “Tom, I hear that you’re very excited about the program I’m starting. I love that you’re interested in it. However, I have plans for tonight and this weekend. Now, will 9 or 10 a.m. work better for you on

Against Your Boundaries Monday?” Tom didn’t like Elizabeth’s response, or the fact that she stood by her boundaries, but he pulled out his phone, checked his calendar and said, “I think 9 a.m. works best.” Elizabeth smiled, ushered Tom out of her office, locked the door and headed home, looking forward to her evening with her daughter. Tom may have been excited to get involved and prove himself right away, or he may not have had any awareness or sense of Elizabeth’s boundaries. He may have assumed she was as anxious as he was to get started on the project and would jump at the chance to do so. Most people have a sense of what

is and isn’t appropriate when it comes to They see what they’re doing as boundaries, but some people simply don’t. acceptable. Standing up to them may not They have poor boundaries themselves, or change them, but they will learn that you a mental or personality condition that don’t respond to their boundary breaking. affects their ability to grasp the subtleties The best thing you can do is enforce of some people’s boundaries. your own boundaries so you won’t have to True, there are people deal with them over and over who do know and again. If you’re recognize boundaries and uncomfortable with people prefer to push against them who push your boundaries, “Healthy boundaries take these 5 steps: in an attempt to manipulate the person that’s setting are not to be confused them, but most of the time 1. Clarify your with threats. Threats the offender is just boundaries. Write them unaware. are old fear motivated down so you know the “There’s a rule of exact edges of your behaviors, boundaries property line, so to speak. thumb for when people push against our “A boundary is a are love motivated boundaries, and a word for communication to inform behaviors,” the continued disrespect of another important person in our boundaries,” Phillip your life about how you Mitchell says. wish to be treated, ~Phillip Mitchell “That word is abuse,” respected and loved,” he says. “No part of spirit Mitchell says. or God is served when you allow yourself People can’t treat you like you want to to be abused. That’s why God gave us be treated if you aren’t clear about how those things at the end of our legs that you want to be treated to begin with. makes us portable.” Mitchell is a therapist and clinical Elizabeth’s boundaries around work trainer at Sierra Tucson, an internationally were very clear. After months of arguing recognized treatment facility for addictions with her family about working late and and mood disorders where he teaches never being home, Elizabeth and her boundaries and boundary setting for a husband and kids wrote down very specific wide range of clients. boundaries for the entire family. They “Boundaries open the door for a whole included time management and an range of healthy responses,” Mitchell says. agreement not to work after 5 p.m. unless “They range from when it’s time to move her supervisor told her she had to stay. on and say ‘goodbye,’ to when it’s time to They also agreed that as a family they deepen our relationship with healthier would discuss weekend plans before communication and a whole host of steps anyone committed themselves to an in-between.” outside activity that involved work. Friday Because people don’t stand up to them nights were “date” nights, where Elizabeth when they do push back, the idea that and her husband took turns taking each of pushing or breaking other people’s their children out for dinner and a movie or boundaries is acceptable gets re-enforced.

to discuss their child’s week and any issues Look at the boundaries the people in or problems they had. your life tend to break or push and whether Alternating weeks were for family they’re willing to change given more date night and then a date for Elizabeth severe consequences. and her husband. It was a sacred day for Some may push for time, money, them all and not missing or being late for attention or your assistance. Others may the date was a solid boundary. only be inappropriate with questions and Other boundaries their interest in your Elizabeth had involved life—in other words, waiting to see how a team they’re nosey gossips, “A boundary is a member performed before o r j u s t n o s e y. I f asking them to be on her you’re not sure if communication to projects. they’re breaking inform another She’d had some boundaries or being unpleasant experiences with inappropriate, trust important person in inexperienced interns and gut. It’s easier to your life about how you your learned to wait and see if recognize trespassers wish to be treated, people were right for the if you’ve written out program before asking. She your boundaries, but respected and loved,” knew nothing about Tom if you feel awkward, except that he was new, and uncomfortable, now she knew he seemed resentful, angry or ~Phillip Mitchell clueless about being offended, sick, scared appropriate. The next step or wrong, or have an was to determine if he simply adrenaline rush had poor or non-existent awareness of during the conversation, chances are boundaries, or if he was an abuser. they’re violating a boundary. If they continue to violate or push against your 2. Identify the people, co-workers boundaries, reconsider allowing them in and friends in your life who don’t your life. Healthy people respect other respect your boundaries. Some people people’s boundaries. may inadvertently trample a boundary, but some may consistently push your buttons 3. Engage brain, shut mouth and and trespass your boundary lines. think before you react. When someone If people consistently break, push or pushes, breaks or outright tramples our trample your boundaries, up the ante on boundaries, the tendency is to react, often the consequences. with anger, sarcasm or a remark that can “If someone continues to break or push make it harder to communicate with the your boundaries after you up the ante, then person. If they are truly unaware they’re that person is abusing you,” Mitchell says. being inappropriate, compassion and If that’s the case, it’s time to walk away. understanding will have better results than “Boundaries aren’t about changing or anger and a tongue-lashing. Consider fixing others. They’re about taking care of exactly what boundary they’re pushing yourself,” he says. against or violating.

Elizabeth did this later when she met we’re training them that if they push hard with Tom on Monday. She simply said, enough we’ll give in. The more you stand “Tom, I appreciate your enthusiasm for my your ground and respect your own program. It’s great to see. I know you’re boundaries, the more others will too. If new so you couldn’t have known this, but you don’t break down or give in, chances I leave work at 5 and Fridays and are the trespasser will find someone else to weekends are set aside strictly for my push. family.” 6. Repeat your boundary, or answer. Tom apologized profusely and It’s called, “Being a broken record.” As confessed that he just wanted to fit in and many times as the offender pushes, push contribute as quickly as back with the same answer. It possible. He hadn’t even can seem like telling a child “There’s a word for considered that his “no” to candy 100 times, but enthusiasm might be that’s exactly what it is. There the continued misconstrued. Like most is a limit to being a broken disrespect of a people who push or violate record. After the second or our boundaries, he was just third time your boundary is boundary and that not aware of what he was violated, it’s time to: word is ‘ABUSE.’ doing. 7. Up the ante or No part of spirit or 4. Be blunt. Trying to consequence. God is served when soften or sweeten your If someone continues to boundary may actually you let yourself be violate your boundaries, confuse a boundary increase the consequences of abused.” breaker. their doing so. If someone consistently If someone consistently breaks your boundaries, or criticizes you and you tell ~ Dr. Phillip Mitchell pushes back at your them you won’t talk to them boundaries, you need to be for a day, then two days, then blunt and tell it like it is. a week and they continue to criticize you, Don’t beat around the bush, don’t worry about that’s abuse. being polite or hurting their feelings. If they’re It’s time to create a new boundary, as breaking a boundary, they need to know. in, “In order to take care of myself I no If Tom had persisted in his boundary longer want to have any contact or violations, Elizabeth would have said, “Tom, I’ve communication with you until such time told you ‘no’ several times already. No means no. as you can respect my boundaries.” “When you keep pushing me to change Then respect yourself enough to honor my mind you’re trespassing a boundary. your own boundary and leave. My boundary is that when I say no, people respect it. Please do not keep trying to change my mind when I say no. If I’m undecided I’ll tell you, but when I say no, it means no.” 5. Don’t give in or back down. We train people how to treat us. By giving in

QUICK TIPS •

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Smile before you speak. Smiling puts the other person at ease and sends the message you value the interaction. Start your response with something positive, or at least neutral, as in, “I appreciate your interest/concern/ question/opinion.” Clarify your boundaries. “I’m not sure if you were aware that I [Express your boundary] and conclude with, “I’m doing this in order to take care of myself.” If the person is a serial or repeat violator, don’t hesitate to be blunt and to up the ante on the consequences of ignoring your boundary. If they continue to ignore your boundaries over time, consider leaving the relationship until they can and do respect you. If you can’t leave the relationship (family, work, etc.) then limit interaction with them as much as possible. Don’t give in, back down or be bullied or intimidated into changing your mind or your boundaries. Stand your ground. It’s the best way to ensure future encounters with the boundary pusher are healthier and your boundaries are respected.

