Section 4: Reflection and Self-Care

Providing grief and loss support can present a special challenge to counsellors. According to Worden (2009), the impacts of grief on counselling work include:

• Challenging the counsellor’s desire and ability to be helpful. “The loss of a loved person is one of the most intensely painful experiences any human being can suffer, and not only is it painful to experience, but also painful to witness, if only because we’re so impotent to help.” (Bowlby, 1980, p. 7, cited in Worden, 2009). The nature of some losses can make it difficult to be or feel helpful, resulting in counsellor frustration or distress.
• Working with the grieving increases awareness of the counsellor’s own losses. This is particularly true if the client's loss is similar to those experienced by the counsellor. If the loss is recent or has not been adequately integrated, it can negatively impact the counsellor and the counselling process. However, if the counsellor has adapted to the loss, their own experience of loss may be helpful to the counselling process. For example, a counsellor who has recently experienced a miscarriage may find it extremely difficult to counsel a client dealing with the same loss. However, if the miscarriage occurred some time ago, and the counsellor has come to terms with the loss, her experience may enhance her understanding and empathy (although the counsellor must be careful not to assume that her and her client’s experiences are necessarily similar or to allow her own experience too much space in the counselling relationship).
• Fear or anxiety around possible losses. In our day-to-day lives, the potential for loss tends not to be regularly present at the conscious level, but counselling clients who have experienced losses makes us more aware of them. This can mean counsellors become particularly aware of, and afraid of, the potential for losses in their own lives. This can, of course, have both personal and professional consequences, potentially interfering with the counselling process. For example, a counsellor supporting a person whose child has died may become overly anxious about and over-protective of their own child or may (without realising it) steer their client away from discussing the loss due to the counsellor’s discomfort and fear.
• Existential anxiety and awareness of one’s mortality. Working with bereaved clients confronts counsellors with the inevitability of their own death, particularly if the deceased loved one was similar to the counsellor in age, gender, or other shared characteristics.

Stress and Burnout

The demands of grief and loss work may gradually accumulate, and the counsellor can begin to experience various stress responses that impact them personally and professionally. According to the Centre for Clinical Interventions (n.d.), these include:

A counsellor’s primary resource is their own ‘self’ – the ability and resources to engage empathetically, openly, and compassionately with clients. Working in grief and loss presents specific stressors and risks to the counsellor, including burnout and compassion fatigue, and to their practice.

Burnout is a state of physical, emotional, and mental exhaustion resulting from an imbalance between work demands (for example, the occupational demands of the job as well as internal factors such as the counsellor’s own issues, inadequate preparation for the work, fears and anxieties) and counsellor resources (for example, coping strategies and supports). If the balance is not restored, either by reducing the demands or increasing resources, the counsellor may progress to a state of “chronic emotional strain and exhaustion, depersonalisation and sense of reduced accomplishment and satisfaction” (Winokuer & Harris, 2012, p. 202). (You may have noticed that this discussion of stress and burnout has distinct similarities to the stress-vulnerability model we explored earlier!)

Counsellors who experience burnout typically begin to cope with the emotional overload by distancing themselves from clients to protect themselves emotionally. This may result in indifference and decreased compassion and concern (Winokuer & Harris, 2012).

Of course, this means that the service the counsellor provides suffers, with negative implications for clients, making burnout both a personal and professional issue. In fact, taking care of ourselves concerning burnout and other issues that can impact our practice is a central ethical responsibility for counsellors (Bond, 2015).

Compassion Fatigue and Vicarious Traumatisation

Compassion fatigue and vicarious or ‘secondary’ traumatisation may result from working closely or solely with people in a great deal of pain over an extended period. The type of stress associated with compassion fatigue differs from job overload or burnout, although there are commonalities. Here, vicariously experiencing or ‘taking on’ the client’s pain or trauma causes particular difficulties for counsellors. Ironically, counsellors with the greatest capacity for feelings and expressing empathy may be at the highest risk for developing compassion fatigue (Winokuer & Harris, 2012). Symptoms of compassion fatigue include:

Compassion fatigue is detrimental to both personal and professional functioning, putting both counsellor and client well-being at risk, with counsellors at increased risk for depression and anxiety disorders, other personal and interpersonal problems, and professional issues including reduced practice effectiveness and leaving the profession (Winokuer & Harris, 2012). Given the impacts that these present professionally, physically, and psychologically, it is imperative that counsellors remain aware of their needs and limitations and engage in strategies to protect themselves, including seeking support.

