• Wellness Pointers for Recovery from Addictive Disorders

    A distinctive feature of recovery from addictive disorders is that while people entering recovery have reached a point where they are powerless over the addiction per se, they must assume central responsibility for holding the addiction at bay.  

    Read More >>

  • CCAPP Election Sets the Stage for a Productive 2017

    With multiple nominations and tight races for California Consortium of Addiction Programs and Professionals (CCAPP) board of directors positions, CCAPP started 2017 with a full board of motivated professionals.

    Read More >>

Provider Self-Care through Conscious, Balanced Relationships

Feature Articles

The very work of counseling and psychotherapy is relational. Those of us in the field use our very selves as a tool of intervention. We actively utilize our knowledge and insight, training and clinical intuition, and our natural talents and the personal history that has shaped us to become who we are in an efforts. We attempt to effect change, health and wellness, growth, increased insight and awareness, and hope in those with whom we engage and serve. We access these various aspects of ourselves as we interface with our clients, patients, consumers, and the students and supervisees we train and guide. These facets of our person are also active, albeit somewhat differently, within our personal and intimate relationships with friends, family, lovers, partners, and children. As we move through our lives beyond our offices or treatment spaces to our homes, communities, and larger society, we are steadily utilizing these same attributes, skills, and knowledge to varying degrees. We do this even as we shop, drive, plan our daily routine, prepare meals, stay present to our partners and children at home and school, manage our finances (personal and professional), and hopefully live a fulfilled, quality life. We can feel the pressure mount even as each additional phrase of the last sentence is read. Yet it is more than words. Those of us in the work of service, whether in the profession of health, mental health, addiction, or our partnerships with education, police, fire, and other emergency services have professional lives that require us to focus on others and their safety, health, education, and well-being. Many of us in these roles continue that focus on others in our personal lives as parents, partners, spouses, family members, friends, and as active social and community participants.  

 

This is not to say that these various roles are simply put upon us; we are not victims. Those of us drawn to the fields of health, mental health, addiction, education, and service in general, typically are drawn to relationships, to the people in our lives through home, community, and profession. We typically enjoy people. As a group, we are often deeply fulfilled in helping and facilitating healing. We are generally pretty good with people. Engaging with people and facilitating the growth and healing of others is part of what motivates us. 

 

As healers, many of us have felt a sense of being “called” to this work. We are often intrinsically fulfilled through our healing efforts and our attunement to others. We know the healing power of relationships. Whether we entered the field with conscious intent or by accident, there have always been unconscious processes and motivations at play. Human beings unconsciously continuously recreate early relational attachment patterns and dynamics with those we engage. Those of us who are health care providers are no different. Much of our unconscious relational patterns incorporate relational defenses and long-standing attachment patterns, both with patients, clients, students, fellow healers, and our friends, family, lovers, and life partners. 

 

We providers of care, healing, and service are, by the very nature of our work, involved in relationships. By definition, our work requires that we be attuned to the needs of others. In my work, I refer to the myriad of professionals, paraprofessionals, and volunteers in these roles of providers as “healers.” The term is both metaphorical and yet, true. As healers, we are often required to attend to and navigate the emotional and relational dynamics that each person we serve brings with them. We are also required to navigate our own emotional and relational dynamics in this process. Each of us navigates these relational dynamics with varying degrees of self-awareness and consciousness.  

 

Many of us are quite good at navigating as we have been doing it for most of our lives. Many of us attuned to the care of others are naturally gifted in this act of attuning to others. We were born highly empathic and sensitive to emotional states and relational dynamics. We often used these very skills to negotiate family dysfunction, power struggles, and our personal and professional growth. Some call this “emotional intelligence” or “high empathic ability” or capacity.  

 

And yet, within our culture of health, wellness, and education professionals, we are finally acknowledging trends that can and do at times yield one of the hazards of our profession. Our emotional intelligence, empathic abilities, and learned knowledge and skills fail us as crises of compassion fatigue and burnout that are rooted in living lives of relational unconsciousness and imbalance do occur. It is a very real risk of our healing and helping professions (Rothschild & Rand, 2006). Attunement to other is often not balanced with attunement to self. Conscious awareness of our own vulnerability and need for care as a fellow human being is often lacking, forgotten, or purposely set aside. These patterns can result in a crisis resulting from lack of awareness of our unconscious ways of making meaning of relationships and the ever-shifting emotions that emerge in every interpersonal interaction we engage, professionally or personally, socially or intimately. “Self-care” has become the current cultural buzzword for attending to this phenomenon of compassion fatigue that can result in very real symptoms of imbalance and disorder that can express as physical, emotional, mental, spiritual, behavioral (Portnoy, 2011), financial, and yes, relational dysfunction and disorder. I will use the term “self-care” as it resonates for so many of us now. I also will challenge you to join me in deepening its meaning to incorporate self-attunement and relational consciousness and balance, and even consider the psychodynamic concepts of transference, an unconscious way of organizing relational experience based in early attachment patterns and experiences. 