Are You a Frightened Pup or ...

5 Ways to Enforce Your Boundaries in Healthy Ways People who learn to set boundaries as adults often have a hard time enforcing their boundaries when they first start learning how to say no. They either cave entirely in the face of the trespasser, and don’t speak up; or they go all rabid-dog angry and overreact to the trespass. Either reaction tends to make them feel like boundaries “don’t work.” Cindy grew up in a family with no boundaries. She finally started learning about boundaries in her early 50s. Her initial reaction to people who didn’t respect her boundaries was to respond inappropriately with anger, and lots of it! She was sarcastic, cutting, demeaning and horrid. People not only learned not to push

her boundaries, but to never come near her again. She scared them! What she saw as “enforcing” her boundaries they experienced as bullying. She came across as saying, “Treat me like I tell you too or I’ll make your life hell.” When friends pointed this out to her, she went to the other extreme, becoming a pusho v e r. W h e n p e o p l e r e s p e c t e d h e r boundaries, that was great! But when they didn’t, she pulled back and became a pushover. She didn’t defend or enforce her boundaries at all, so people learned that and stopped respecting them, leading to the pendulum-swing back to rabid-dog. According to the experts, that’s a pretty

a Snarling Dog? common progression for anyone learning to set boundaries. Timing Most of the time, we’re not aware we’ve violated someone’s boundaries until there is a fight, a disagreement, a blow-up or a rabid-dog reaction. In a healthy relationship, people realize what’s happening when they transgress a boundary and work together to resolve the problem. Boundaries create good selfesteem and emotional health and are created by people with good selfesteem and good emotional health. However, we’re all on a continuum of

skill on the boundary setting and enforcing spectrum. Some people are better at setting and enforcing their boundaries than others. So when you may encounter someone with better, or worse, boundary skills than you, you get to learn or teach something about boundaries. The trick to improving your boundary skills is to learn something from everyone you meet. For instance, people who want to learn a sport, like tennis or golf, play with players who are better than they are. They may “lose” most of the time, but they learn enough to improve their own skills. Being around people with healthy

boundaries may sting if you’re not adept at spotting, respecting and honoring their boundaries and they call you on it, but you’ll quickly learn lessons you can apply to yourself. Learning how to find a happy, healthy midpoint between doormat and push-over versus rabid, angry gatekeeper is hard, but not impossible. Here are some secrets for finding that healthy middle ground: Think before you speak or act. Knee-jerk reactions and responding from a place of pain, anger and feeling violated are what trigger the rabid-dog response. Bite your tongue and silently count to ten while considering your response. If you are still seething, simply say, “I’m feeling too upset/angry/shocked to continue this discussion right now. Let’s talk about this later when I’m feeling more grounded.” Then simply leave. Or shorten it to, “I can’t discuss this right now. I’ll get back to you when I can.” Decide what it is you want to accomplish with your response or comeback.

A goal of making the offender “back off” is appropriate. Calling them an idiot (or worse) in order to intimidate them into doing so, is not. Focus on the outcome, not on what you’re feeling in the moment. If the goal is to have a calm, rational and respectful conversation and you’re feeling angry and flustered, you might want to say, “I’m not ready to have this conversation right now. I’ll get back to you when I am.” And then leave. There is nothing wrong with taking time and space to gather your thoughts. Just because the person says, “Well I’m ready and we’re talking about this now,” doesn’t mean you have to. That’s just more abuse. Repeat your original statement. Or, say, “You may be ready, but I am not and I’m leaving/ hanging up/going now.” And then do.

“Healthy boundaries means taking responsibility for your own emotions and reactions and not taking responsibility for the actions or emotions of others.” ~ Mark Manson

Client Suicide 9 Things To Do in the Aftermath

The harsh fact about working with mentally ill people is that there’s a good chance one of them will commit suicide under your care because client suicide is an occupational hazard in the mental health care field. When it happens, chances are very, very good that it will probably devastate you, especially if you are an intern, untrained or new to the profession and that you’ll never forget it. In fact, McAdams and Foster (2000)1 found that most mental health practitioners remember the name and the details of their first client suicide even 20 or 30 years after the event. This alone indicates that the experience itself had a profound impact upon the clinician. Dr. Herbert Hendin, the medical director of the American Foundation for Suicide Prevention and the lead author of a report on therapists and client suicide which appeared The American Journal of Psychiatry in 2005, says that, “Having a patient commit suicide is the most traumatic event of a therapist’s professional life.” Statistics vary, but on the low end of probability, one in four psychologists will lose a client to suicide at some point in his or her career. Half of all psychiatrists, who tend to see more severely troubled patients, lose at least one patient during their career. Those rates are climbing. Suicides have increased more than 40 percent worldwide within the past 50 years. For individuals aged 15-44 years old, suicide

Get a mentor or supervisor ASAP

is the third leading cause of death in both males and females. Although the elderly (age 65 and older) comprise about 13 percent of the U.S. population, they account for more than 18 percent of all suicides. So what should you do in the aftermath of a client suicide to ensure you and your practice don’t suffer what can be a career-crippling event? Be proactive. Learn all you can about what happens and what to expect before it happens. Even if you’re one of the lucky ones who never experience the loss of a client at their own hand, you’ll be in a better place to advise those who are not so fortunate. Develop a support network and talk about client suicide before it happens. It’s not just the fact that they’ve lost a client that makes the aftermath of a suicide such a difficult time. It’s that even though every mental health professional knows that no one can truly prevent someone from committing suicide if they are intent upon killing themselves, peers, co-workers and even other patients will pull back upon hearing the news. People you thought had your back may not be there for you after all. In addition to the grief you’re dealing with, you may also feel betrayed by the people you most trusted—colleagues and professional acquaintances. They may avoid, criticize or even second-guess you on whether or not you did everything you could.

Review your client notes and history

Contact your attorney ASAP 39

Fear of lawsuits, being called to testify or even being deposed for the investigation can be intimidating to those who know you, even if they believe you did everything you could. Having a support network in place, discussing the possibility and what steps to take afterwards are critical for your healing. Establishing that kind of professional support network before an event means you’re more likely to find safety and solace in it if the time comes when you need it. Speak with your supervisor about the protocol the agency or practice has. Don’t wait until it happens to learn there is no protocol. If you are a supervisor, now is the time to learn how to work with employees when someone on their caseload commits suicide, or even attempts suicide, because chances are very good that one day you’re going to have to deal with the aftermath of a suicide within your agency’s caseload. “If you are a supervisor and this happens to one of your employees it’s your job to seek out your staff person.