The following ethical and professional strategies can help to protect counsellors from risks associated with grief and loss counselling, including:

• Adherence to professional boundaries between client and counsellor
• Limiting self-disclosure
• Restricting the overtime spent at work (and limiting caseload)
• Recognising professional (and personal) limitations and referring clients when appropriate
• Additional training and professional development in grief and loss counselling
• Attending regular supervision with a counsellor with experience in grief and loss work.

How a Psychiatrist manages Vicarious Trauma

In this video, Dr. Andrew Ellis, Clinical Director of The Forensic Hospital, the highest security mental health facility in Australia, speaks about psychiatry, forensics, work-life balance, terrorism, vicarious trauma, among other fascinating topics. 

watch

check your understanding of the content so far!

Although the ability to be empathic with bereaved clients is essential, there is a line between empathy and over-identification with the client. Self-awareness is critical to maintaining an appropriate professional distance from the client’s pain and suffering while remaining empathetic and genuine (Pomeroy & Garcia, 2009). Counsellors need to be aware of and have processed their own grief experiences, including through personal counselling or supervision where necessary. Without this awareness, counsellor issues can negatively affect the counselling process.

Loss History

Developing a timeline of our own losses can help counsellors to identify the multiple types of losses that clients may experience; understand the grieving process and what it is like to experience grief; as well as developing our understanding of grieving styles, coping, and those strategies which are helpful (Worden, 2009).

Comfort with Emotions

As you learned in the previous section, working with emotions is a key component of work in the context of loss. Counsellors need to critically consider their comfort level with emotions, forms of emotional expression, and tolerance for witnessing intense emotions in clients. No counsellor feels totally comfortable with all types of client experiences and emotional expressions, so this is not a ‘box ticking’ exercise where we claim to be ‘okay’ with emotions. Rather, this requires an ongoing process of genuine reflection and development across our working lives. Supervision is a particularly important resource in this regard. Talking with supervisors can help counsellors identify areas in which they are uncomfortable or not yet competent, address the personal factors impacting their practice, and learn helpful strategies for improvement. Talking with other experienced counsellors can also be very helpful, as can accessing personal counselling.

Monitoring Stress Levels

As stress is a key feature of burnout and compassion fatigue, monitoring your stress levels regularly should be part of your professional practice. Remember that counsellors may not notice that they are stressed until things escalate or unavoidable symptoms occur, so you must develop strategies for identifying signs of stress before they become more serious. It is easy to forget that counsellors, just like their clients, face various life stressors (for example, financial stress, relationship issues, grief and loss). Hence, you must be aware of stressors in your life that could impact your stress level at work. You can then take actions to address increases in stress, whether through self-care; adjusting your workload or work practices as appropriate; or getting additional support from a manager, supervisor, or other professional.

The following table consists of the stress components of the Depression, Anxiety and Stress Scale (DASS), which some counsellors and mental health professionals use to assess indications that problematic stress, anxiety, or distress levels may be present. Since regularly assessing your own stress and distress levels should be part of your regular practice, using this or another relevant inventory to help your reflection may be worthwhile. You may like to try it now.

Having circled a number for each item, selected numbers are added, providing a stress ‘score’. The general guidelines for assessing stress scores on this scale are normal (0-7), mild (8-9), moderate (10-12), severe (13-16), and extremely severe (17+).

The extract of DASS is included here simply as an example of a tool that counsellors could use in personal reflection to monitor stress levels. Whilst it is also commonly used with clients, specialist training is required to use the DASS in practice. Whatever process you use to monitor your stress levels, we all must address elevated stress scores (particularly those in the moderate range and over if using a tool such as the DASS), including through self-care strategies and supervision or personal counselling.

Some counsellors seem to have serious difficulty accessing their own help and support systems (or perhaps difficulty admitting that they need support), no matter how personally and professionally necessary such support is (Worden, 2009). This has serious implications for the counsellor’s own wellbeing and for the service they provide to their clients. Acknowledging support needs, accessing support regularly, and getting additional support when required are key components of ethical counselling practice. The following support structures offer valuable sources of support for counsellors no matter how long they have been practicing.