 

The term “self-care” has emerged as a global and highly generalized umbrella for multitudes of interventions for and prevention of compassion fatigue, burnout, and vicarious and secondary trauma. From practicing yoga, tai chi, qigong, meditation, and mindfulness, to incorporating nutrition, breathing, exercising, and taking vacations, each is an example of a powerful approach to self-care. Self-care has become a steady drumbeat in the lives of those of us who attend to the care, education, intervention, and healing of others. Over the last decade, awareness of the very real and not uncommon experiences of trauma, fatigue, and burnout within our professional lives is increasing across all fields of service from nurses to psychotherapists to physicians, alcohol and drug treatment counselors, and police, fire, and emergency professionals and paraprofessionals. In my journey the last several years of teaching and attending to compassion fatigue and self-care, I have repeatedly discovered that in addition to health, mental health, and addiction professionals that mothers, fathers, teachers, clergy, attorneys, financial planners, and even estheticians, massage therapists, yoga teachers, and veterinarians are affected and in need of understanding regarding its reality and needed intervention. 

 

The Power of Relationships

 

As I teach and consult on the subject of compassion fatigue and self-care, I always address the deeper underlying relational processes that lie at the root of compassion fatigue. These relational processes are largely unconscious and can be understood as psychological and somatic transference that is active and affecting every healer and helping professional and the person they are serving or treating. Though compassion fatigue can develop from unresolved single or ongoing experiences of vicarious and/or secondary trauma, as well as the sustained engagement of empathy in response to trauma (Figley, 2015), understanding the concept of relational transference as the root of compassion fatigue and burnout is essential (Crim, 2015). And, unless these unconscious ways of making meaning of emotional and relational attachments and past and current relational traumas are explored and healed, many healers will continually find themselves neglecting themselves and the very self-care interventions they value or espouse to others. Further, research supports that problems can arise in nonanalytic therapies when the transference between therapists and clients is not attended to by therapists (Gelso & Carter, 1994). I would extend the importance of attending to transference that emerges in all relationships by those within those relationships when capable.

 

We typically think of transference as a mental and emotional process in which a therapist analyzes and identifies the various ways that she and her client are organizing and making meaning of an emotional and inherently relational experience (Stolorow, Brandchaft, & Atwood, 1987). The process of developing new [ways of organizing or making meaning of relational experiences] within the context of the therapeutic relationship can also be now understood as a neuropsychological process as we [respect] the plasticity and ongoing development of our brains and neural networks throughout our lives (Crim, 2009, 2012).

 

Just as infant neural networks, biochemical cellular and organ system health, and immune system functioning develop through parent-infant attachment, so are new neural networks, cellular health and immune system functioning, and overall mind-body health affected through current and ongoing attached and meaningful relationships (Stern, 2000). Regarding the neurobiological power of relationships, “Dan Siegel (2001, 2007) [and Alan Schore (2001, 2012)] echo Stolorow (1987) neurologically as [they] discuss the development of the brain in the context of relationship, addressing mirror neurons and the flow of energy and information within one brain and between two brains in the intersubjective field they share. The latter is the process of both parent-infant attachment and relationship and the potentially healing developmental and therapeutic therapist-client relationship” (Crim, 2012). It can also be witnessed in the healing and generative power of conscious and committed couples who experience enhanced mind-body-spirit relational healing and sense of well-being as well as longevity, through their safe, intimate, and genuine relationship with one another (Tucker, Friedman, Wingard, & Schwartz, 1996). This mindful awareness enhances growth for all relationships in which it is actively attended. Parent-child, friend to friend, colleague to colleague, psychotherapist to patient, counselor to client, nurse or doctor to patient, husband to wife, lover to lover. The healing and generative power of self-care through conscious, balanced, safe, and where appropriate, mutually nurturing relationships can be astounding.

 

Somatic Transference

 

Healthy, connected relationships afford more than emotional and mental fulfillment. Living life within the context of relationships in which we balance attunement to self with attunement to others will affect physical, spiritual, and even financial health as well. In a 2012 article I wrote, “A person’s sense of self and experience of relationship are more than thought and emotion; both also require body awareness to be complete. Body awareness is key in experiencing and identifying emotion and develops in the context of relationship with self and with other. Body awareness is often overlooked by both therapist and client, [and though improving,] ironically the very field of mental health itself” (Crim).