Seek out a trusted colleague

Decide whether to attend the funeral

“They might not want to come to you, but it’s your job to seek them out and to find out how they’re doing and offer your support. “They may not be ready to talk about it right then and there. That’s okay. Give them a couple of days and then go back to them and say, ‘How are you doing now?’ “It’s really important to just be there for that person and help them talk about it because they need to talk about it, ” Allene Lyons, a LCSW who gives workshops on supervisory skills, said. Lyons has strong advice for social workers and therapists who do experience either attempts or completed suicides. “When you have that happen it’s so important to seek out other people,” says Lyons. Lyons said she’s had clients attempt suicide, but none have completed the act. “An attempt can be as devastating as a completion,” she said. “It’s so important to seek out other people to talk to. It’s not that uncommon to say or think to yourself, ‘What did I miss?’” she said. “It’s good and healthy to ask yourself if you missed something, or

Contact the family to express your condolences

Take time to grieve, and time for yourself

did something wrong, but it’s not healthy to beat yourself up over it.” Supervision or Mentoring Contact your mentor or get supervision for your caseload as quickly as possible after the attempted or completed suicide of a client. Supervision is necessary not because you’re a bad therapist, but to reassure you that you’re doing the same good work you’ve done all along. They also help normalize things and provide support until you are able to grieve and process the event. Self-doubt, guilt and fear of making a mistake will be strong for some time after the client’s death. Supervision is just as important for your health as it is your patient’s. Depending on how long you treated the patient, how well you knew them, and your personal feelings about their care, you may experience guilt, doubts about your skills, and fear of retribution from the client’s family or friends. You may feel like you’re going crazy, that you’re a failure, that you are a bad

Contact your insurance company or not

Avoid extreme reactions, like quitting your job.

therapist, that you missed some sign, that somehow—it’s your fault. Other reactions reported by therapists after losing a patient are shame, embarrassment, betrayal, anger and shock. It’s not your fault, but it may feel like it is for a long time to come. And that’s normal, says Dr. Hendin. Apart from the emotional fallout, pain and doubts you’re experiencing, there will be the legal, social and investigatory things you’ll need to tend to. Reducing the event to “business as usual” and tending to paperwork, questions, insurance and the necessary routine tasks of closing the file and moving on can seem surreal. Knowing what you’ll need to do ahead of time and being prepared, having an attorney, talking to your insurance company and having a plan in place for the somewhat likely event can cut your stress in half. Many of us don’t like to jinx ourselves by talking about the possibility, but it’s important to do so. Things you’ll need to consider after the death: Should you or shouldn’t you call your

Resist the urge to overcompensate

Learn from the experience and move on.

insurance company? Are you going to be sued? Do you need an attorney? Do you have an attorney? How do you find the right attorney, one who will understand your concerns and be supportive as well as an advisor when something like this happens? Can you afford an attorney? Once you’ve received the news you’ll want to decide how involved, if at all, you want to be with the family. Should you contact the family to express your condolences or not? Would your client have wanted you to contact their family or not? If your client left children or a spouse behind, how much can you tell them, if anything, about their loved one? Will they hate you? Blame you? Sue you? In almost all studies where clients committed suicide, researchers found that relatives were not critical of the therapist and saw them as trying to help. Let Your Peers Know Bad news travels fast. When a patient commits suicide it’s likely most of your peers will learn of the event almost as quickly as you, particularly if you work in an agency or small practice. Fears many social workers, counselors and therapists report having are: What will my peers think? How will I explain what happened, or should I explain anything at all? How much, if anything, should I share? Should I quit my job? Should I stop seeing suicidal patients all together? There are a lot of questions you’ll be

faced with and need to answer while under severe emotional distress. But you’re not alone. And talking to their peers is what most people do. Menninger (1991) reports that 90

percent of respondents handled the suicide by discussing their experience with colleagues, one-third sought consultation, and 5 percent sought treatment.5 Two-thirds of the therapists surveyed

reported that the experience changed the way they practiced (i.e., they became more thoughtful about termination, they took more clinical notes, sought more second opinions, were more vigilant about patients’ comments about hopelessness,

and were quicker to hospitalize patients). Several case studies found what proved most helpful to clinicians in coping with the aftermath of a client suicide was talking with a colleague who knew the patient or who had had a similar

experience with a patient; such talks reduced the sense isolation and provided support (Alexander, 1991; Berman, 1995; Hendin et al., 2000)2. Breathe The old adage “Never make a lifechanging decision under stress or duress” was never truer. Don’t make any major changes in the heat and pain of the moment. Take time for yourself, but don’t quit your job and change careers just yet. Breathe deeply, feel your feelings and trust the process, don’t rush it. You will get through this and be an even better counselor, social worker and person because of it, even if it doesn’t feel like that for a long time. If you’re a trainee, or are supervising a trainee, expect a more dramatic reaction to a client suicide. Research shows that differences between a trainee’s approach and an experienced professional’s approach to helping clients is significantly different and may exacerbate the impact of either an attempt or a completion of a suicide on trainees. Trainees tend to rely on their own personal qualities as a means to help clients, whereas experienced mental health professionals use practiced technical skills, in addition to their personal qualities, to help their clients.3 Consequently, trainees were more likely to feel they failed as a person whereas experienced professionals did

Over Compensation excessive compensation; specifically : excessive reaction to a feeling of inferiority, guilt, or inadequacy leading to an exaggerated attempt to overcome the feeling. [Merriam-Webster] Signs an employee or co-worker may be overcompensating after a client suicide. Aggression, Hostility: Becomes hyper-sensitive to perceived criticism. Counterattacks perceived criticism through defying, abusing, blaming, attacking, or criticizing others. Micromanaging caseload: Double-guessing and micromanaging cases similar to the patient they just lost. Over reacting to threats of self-harm from other clients. Turning down or refusing to accept new clients who are depressed or suicidal. Recognition-seeking, Statusseeking: Overcompensates through impressing, high achievement, status, attention-seeking, awards, taking on super difficult clients, developing a savior complex and seeking out high risk clients. Passive-aggressiveness, Rebellion: Appears overtly compliant while punishing others or rebelling covertly through procrastination, pouting, “backstabbing,” lateness, complaining, rebellion, nonperformance, risk taking, acting out. (Coping Styles and Responses, by George Va r v a t s o u l i a s ; J u n e 7 , 2 0 1 3 . h t t p : / / www.scribd.com/doc/146383350/CopingStyles-and-Responses-Surrender-AvoidantOvercompensation

Don’t try to become Super-Therapist to compensate for the loss of a client.

not. Trainees were less likely to be able to separate “personal failure from the limitations of the therapeutic process” (Foster & McAdams, 1999, p. 24)1. As a result, trainees benefited greatly from supervision after a client suicide.

Review your client notes and history. You’re going to doubt yourself and play the “What if?” game anyway. Going over your notes provides facts about what happened and gives you a more realistic sense of what you did right.

Other Things to Expect Therapists and social workers alike report feeling either great difficulty in connecting with other patients after a suicide, or connecting too deeply and becoming overprotective. Others have reported feeling like colleagues were “being voyeuristic” about both the suicide and the clinician’s intense emotional state and response to it. Some therapists feel they are being judged, or shunned by their colleagues and some report finding it difficult to find a s u p p o r t i v e , understanding peer to discuss the event with.

Call your attorney. Having an attorney prior to something like this happening is a best case scenario, but if you don’t have one, don’t hire the first one you speak with. Ask for referrals from colleagues who have been through this as well. Interview several attorneys and trust your gut, even if you’re thinking your instincts are haywire. Keep a copy of your insurance policy on hand so you can give it to him/her as soon as possible.

Nine Things to Do After a Patient Suicide A lot of the actions you take depend on the circumstances. Were you actively treating the patient? Or did they commit suicide weeks, months or years after leaving treatment? Had they threatened suicide the day or evening or week before? Or were they in a good place? This is where your notes and history with suicidal patients is important.

Contact the family to offer your condolences. Your attorney will advise you what you should or shouldn’t say beyond offering your condolences. Every case is different. Only you can determine whether contact with the family is appropriate, but in most cases it is appropriate to offer your condolences whether you choose to attend the funeral or memorial services later or not.

Get a mentor or supervisor to help with this client case and your other case load as soon as possible. A supervisor or mentor will help normalize things and provide support while you’re going through the process of grieving, healing and dealing with the loss.