Debriefing

The term ‘debriefing’ refers to conversational sessions that revolve around the sharing and examining of information or aspects of a particular event, such as what happened in a challenging session or the emotions and thoughts a counsellor had when working with a client. Counsellors should be continuously self-monitoring and reflecting on the counselling process. If a client has shared something particularly confronting or triggers a strong response in the counsellor, the counsellor should immediately process this with a supervisor or experienced peer. By doing this, a ‘traumatic overlay’ is less likely to occur (Winokuer & Harris, 2012), reducing the risk of secondary traumatisation and other issues.

Supervision

As you have learned in previous modules, supervision is an essential component of competent practice, providing the counsellor with a more objective and expert perspective on client issues, the interactions between client and counsellor, the counselling process, and the counsellor’s own issues. Supervision provides an important source of professional support to counsellors, allowing them to process their work with clients without violating client confidentiality (Pomeroy & Garcia, 2009). Supervisors can also provide support to counsellors when personal issues are triggered by or impacting upon the counsellor’s work.

Peer Support

Professional peer support groups provide counsellors with an opportunity to engage in the development of self-awareness, share self-care strategies, and learn from interactions with others engaged in a similar field of practice. Having access to regular peer support with other counsellors reduces the isolation and alienation that can occur from conditions of confidentiality and working alone (Winokuer & Harris, 2012).

Counselling

Many counsellors access counsellors of their own. This can be incredibly valuable in helping counsellors develop self-awareness, address issues, build personal and professional skills, and cope with the demands and stressors of their work. In fact, in some counselling traditions, it is essential to engage in personal counselling or therapy to train and be considered competent in applying the approach. Don’t be afraid to seek out counselling at any point. Counsellors (and others) may worry that they will appear ‘weak’ or raise concerns that they are not coping if they acknowledge the need for counselling, but quite the reverse is true. By accessing counselling or other supportive interventions when required, counsellors demonstrate their capacity to identify and meet their own needs, which are crucial aspects of professional responsibility.

Self-care strategies are a vital but often neglected part of reducing the risk and impact of work, such as supporting grieving people. In addition to the support strategies we have discussed, which also make up part of an appropriate self-care regime, self-care strategies focused on maintaining a balance between work and home life may include reducing stressors where possible (for example, workload limitations); paying attention to nutrition, exercise and sleep; having multiple satisfying and supportive personal relationships; and engaging in relaxation and enjoyable activities away from work. Harris and Winokuer suggest the following:

Essentially, counsellors will need to determine which self-care strategies work best for them, in addition to those set out in the workplace guidelines (for example, regular supervision), and ensure that these strategies are integrated into their practice.

The Missing Ingredient in Self Care 

This video describes a holistic and inclusive approach to self-care that takes into consideration how cultural and social factors, as well as experiences of discrimination based on identity markers (e.g. race, class, gender identity, sexual orientation) may trigger one's need for self-care and shape one's willingness--or reluctance---to engage in self-care practices.

watch

Re-train Your Brain With Self-Care

This video looks at how the science we have can impact our well-being and improve the way we see ourselves. 

watch

Another important responsibility of counsellors in maintaining a competent service is to engage in the ongoing evaluation of client work in order to identify and address areas for improvement. This can be done through evaluating client feedback and critically reflecting on your practice.

Client Feedback

It is important to get the client’s feedback throughout the counselling process and to evaluate outcomes along the way as well as at the end of counselling. This way, you can check whether your support matches their needs and identify where further support is warranted. You should be seeking feedback about whether the sessions themselves are working for the client, whether their needs are being met, what you are not doing that could be helpful, and your own approach and communication with the client.

You can do this by ‘checking in’ with clients during sessions and obtaining feedback at the end of sessions. Some counsellors find asking for client feedback during the session challenging or inappropriate. They prefer giving clients feedback forms at the end of sessions so that they can fill them out privately and return them to the counsellor then, or return them at the next session. Organisations often have designated processes and documents in place for evaluating client feedback. These usually involve having clients fill out feedback forms and outcome measures at particular points of the counselling process (for example, after every third session and at the terminating session). Ultimately, obtaining client feedback regularly should provide useful insights into what you are doing well and areas you can improve.