 

“Somatic transference” is a term I have used to “capture the process of emerging and often unconscious bodily states that are activated within and between therapist and client in the shared relational space. When using the term ‘bodily’ I am referencing the physiological, energetic, bio-chemical and/or neurological organizing activity of the intersubjective states between two people that is inherently relational” (Crim, adapted from Stolorow et al., 1987). I explain this in an article I wrote specifically on somatic transference:

 

The key to identifying mind-body processes as “somatic transference” lies in understanding that the bodily expressions that emerge are not always conscious or attended to (Van der Kolk, 1994; Ogden, Minton, & Pain, 2006). We live in a society that trains us to play down our physiological disruptions, to negate the pain signals when they sound. As therapists and counselors, helpers and healers, many of whom played the role of the helper/healer in our family system of origin, the denial of self for the service of other can be deeply ingrained (Crim, 2012). 

 

As previously noted, we often continue this pattern of self-denial in our personal and intimate relationships as well. Examples of somatic transference for a healer may include: 

 

. . . feeling energized or physically good entering a session, but tired, physically drained following that session; experiencing headaches following sessions or several sessions; feeling sleepy or struggling not to yawn with certain patients; feeling lighter and energized, physically better after meeting with a certain client on a regular basis; feeling the nervous system’s heightened state and pulsing adrenaline following a session with a raging client. Somatic transference for a client or patient may include reports of migraines or missing sessions due to illness on a routine basis, not breathing deeply, sitting stiffly on the edge of their seat, having physical pains while discussing certain issues. The latter can be experienced by the therapist regarding certain cases or their entire practice as well (Crim, 2009, 2012).  

 

Learning to pay attention to these often subtle mind-body shifts within ourselves, even while relating and attuning to others, is critical to maintaining our balance and health. Regardless of setting and relationships, healers and helpers can struggle in developing healthy, committed personal intimate relationships that are meaningful, balanced, and mutually nurturing; even as they are successful in helping others form them. And yet, relational health is interconnected with physical, emotional, mental, spiritual, and financial health. We arrive to these healer roles as imperfect, imbalanced, and injured souls in need of our own relational nurture and attunement. We have our own issues, transference dynamics, and mind-body-spirit symptoms that express these imbalances and injuries. Yet, it is easy in a field in which the appropriate and ethical focus is on the care of clients, patients or students to leave care of self and healing and restoration of self to last. We increasingly are learning how much of our mental, emotional, physical (neurobiological and energetic), spiritual, financial, and relational health is mediated through sustained, committed, healthy, attuned, and nurturing relationships. 
 
When working with healers, I repeatedly find both for myself and others that the shift in focus from others’ needs for healing and care to a focus on healers’ own personal needs for healing and care is often quite difficult. When I teach or lead consultation groups—and even as I discussed the issue with a trusted and highly self-aware colleague—the idea of exploring personal unconscious dynamics as they emerge within us as healers can easily slip into a focus on how those dynamics affect those for whom we provide care. While this is important and ethically necessary, it often precludes an equally important focus: the exploration of personal unconscious relational dynamics for the sake of our attending to our own holistic health and wellness, for its own sake. It seems that for healers, the sustained focus on self for our own personal health, wellness, and fulfilling relationships with others is often the most elusive. The difficulty in sustained empathic self-inquiry and self-exploration (Kohut, 1971; Stolorow et al., 1987) often seems anchored at least in part in a deeply ingrained and unconscious organization of our past and recurring relational dynamics, attachment, and transference that is based in early childhood, family, and community relationships.  

 

Early Childhood Factors

 

Sadly, some of us offered “inordinate caretaking” of our parent or parents for our own survival (Katehakis, 2014). It is not uncommon for healers to have experienced parents or other adults who required, most often unknowingly, that we empathically attune to them, often to the neglect of our own self-attunement and instead of their attuning to us. For some healers there were grave consequences for not taking on the empathic emotional and at times physical caretaking role of our parents. For others of us it saved us from neglect and abuse even as less empathic and insightful siblings suffered. For many in more stable families, we found ourselves gifted empathically in ways that differed from other family members, resulting in their depending on our gifts in keeping the family’s emotional balance. Many of us were parentified as children repeatedly within our relationships since our early childhood based on our ability to attune to the need of the adults in our lives. Since childhood, many healers have formed friendships based in listening and giving to a close friend without allowing or requiring that same care in return. 