Seek out a trusted colleague to debrief with and who is willing to offer support during the aftermath. If you don’t have a colleague, seek out a therapist and get counseling for yourself. Decide whether or not to attend the funeral. This decision may rest on the family’s decision, how long you knew the client and the circumstances of the client’s relationship with their family. There is no right or wrong, good or bad call on this. It’s what makes you the most comfortable and will help you heal and grieve.

major change they would have made in their patients’ treatments; most frequently mentioned were changes in medication, earlier hospitalization of the patients, and consultation with the patients’ previous therapists. Learning from the loss and improving or changing your practice is part of being a mental health professional. If you haven’t experienced a loss, remember it can and probably will happen if you’re in practice long enough. Before it does, prepare for it. Discuss the possibility with co-workers, an attorney and your insurance c o m p a n y. F i n d a n d maintain a good support network. Don’t rush to judgment if a co-worker or colleague experiences a loss.

“If you’re good you don’t blame yourself for what happened. Hopefully you learn and move on,”

Decide whether or not to report the suicide to your insurance company. ~Allene Lyons, LCSW This is a decision best discussed with your Recommendations attorney. Many therapists fear they may lose In October of 2006, Marquette University their insurance if they report a patient published a report entitled, Therapists in suicide whether it was due to negligence on Training Who Experience a Client Suicide: their part or not. Implications for Supervision. In it they recommend that agencies Take time for yourself. develop protocols and supervisor training for Take time to grieve and process the responding to client suicide, particularly when event and how it has affected you. Don’t the treating therapist is in training (e.g., how rush the process. Many therapists grieve the best to tell trainees of their client’s death; the loss of a patient for years. normal responses to client suicide; how supervisors can respond most helpfully to such Learn from the experience and move on. an event; etc.). In 21 out of 26 cases in Dr. Hendrin’s The report is directed at trainees, but the study2, therapists identified at least one suggestions are universally applicable:

•

Whenever possible, supervisors should tell counselors of a client’s suicide privately so they can react to and process the death in a supportive atmosphere. Supervisors should continue to provide a supportive time and place for their staff to work through the client suicide, even after the immediate responses seem to have abated. Attend to both affective (e.g., anger, sadness) and clinical (e.g., questioning of clinical skills) sequences of the event. Acknowledge that the effects of a client suicide, both short term and long term may be painfully-learned growth.

There are no easy answers, no shortcuts and no simple solution to client suicide attempts or completion. But you and your agency and/or practice can be prepared. Perhaps Lyons has the best advice. “If you’re good you don’t blame yourself for what happened. Hopefully you learn and move on,” she said.

1 McAdams, C. R., & Foster, V. A. (2000).

Client suicide: Its frequency and impact on counselors. Journal of Mental Health Counseling, 22, 107–121. and Foster, V. A., & McAdams, C. R. (1999). The impact of client suicide in counselor training: Implications for counselor education and supervision. Counselor Education and Supervision, 39, 22–29. 2 Herbert Hendin, M.D.; Alan Lipschitz,

M.D.; John T. Maltsberger, M.D.; Ann Pollinger Haas, Ph.D.; Shelly Wynecoop, B.A., Therapists’ Reactions to Patients’ Suicides Am J Psychiatry 2000;157:2022-2027. doi:10.1176/appi.ajp. 157.12.2022. (December 01, 2000) 3Brown, H. (1987). The impact of suicide

on therapists in training. Comprehensive Psychiatry, 28, 101–112. 4 Sarah Knox; Alan Burkard, Julie A.

Jackson; April M. Schaack, Shirley A. Hess. Professional Psychology: Research and Practice. Volume 37, Number 5 (October 10, 2006) 5 Anderson, 1999; Hendin, Lipschitz,

Maltsberger, Haas & Wynecoop, 2000; McAdams & Foster, 2000; Menninger, 1991) Knox, Burkard, Jackson, Schaack & Hess Anderson, E. J. (1999). The personal and professional impact of client suicide on master’s level therapists. Dissertation Abstracts International, 60 (9). (UMI No. 9944663) 47

Death on the Caseload by Becky Blanton

Three social workers in Boston, Massachusetts, were fired recently after the remains of Jeremiah Oliver of Fitchburg, Massachusetts, age 5, were found almost a year after the boy went missing from his mother’s home in 2013. His mother didn’t report his disappearance for months. Neither did caseworkers, because they had missed routine visits with the family. An investigation after the boy’s remains were found showed that Department of Children and Families (DCF) had an open case with the Oliver

family. Criminal charges were later filed against his mother and her boyfriend in connection with the boy’s death. The DCF called for changes within the agency over the incident, claiming it’s impossible for social workers to manage the caseloads they currently have. Workers are now picketing and calling for reduced caseloads so unnecessary deaths like Oliver’s don’t happen again. Caseworkers say their caseloads are often upward of 35 to 40 investigations

a month, making it impossible to ensure every child or family gets the attention they need. In a state with one of the lowest child death rates in the country, it is even more tragic that this one could possibly have been prevented if caseworkers weren’t responsible for two and three times the recommended number of families on their caseload. EVERY STATE SUFFERS Fitchburg is not the only agency in the country with problems. Every day, an average of 2,400 children are victims of child abuse, and approximately three children die each day as a result of child abuse or neglect (U.S. Department of Health and Human Services [DHHS], 2002). Nationwide, child protective services (CPS) agencies receive more than 50,000 calls per week regarding suspected or known instances of child abuse (DHHS, 2001), with more than two-thirds of these calls determined appropriate for CPS investigation. In Colorado alone, more than 40 percent of the children who died of abuse and neglect in the last six years had families or caregivers known to child protection workers who could have saved them. So why are thousands of children dying every year? Because of case overloads that prevent caseworkers from managing their load effectively, say experts in every state. MEDIA ATTENTION IS MISPLACED Just the sheer number of cases each social worker handles almost guarantees that deaths will happen again, and social workers will have to face the public’s anger and frustration yet again at the news the childcare system has failed. A child fatality is always a traumatic event for the public, but it’s also devastating for child welfare professionals, especially for Division of Social Services (DSS) caseworkers and Guardian ad Litem (GAL) volunteers who work with these children. What the media often forgets in its race to try the death in the news, assign blame and presume fault, is that what they think they know and the

reality of a situation are often two different things. The big question to ask is, “Where is the media when caseworkers are struggling to get their caseloads reduced so these tragedies don’t happen?” Apparently preventive options aren’t nearly as newsworthy as the fresh death of a child. Educating the media about the system, including statistics, facts and reality, is one place to start. WHO ARE THE PERPETRATORS? Child abusers come in all ages, races, occupations, religions and backgrounds. There is no single causal factor predictive of families who abuse and neglect their children. A wealthy CEO or physician is just as likely to be an abuser as a construction worker, college student or fast food worker. However, families with multi-stressors in their lives do tend to be more prone to abuse. Lack of income, loss of a job, a car, economic strains, poor parenting skills, limited social circles and support can all add to stress levels. There is literally no way to determine which families on a caseload are the most likely to offend. Interestingly enough, according to the American Federation of State, County and Municipal Employees (AFSCME), 19 percent of members report having been victims of violence, although 63 percent say they have been threatened at some point in their child welfare practice. Seventy percent of front-line caseworkers have been victims of violence or received threats of violence and those statistics were from a 1989 AFSCME report. EFFECTS ON SOCIAL WORKERS Social workers who experience a death on their caseload due to murder, abuse or neglect experience much of the same things a therapist does when a client commits suicide—including shock, disbelief, grief, anger, fear and guilt. Unlike a suicide, however, the caseworker and their agency often come under intense media