Reviewing Practice

As well as making sure each client’s needs are being met, it is important to review your professional counselling practice to identify opportunities for improvement. You may remember the ‘reflective practice cycle’ (North Carolina Department of Public Instruction, n.d.) from previous modules. The reflective practice cycle provides a structure of self-reflection that you can use to reflect on your counselling work:

• Step 1: Select the issue or situation that you will reflect on.
• Step 2: Describe the situation or issue — answer who, what, when, and where questions.
• Step 3: Analyse and assess the situation. Explore why and how the action was taken or why and how the decision was made.
• Step 4: Appraise and evaluate your behaviour and its impacts. This is where critical self-reflection is required. The involvement of a peer or supervisor can be very useful here (while maintaining confidentiality, of course).
• Step 5: Transform – ask yourself what you have learned and how you will integrate this into your work. What will you do differently in the future? How would you respond to a similar situation or issue? What further professional development can you undertake to improve in this area, and how will you go about this?

Reflective processes such as this can be used to identify areas and processes for improvement, both for individuals and organisations as a whole. Beware, however, that while engaging in regular independent, reflective practice is important, others should also be involved, particularly when reflecting on serious issues and areas for practice improvement. Your manager or supervisor, for example, may be a valuable resource in reflection, helping you identify issues and options you have missed and helping you effectively use the ‘transform’ stage.

Case Study

Ari has just completed an initial session with a client and is discussing his assessment with his supervisor. He reports that he used active listening skills to help the client tell her story and has simultaneously gathered important information about the nature of her loss and the grief reactions she is experiencing. He also carried out a risk assessment and found his client to be at low risk of harm to herself or others.

However, as he describes the client’s responses to his supervisor, it becomes clear to the supervisor that this client is suffering from trauma symptoms that have lasted for several months. The supervisor advises Ari that his client needs a more specialised assessment and may need to work with a trauma specialist. They go over the trauma symptoms together, and the supervisor describes what factors and symptoms indicate trauma in this case and what Ari can look out for in the future. She gives him some resources about trauma in the context of grief to read and advises Ari to review his organisation’s referral procedures.

On an individual level, there are various areas for improvement that you may identify through the reflective process. These are usually around becoming aware of biases and values and addressing gaps in knowledge and skills. As you work on developing your skills in supporting people experiencing loss and grief, ask yourself questions such as:

Counsellors do need a combination of activities for effective professional development. This involves reflecting, learning, and practicing through different methods, including independent research (for example, textbooks, journals), workshops and other training activities, and peer and professional supervision.

Self Care for Therapists

In a career that is all about helping others, this video provides some thoughts on how to shift your perspective about the concept of self care as a counsellor.

watch

In this section, you learned about the various risk and impacts that working with grief and loss presents to counsellors and other helping professionals. You learned how to reduce these risks by accessing supports such as debriefing, supervision and peer support, and self-care strategies. We also emphasised the importance of self-awareness, critical reflection, and ongoing professional development in this area.

Bond, T. (2015). Standards and ethics for counselling in action. London, UK: SAGE.

Black Dog Institute. (n.d.). DASS 21. Retrieved from https://www.workcover.wa.gov.au/wp-content/uploads/sites/2/2015/07/3.dass21withscoringinfo.pdf

Centre for Clinical Interventions (n.d.). Coping with stress. Available from https://www.cci.health.wa.gov.au/

Harris, D. L., & Winokuer, H. R. (2016). Principles and practice of grief counseling. (2nd ed.). New York, NY: Springer Publishing Company

Machin, L. (2009). Working with loss and grief: A new model for practitioners. London, UK: Sage

McLeod, K., & McLeod, J. (2011). Counselling skills: A practical guide for counsellors and helping professionals. (2nd ed.) New York, NY: Open University Press.

Pomeroy, E., & Garcia, R. (2009). The grief assessment and intervention workbook: A strengths perspective. Belmont, CA: Brooks/Cole Cengage Learning.

North Carolina Department of Public Instruction. (n.d.). Self-assessment: The reflective practitioner. Retrieved from http://electronicportfolios.org/academy/reflection4learning/teachers/nc-reflection-model/index.html

Winokuer, H. R. & Harris, D. L. (2012). Principles and practice of grief counseling. New York. NY: Springer.

Worden, J. W. (2009). Grief counseling and grief therapy. A handbook for the mental health practitioner. New York, NY: Springer Publication Company.

Walsh, K. (2012). Grief and loss: Theories and skills for the helping professions (2nd ed.). Upper Saddle River, NJ: Pearson.