The Child Welfare League of America recommends caseloads of between 12 and 15 children per worker. The Council on Accreditation recommends that caseloads not exceed 18 per worker, however the average caseload for a child welfare worker is between 24 and 31 children. Caseloads range from 10 to 100 children per worker. ~ (ACF, APHSA, CWLA, 2001) 50

scrutiny and blame for the incident by a system agencies had an average of 26 staff, which and people who don’t understand caseloads, the included social workers or caseworkers, system or the facts of the case. supervisors, support staff, case aides, specialist Even though social workers are in the workers, and managers (U.S. Department of profession of providing mental health, there’s Health and Human Services [DHHS], 2003). still a stigma attached to receiving it for oneself These agencies averaged, “Three staff with when stress, including high caseloads, and less than a Bachelor’s degree, 13 staff with a Secondary Traumatic Stress (STS) are impacting Bachelor’s degree, three with a Master of Social their performance and lives. Work (M.S.W.) degree, and one employee (or Professionals suffering from STS experience staff person) with some other type of advanced a variety of symptoms which can impact their degree” (DHHS, 2003, p. 2-2). work, including anxiety and depression. The anxiety and depression not only contribute to WHAT DOES THE FUTURE HOLD? psychological distress, burnout, and turnover, In 2012 some 1,300 babies in Massachusetts they affect the level and quality of care the case — about three to four each day — were born worker is able to provide. already addicted to If STS weren’t enough, prescription drugs such as after a child abuse homicide or Oxycontin or methadone. In a “It is estimated that fatality occurs, caseworkers first of its kind survey by must then undergo a strenuous child welfare workers local hospitals, researchers review process and legal found that the 2012 numbers spend 50 to 80 percent proceedings during the are doubling, meaning more investigation. drug and alcohol impaired of their time on In addition to the grief and babies are being brought into paperwork. stress the worker is already a system that is already experiencing from the fatality, overcrowded. doubt, accusations, negative ~ GAO, 2003 media coverage and social After a hasty emergency pressure only add to the STS. legislative approval of $9 million dollars, the state hired another 150 caseworkers in the CASEWORKER EDUCATION aftermath of Jeremiah Olive’s death and the Research has found that holding a degree in governor has requested an additional $17 million social work correlates with higher job for another 175 case workers. performance and lower turnover rates among Is it too little too late? In spite of the child welfare workers (U.S. Government additional hirings, the governor’s office Accounting Office [GAO], 2003). But the continues to blame the three employees who National Association of Social Workers (NASW), were fired, saying Oliver’s death was related to however, says that all the education in the world “Improper oversight and falsified reports.” can’t overcome an imbalanced workload. Social workers disagree, saying their Although the public’s perception is that child caseloads force them to triage families and put welfare services are staffed primarily by degreed the ones considered least urgent and least at risk social workers, studies show differently. at the bottom of their caseload, something that A recent study of local Child Protection can’t end well because, as one worker said, Services agencies found that child protection “They’re all at risk.” 51

Supportive Twenty years of social work had prepared Sarah for a lot of things, but becoming a supervisor wasn’t one of them. “I felt so lost,” she said. “One week I had all these great friends at work, people I’d worked with for years. Within the first month I think they all hated me.” As much as we’d like to think our friends won’t change when they become management, the sad fact is, they do. It’s not only our professional relationship that changes, it’s our personal ones too. People at work who were once our friends are now employees first. It can be really difficult to adjust, particularly if there is no additional training. “I had to find and take managerial training on my own,” Sarah said. “There was no money in

the budget and they told me that after 20 years of being in the profession I knew all I needed to know. I just needed to get in touch with my managerial side.” But management isn’t something most people absorb automatically. A lot of it has to be taught, Allene Lyons, a licensed clinical social worker, said. Lyons teaches a three-part, three-day seminar on supportive supervision for social workers, “Administrative, Supportive and Educational Supervision.” People who take the class learn what Sarah did. “People find out they’re not alone. They see that other people have similar experiences to theirs. “It’s not uncommon for people to be

Supervision promoted into a supervisor position and then being told, ‘Here, go ahead,’ without getting support or training on how to be a supervisor. How do you handle not only guiding your staff, but how do you handle problems and disagreements? “Most people are not trained on how to be a supervisor. Many people think they’re being a supervisor because they’re telling people what to do, but that’s not supervising,” Lyons said. Every agency and practice is different because each has its own politics and culture, Lyons said; but the one problem she sees across all agencies is “a lack of support.” “Attendees feel they don’t get support from their administration,” she said. “You can’t change the administration. The only person or thing you

can change is yourself. In social work we all learn that, but we forget about it when it comes to ourselves. The most important thing I can teach them is to ask themselves, ‘How can I provide the best experience for myself within the boundaries that I have at work?’” Lyons said supervision is largely a creative process. “It takes some thinking and some creativity to find out how you’re going to do provide that experience,” Lyons said. “Every workplace has its own personality, rules and expectations. No two places I have worked have been the same. Bosses are different, administration is different. They handle the same situations differently. You have to learn to adapt and to help your staff adapt. Sometimes you just have to be that ear

“Many people think they’re being a supervisor because they’re telling people what to do, but that’s not supervising someone.” ~ Allene Lyons, LCSW

Workshop May 2 -2014 Putting the Pieces Together: Supportive Supervision

when your staff is frustrated.” Lyons said one of the things she and her workshop attendees talk about is the fact that their staff comes to them when they’re frustrated, but they ask, who do supervisors go to when they’re frustrated? “It’s important to be able to find that inside or outside of your agency. I’m not saying go out and say bad things about your agency, but do find someone you trust who you can talk to about what you’re going through,” she said. “I come home and talk to my husband. We take turns talking about our day. People need that. They need someone to bounce things off of that’s not involved in the situation.” Becoming a good supervisor is a lot like becoming a good social worker. It takes practice. “I’ve had a whole range of people attend my workshops. Some have been supervisors for a long time, some are new supervisors, some want to become supervisors. There’s a whole range,” Lyons said. No one ever really knows everything there is to know about supervising employees, so there’s always room for improvement. Being able to spend three days with other supervisors of all skill levels, and with a huge variety of experiences and challenges, is a great way to learn from those who have dealt with situations you may not have encountered, Lyons said. “Everyone gets something out of it,” she said.

Top 7 Tips for the New Supervisor You may not have received any training when you were promoted. You may feel like you were just 54

dumped in the deep end of the pool wearing concrete shoes, but there are things you can do until you get yourself the training you need: 1. Review any and all written material, policies and procedures as soon as possible. There’s a great chance that 90 percent of the issues you will encounter have already been addressed through existing protocols. Don’t depend on others to dole out information you already have access to. Learn what needs to be done. Use your boss as a mentor, not a walking, talking procedure manual. 2. Start Slowly. Do not “clean house” and issue new rules and edicts until you understand what works and doesn’t work and why. 3. Gather Information. Your view from the employee’s side of the fence just changed. It’s time to learn how management sees the world. Observe, ask questions and learn. Understand your staff, your job and the politics and culture of management before making any changes. Let people know you’re open and welcome questions and feedback, but don’t act on it immediately. 4. Be Visible. Even if you know everyone in the workplace and have for years, move around and talk to them, get to know them. Emphasize teamwork. You’re new and still establishing your authority. Until you earn your team’s respect you need to empower them as team members. Be fair, just and consistent when dealing with your staff. 5. Discover your staff’s weaknesses and strengths for yourself. Don’t rely strictly on past

Date: Friday, May 2, 2014 (Also offered Nov. 14, 2014) Time: 8:30 am Registration Workshop: 9am to 4pm Location: Belmont Center, 4200 Monument Road, Philadelphia, PA 19131 Credits: 6 CEU’s for PA Social Workers; MFT’s and PC’ s and NJ Social Workers COST: $110.00 Presenter: Allene Lyons, LCSW reviews, gossip and rumor. They may all be biased. Especially beware the overly helpful staff members who step up immediately to fill you in on the negative (and positive) aspects of everything and everyone your first week in the job. Their information may be more self-serving and manipulative than helpful. 6. Make your own decisions. As the new kid, people will push you to see how much they can manipulate and influence you. Make it clear that even if you’re seeking information or advice it’s because you are simply gathering information to make YOUR decision. You are not giving up control or power.

7. Keep your promises. Provide open, just, fair and honest communication between you and your staff and you and your manager. Let your staff know that you will listen and then consider changes. Make sure that you keep your staff informed whenever possible. Tell them the truth without sugar coating it. Build the trust you’ll need to be the best supervisor you can to them. Don’t be afraid to let your staff know that you care about them. People follow people they trust and feel safe with. Above all, when you fail, don’t give up. Get up, make any apologies needed, and try again.

Allene Lyons graduated from the University of Connecticut School of Social Work in 1974. Her career has been spent in the mental health sector, working in a variety of settings with children and their families. For the past 20 years Allene’s career path has gone from Clinical Supervisor to Director to Regional

Director of Behavioral Health for a number of agencies overseeing multiple programs. In addition, Allene has provided clinical trainings to a variety of agencies. Allene’s interest is in providing clinical supervision to graduate students and clinicians working towards their LCSW.

GOAL: This training will address the various areas of supportive supervision – how the supervisor motivates his or her staff, the use of empathy, secondary trauma and how it effects staff’s ability to provide services (including burnout), and recognizing and rewarding staff. According to Alfred Kasdushin, long considered the father of social work supervision, there are three components to effective social work supervision: administrative, educational and supportive. Supervisors must provide all three components to new and seasoned social workers in order to be an effective supervisor.

OBJECTIVES At the end of this six hour training, participants will be able to: • • • •

Develop a positive work environment Discuss the five modes of empathy and when to use each with staﬀ Discuss the characteristics of vicarious trauma and how to assist the worker in coping with it Develop ways to reward staﬀ for a job well done

Helping Medical Patients Cope

When patients are faced with a medical condition, particularly a serious or life altering one such as heart problems, stroke or a diagnosis of diabetes, they can freeze, or even go into a state of shock, says Stephanie H. Felgoise, PhD, ABPP. Felgoise teaches workshops for social workers and others in how to use basic coping skills to assess, respond and manage challenges that come about with new, or ongoing, major medical issues, diagnosis’ and crisis in their lives. “Many people experience stress, depression or anxiety in reaction to the diagnosis and the changes they’re expected to make in their lives,” Dr. Felgoise says. “In the effort to support them their doctors may suggest they seek therapy or even offer it as part of integrative care.” That’s where social workers have the opportunity to help, with what she calls “Social problem solving.” “Social problem solving is a rational and systematic way of helping patients cope and deal with the problems they encounter in daily living as a direct or indirect result of their medical diagnosis. The treatment is delivered in a brief model and many patients gain significant skills and support in as few as six-to-ten weeks of therapy.”

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There’s been a lot of research done to show it’s been very effective for people with cancer, obesity, cardiac conditions and depression. “It’s also been shown to be a very effective treatment for people’s day-to-day coping and adjustment to life. There are a lot of stroke patient spouses and caregivers of dementia patients and other populations who have also benefitted from this training,” she says. “The workshop is really teaching people skills they may already have and are using on a day-to-day living situation, but they don’t think to apply those same skills to this new situation that they’re having.” The workshop Dr. Felgoise teaches helps patients and their families learn to refocus and apply their coping and problem solving skills to this new challenge in their life. It’s a skill she teaches social workers too since most of them have clients who need these kinds of skills and turn to them for help. Some of the skills she teaches include learning to use their emotions as cues to which to respond to rather than stuffing, or ignoring, or expressing them in unhelpful ways. “When you use emotions as cues instead of stopping yourself from experiencing emotions related to life changes, you can use those emotions productively to solve problems and manage what is going on with your life,” she says. Patients can’t always change the situation they’re in, or change their medical or health issues, but they can change their reactions to those issues. “Oftentimes when you change your reaction to a situation, you can redefine your goals and make the problems more manageable. When you can't change the overall situation, oftentimes changing your reaction to the problem will allow you to see what things you can control and change, and this will help you redefine your goals.” Dr. Felgoise says. Dr. Felgoise also points out that when patients when patients can increase their sense of control over their stress or emotional reactions, they can also more clearly identify their goals and solve problems in daily living, either emotionally or mentally to the stress or shock of a situation they’re able to more clearly identify their goals Helping to more effectively and objectively identify the problems they need to cope with makes it easier to set realistic goals, recognize barriers, and do a cross benefit analysis of the options they do have. They’re also better able to create plans for implementing their goals, evaluating the consequences of their actions and decisions and to learn how to restructure their process when and where needed. “The nice thing about this is it’s not mystical or magical. It makes sense to patients, but it’s not something they’ve have often thought about in a structured way or in a way that they’ve been able to apply it in difficult situations,” she said.

“When you use emotions as cues instead of stopping yourself from experiencing emotions related to life changes, you can use those emotions productively to solve problems and manage what is going on with your life,” ~ Dr. Stephanie H. Felgoise, PhD, ABPP

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Workshop May 16-2014 Helping Medical Patients Cope: A Problem Solving Therapy Approach

Goal: Provide learners with an understanding and ability to implement this empirically-supported, manually-driven approach to help persons cope with daily medical and non-medical problems resulting from diagnosis, treatment, terminal illness, or living with medical conditions. Objectives: After completion of this course, participants will be able to: • Explain the social problem-solving model of distress, and how to assess and teach problemsolving skills to persons with medical conditions and other emotional difficulties. • Examine individual differences and diversity among persons and populations and how problem-solving therapy can be instrumental in facilitating individual coping across backgrounds. • Identify, define, and help clients overcome maladaptive behavioral response styles to problems. • Understand how to adapt problem solving therapy and skills training for different formats (i.e., couples, groups, workshops).

Problem-solving therapy, originated by Marvin Goldfried and further developed by Thomas D’Zurilla, Arthur Nezu, and colleagues, is based in cognitivebehavioral theory and uses many familiar cognitive and behavioral techniques. Effective problem solving, according to the social problem-solving model, offers a structured approach to coping and adjustment to major and minor life events. In brief, social problem solving is a rational and systematic way of thinking about problems in daily living. The major components of social problem solving include the following: problem orientation, problem definition and formulation, generation of alternatives, decision-making, solution implementation and verification. This introductory training course is designed to provide learners with an understanding and ability to implement this empirically-supported, manually-driven approach to help persons cope with daily medical and non-medical problems resulting from diagnosis,

treatment, terminal illness, or living with medical conditions. Emphasis will be on problem-solving therapy for persons with medical conditions such as cancer, irritable bowel syndrome, diabetes, and cardiac disorders; discussion and examples of problem-solving therapy’s application to treatment of anxiety and depression will also be highlighted. Problem solving techniques can also be used in stress management training, couples therapy, management of acute, chronic, and terminal healthrelated problems, and programs or interventions designed to enhance quality of life and well-being. Methods of instruction will include interactive lecture, video and live demonstrations, and roleplaying. Foundations in cognitive and behavioral therapies are useful for advancing participants’ ability to implement this therapy.

Date: Friday, May 16, 2014 Time: 8:30am Registration Workshop: 9am to 4pm Location: Belmont Center, 4200 Monument Road, Philadelphia, PA 19131 Credits: 6 CEU’s for PA Social Workers; MFT’s and PC’ s and NJ Social Workers COST: $110.00 Presenter: Stephanie H. Felgoise, PhD, ABPP

Presenter: Dr. Felgoise is a licensed psychologist, Professor, Director of the PsyD Program in Clinical Psychology, and Vice-Chair of the Department of Psychology at the Philadelphia College of Osteopathic Medicine. She earned her degrees and postdoctoral fellowship from Hahnemann (Drexel) University, and completed an APA-accredited internship UMDNJ-Robert Wood Johnson Medical School, in Piscataway, NJ. Dr. Felgoise earned her diplomate in clinical psychology by the American Board of Professional Psychology in 2003, and is a Fellow of the American Academy of Clinical Psychology. Dr. Felgoise is a clinician, educator, mentor, scholar, researcher, and consultant trained in the scientist-practitioner model. She teaches doctoral courses and gives workshops regularly in ProblemSolving Therapy for Medical Patients and general clinical populations; Grief, Loss and Bereavement; Improving Quality of Life; Sexual Dysfunction and Sexual Health; Qualitative Methodology, among others. Dr. Felgoise’s clinical research focuses on quality of life in, and psychosocial aspects of, ALS (Lou Gherig’s Disease) and Long QT Syndrome (LQTS, a life-threatening cardiac arrhythmia condition). Research on these topics have emphasized factors relating to quality of life, social problem solving, coping and adjustment, resilience factors (hope, optimism, spirituality), and comorbid psychological conditions (i.e., anxiety, depression). Her work has been grant supported in part by the Pennsylvania Department of Health, and the Center for Chronic Disorders of Aging. These research projects have been funded by the ALS Association and the Christopher Reeves Foundation, and presented at the

Heart Rhythm Society, Society of Behavioral Medicine, Association for Behavioral and Cognitive Therapies, Neurology Associations, and other conferences. She and her collaborators have published their works in the Annals of Behavioral Medicine, Neurology, and Quality of Life journals. Dr. Felgoise has also co-authored numerous national conference presentations in her areas of research, and previously on coping with cancer, including a book published by the American Psychological Association, Helping Cancer Patients Cope: A Problem-Solving Approach. She is also an associate editor and author for the Encyclopedia of Behavioral and Cognitive Therapies by Kluewer, and co-author of a graduate textbook, Clinical Psychology: Integrating Science and Practice. For more than 15 years, Dr. Felgoise has been an active member of the Association for Behavioral and Cognitive Therapies, American Psychological Association, Div. 12 (Clinical), Div. 38 (Health), Div. 54 (Pediatrics), the Society for Behavioral Medicine, the American Academy of Clinical Psychology, and the American Board of Professional Psychology. Dr. Felgoise is Associate Editor of the Journal of Clinical Psychology, and Consulting Editor for Journal of Consulting and Clinical Psychology, and Professional Psychology: Research and Practice. She also serves as an ad-hoc reviewer for Psycho-Oncology and others. Dr. Felgoise has been in private practice for 15 years helping individuals cope and adjust to daily life stressors, medical conditions, sexual health and dysfunction, couples and family problems, anxiety, grief, depression, and helping individuals improve their overall quality of life and positive experiences by use of problem solving therapy and other empiricallysupported cognitive behavioral therapy techniques.

Understanding Military Sexual Trauma and Post Traumatic Stress

By Becky Blanton

Military Sexual trauma can cause more severe PTSD than combat. When men or women sign up to “Be all that they can be” in any branch of the military, they don’t sign up to be raped, molested, abused or beaten. But it happens and it happens to both men and women. In fact, recent investigative reports by the Washington Post, the Boston Globe and other major news organizations suggest rape in all branches of the US military is on the rise. Not only that, military experts say according to statistics, the number of men being raped now exceeds the number of women being sexually assaulted in the military.

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“The inability to get something out of your head is a signal that shouts, “Don’t forget to deal with this!” As long as you experience fear or pain with a memory or flashback, there is a lie attached that needs to be confronted. In each healing step, there is a truth to be gathered and a lie to discard.” ― Christina Enevoldsen

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Rape is rape, but men and women who encounter rape in the context of military service not only have a harder time pursuing and prosecuting the offender, but their experience is also different than that of most civilian assaults. The experience of MST can differ from the experience of sexual trauma in the civilian world. Sexual assault for anyone is horrific. But members of the military are trained to protect each other, to “have each other’s back.” To be assaulted by those they trust and depend on to be there for them is especially difficult. Other factors can also contribute to the added stress of the attack. Factors often unique to MST include: The victim may have had to continue to live and work with their perpetrator, and even rely on them for essential things like food, health

Many MST survivors feel anxious, hyperalert, “on edge,” or like they’re always needing to look over their shoulder in case a perpetrator may be nearby.

care, or watching their back on patrol or in combat. If the perpetrator was/is in the same unit the victim is faced with the possibility of another attack, or with being confronted by their attacker again. The perpetrator may also expose the attack to fellow team members, resulting in additional humiliation and potential attacks by

others. There may a loss of respect by other team members, and on-going shame and humiliation, particularly since the military does not respond well to claims of sexual assault by its members. Many victims worry that others finding out about them may ruin or end their military careers. There is no safe place to hide or get away since squads and units live, work and operate in the same environment. Some of the signs and symptoms of PTSD include, but aren’t limited to: • • • •

Dizziness Alcohol or drug problems Feeling on edge Anger and irritability

• Chronic pain • Always feeling “on alert” • Flashbacks • Feeling guilty • Nightmares • Loss of interest in life, family, friends • Noise or light irritation

Workshop Sept. 26-2014 Understanding Post Traumatic Stress and Military Sexual Trauma Among OIF and OEF Female Veterans

What is Military Sexual Trauma? “Military sexual trauma” or MST is the term used by the U.S. Department of Veterans Affairs to refer to unwanted sexual experiences that both men and women may encounter while serving in any branch of the US Military or Coast Guard. The official definition of MST used by VA is given by federal law (U.S. Code 1720D of Title 38). It is: Psychological trauma, which in the judgment of a VA mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty or active duty for training. Sexual harassment is defined as "repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.”

Sexual harassment is defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.”

In more concrete terms, MST includes any sexual activity where you were involved against your will. You may have been physically forced into sexual activities. Or, no physical force may have been used but you were coerced or pressured into sexual activities.

For example, you may have been threatened with negative consequences for refusing to cooperate. Or it may have been suggested that you would get faster promotions or better treatment in exchange for sex. MST also includes sexual experiences that happened while you were not able to consent to sexual activities, such as if you were intoxicated. Other 66

MST experiences include unwanted sexual touching or grabbing, threatening, offensive remarks about your body or your sexual activities, and threatening and unwelcome sexual advances. If these experiences occurred while you were on active duty or active duty for training, they are considered to be MST. “I remember the faces, the words, the smells, the negative, the unwarranted, unsolicited touches. I remember all of that. And I have friends who also are Veterans and went through worse than I did.” It’s important to know that MST can occur on or off base, and while a Service member is on or off duty. Perpetrators can be men or women, military personnel or civilians, superiors or subordinates in the chain of command. They may have been a stranger to you, or even a friend or intimate partner. Veterans from all eras of service have reported experiencing MST.

If you experienced military sexual assault or harassment, you may blame yourself or feel ashamed. It is important to remember that MST is not your fault. Nothing ever justifies someone harassing or assaulting you.

The information above is from http:// maketheconnection.net and is used with their permission.

Military Sexual Trauma Workshop Military Sexual Trauma among women and men veterans of Operation Iraq Freedom and Operation Enduring Freedom is a major emerging issue for our time. The most widely type of trauma researched thus far is trauma in female veterans who experienced sexual assault (MST) while serving in the military. Despite recent and ongoing research, the study of MST is still in its infancy stage. This presentation will explore risk factors, prevalence, mental and physical consequences and implications for treatment. Learning Objectives: • Define the prevalence of Military Sexual Trauma among women veterans of OIF and OEF. • Describe the risk factors associated with sexual assault. • Explore many of the key points presently researched including mental health and physical health consequences. • Discuss mental health treatment interventions with the strongest levels of empirical support including Prolonged Exposure Treatment and Cognitive Processing Therapy among others.

Presenter: Sister Nancy DeCesare has over thirty years of experience working in the fields of administration, social work and teaching. As a frontline social worker on the streets of New York City, a supervisor, and executive director and now as an associate professor of Human Services at Chestnut Hill College, Philadelphia PA She holds both bachelors and masters in Social Work from Marywood University, and a Masters of Public Administration from the Robert F. Wagner School of Public Service. Sister received her PhD in Clinical Social Work from the Shirley M. Ehrenkraus School of Social work, New York University. She is a member of the National Association of Social Workers, the Academy of Certified Social Workers, and a Board Certified Diplomate in Clinical Social Work. She is a licensed clinical social worker in both New York and Pennsylvania. Sister has received many honors for her work with marginalized populations including the National Jefferson Award, an award founded by Jackie Kennedy given for outstanding public service, the No Time to Lose Award, presented by the Governor of New York and the Beloved Award for her work with street children. Sister is the former Executive Director of Boys Hope Girls Hope of New York, an international program for homeless youth. In addition, Sister is a grant writer, teacher and author. She has served on several boards including the Philadelphia Children’s Foundation and the Governor’s Advisory Board for People with Disabilities for the state of Pennsylvania. Sister Nancy’s professional life has complemented her desire to make a difference. Her research centers on improving both personal and educational opportunities

Sister Nancy DeCesare for young people. Her work in the areas of social policy, mental health and clinical counseling are notable. In 2010, Sister started The Soldiers Project for the State of Pennsylvania. The Soldiers Project provides services to veterans and their loved ones from the Iraq and Afghanistan conflicts free of charge. It is part of the National program of The Soldiers Project. The Soldiers Project PA also provides ongoing continuing education opportunities about the psychological effects of war. These trainings are open to the public, and free to members of The Soldiers Project. Date: Friday, September 26, 2014 Time: 8:30am Registration, Workshop 9am to 4pm Location: Belmont Behavioral Health Credits 6 CEU’s for PA Social Workers; MFT’s and PC’s and NJ Social Workers $110.00 RSVP by paying for the workshop on-line by clicking HERE.

Healing Grief at Work This handbook explores what happens when grief and the workplace meet, and the drastic effects of grieving on employees, their performance, and the overall workplace environment. Touching on the different kinds of grief workers can experience, such as death, divorce, and layoffs, the effective ways to channel grief during the workday, how to support coworkers who mourn, participation in group memorials, and negotiating appropriate bereavement leave, this concise and practical resource gives both ideas for the mourner and the mourner's coworkers. A special introduction for employers, owners, managers, and human resource personnel addresses the economic impact of grief in the workplace and provides practical and cost effective ideas for maintaining morale and creating a productive yet compassionate work environment. Live A Life You Love Being true to your most authentic self and following essential principles of wellness will make you happy, healthy, and passionately in love with life. With insights drawn from her own personal transformation from a depressed medical doctor to a joyful and fulfilled flamenco dancer, writer, speaker, and life coach, Dr. Susan Biali's seven-step plan will help you discover (or re-discover) the hopes, passions, and talents that make up the real you. Learn how to maximize your physical, emotional and spiritual well-being.You will learn how to:.Begin making YOU a priority. Understand your body's language. Improve your most important relationships. Balance your life and find time for what counts. Loss, Grief and Trauma in the Workplace The workplace is not immune to the problems, pressures, and challenges presented by experiences of loss and trauma and the grief reactions they produce. This clearly written, well-crafted book offers important insights and understanding to help us appreciate the difficulties involved and prepare ourselves for dealing with such demanding situations when they arise. People's experiences of loss and trauma are, of course, not left at the factory gate or the office door. Nor are loss and traumatic events absent from the workplace itself. Loss, grief, and trauma are very much a part of life - and that includes working life. Essential reading for anyone concerned with making the workplace a more humane and effective environment, or anyone wishing to develop an understanding of the complexities of loss, grief, and trauma in our lives.

Preventing Boundary Violations in Clinical Practice What do you do when you run into a patient in a public place? How do you respond when a patient suddenly hugs you at the end of a session? Do you accept a gift that a patient brings to make up for causing you some inconvenience? Questions like these—which virtually all clinicians face at one time or another—have serious clinical, ethical, and legal implications. This authoritative, practical book uses compelling case vignettes to show how a wide range of boundary questions arise and can be responsibly resolved as part of the process of therapy. Strategies for preventing boundary violations and managing associated legal risks are highlighted.

The Enabler: When Helping Hurts the Ones You Love Co-dependency-of which enabling is a major element-can and does exist in families where there is no chemical dependency. Angelyn Miller's own experience is a dramatic example: neither she nor her husband drank, yet her family was floundering in that same dynamic. In spite of her best efforts to fix everything (and everyone), the turmoil continued until she discovered that helping wasn't helping. Miller recounts how she learned to alter the way she responded to family crises and general neediness, forever breaking the cycle of co-dependency. Offering insights, practical techniques, and hope, she shows us how we can transform enabling relationships into healthy ones.

Boundaries: When to Say Yes, How to Say No to Take Control of Your Life Dr. Cloud is a leadership consultant, best-selling author, and speaker whose 20 books on leadership, boundaries and business have sold well over 5 million copies. He consults and speaks for companies and organizations in the area of leadership and performance, and is highly regarded for his ability to connect personal and interpersonal development with the needs of business. He is a clinical psychologist and leadership consultant. Boundaries, a primer on what boundaries are, how to create them, communicate them and enforce them, has sold more two-million copies. Dr. Cloud co-hosts the nationally syndicated radio program New Life Live, which is heard in over 180 markets. Boundaries for Leaders In Boundaries for Leaders, clinical psychologist and bestselling author Dr. Henry Cloud leverages his expertise of human behavior, neuroscience, and business leadership to explain how the best leaders set boundaries within their organizations—with their teams and with themselves—to improve performance and increase employee and customer satisfaction. In a voice that is motivating and inspiring, Dr. Cloud offers practical advice on how to manage teams, coach direct reports, and instill an organization with strong values and culture. This book is essential reading for executives and aspiring leaders who want to create successful companies with satisfied employees and customers, while becoming more resilient leaders themselves.

Necessary Endings Henry Cloud, the bestselling author of Integrity and The One-Life Solution, offers this mindsetaltering method for proactively correcting the bad and the broken in our businesses and our lives. Cloud challenges readers to achieve the personal and professional growth they both desire and deserve—and gives crucial insight on how to make those tough decisions that are standing in the way of a more successful business and, ultimately, a better life.

Professional Boundaries in Social Work and Social Care. Professional boundaries between worker and client underpin all areas of practice in social work and social care, and the mismanagement of these boundaries can lead to unprofessional conduct and negative consequences for both worker and client. A no-nonsense guide to boundaries – what they are, why they are there and how to maintain them, from legal boundaries and policies governing behaviour to rules surrounding confidentiality. The book offers practical advice and suggestions on how to judge boundaries and how to manage a situation when they have been crossed.

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Dear Social Workers, Employers and Contractors,