 

Many of us learned how to navigate relationships, became highly attuned healers, and developed our careers from these early lessons, even if often unconscious, imbalanced, and at times full of trauma. These unconscious states of relational imbalance and transference can also serve as unconscious psychological defenses that can actually keep our partners, friends, children, fellow colleagues, and coworkers in dependent and injured roles and identities. Sometimes we choose to hide behind our ability to focus on others effectively without experiencing and revealing our own vulnerabilities and painful emotional states. The psychological defenses based in these relational dynamics can also emerge between healers and the very individuals we are endeavoring to help professionally. Ultimately, as relates to our own self-care, these unconscious relational patterns and transference processes will yield imbalances that lay the groundwork for symptoms of compassion fatigue, vicarious and secondary trauma, and burnout. 

 

Unconscious and often difficult or confusing mind-body-spirit relational dynamics that are based in our early child and infant attachment experiences are active in our efforts to form meaningful, safe, and trusting relationships personally and professionally. Many therapists tend toward isolation if not careful. Even though research supports the powerful effects of collaborative, interprofessional treatment teaming (Hammer et al., 2012; Crim, 2013; Crim & Fitzpatrick, 2003), many are loathe or simply hesitant to do it for more reasons than time and financial constraints, which are real to be sure. Many of us are unfulfilled personally with family, friends, spouses or partners. Many are helping others steadily, while quietly suffering privately. Sadly, many of us experiencing this do not realize how not alone in this experience we are. Further, many do not honor the depth of which it is based in a repetitive relational dynamic we have cocreated with others since our early childhood communities and families of origin.

 

Engaging in Self-Care

 

Due to these imbalances and unconscious dynamics, I have for years taught that it is unethical for psychotherapists to not engage in their own psychotherapy and ongoing consultation throughout their lives and careers. I have taught that it is necessary to understand the concept and powerful effect of transference for providers and the patients they treat or clients they serve. In recent years I have evolved to incorporate the reality that we are mind-body-spirit beings. Somatic transference and physical symptoms expressing relational imbalance are real. Both treatment for our clients and patients and our own self-care routine must therefore incorporate a somatic, mind-body healing practice of some sort. For example, I collaborate to bring yoga, acupuncture, and massage into my psychotherapy practice and consultation groups. Additionally, the role of community is essential. Part of the powerful role of Twelve Step meetings is the community, affording another form and setting for meaningful and healthy affecting relationships. Some churches, temples or community member organizations have also provided this in the past. Though these settings are less utilized today as in past generations, the need for safe communities and a shared sense of belonging is no less essential. We as healers need these as well. 

 

For healers, unconscious and unattended relational attachment patterns and transference dynamics can result in poor self-care. The unconscious pull to attend to others to the neglect of self is deeply engrained and often based in early attachment dynamics coupled with our natural temperament and gifts. The latter can disrupt our ability to engage in conscious, present, authentic, and genuinely connected and fulfilling relationships, both personally and professionally. We need safe, trusted, and mutual relationships. We need communities in which we can relax, take off our healer hat, and be our true genuine selves. In reality, many of us are healing to others when we are in our natural, balanced state. If we live from a balanced, conscious, and mutually nurturing stance, we can also experience nurture and healing from trusted others in our relational lives. For many healers, this may be a new or unfamiliar experience. That does not make it less essential; rather, it suggests it is highly indicated in the self-care regimen for mind-body-spirit health.  

 

The process of our ever shifting neurobiology and psychological and spiritual processes and the need for rebalancing both affects and expresses through meaningful interpersonal relationships. The conscious healer develops and manages relationships within her personal and professional life. Intimate committed relationships, including marriage or partnerships, children, parents, family, close friendships,  and trusted colleague relationships require attention for sustained healthy attachment, which affects the healer’s mind, body, spirit, and finances, as well as her professional healing efforts. Healthy relational development requires attention to relational transference, trauma, and attachment dynamics and needs.

 

It is through the process of becoming conscious, self-reflective, and aware within the context of our relational life that we as healers can begin to experience fulfilling and genuinely connected relationships that enhance growth and health at a mind-body-spirit level. It is through conscious healing and restorative interventions that are insight-oriented, transference-based, and body-based that the latter attributes can evolve and emerge with balance and health. This process can all allow us as healers to live a more conscious, free, and vibrant life.

 

Self-care through the lens of relationship requires that we value the healing and restorative power of relationships in our personal and professional life. From a baseline of understanding that we each live with injuries, blind spots, and unconscious relational attachment and transference patterns, we can begin to actively seek personal psychotherapy and professional consultation (peer and paid) to attend to our unconscious attachment patterns, transference processes, and unresolved trauma states. We can remember to honor our natural motivations and talents and set a goal to live free and vibrant lives. We must seek balance and self-awareness as we attempt to develop and engage relationally and with healthy attachment with our personal family and friends and our community of fellow healers. Through this, we can begin to value relationships within our interprofessional communities, developing safe communities made up of trustworthy fellow healers from our shared and other disciplines. We can begin to approach treatment through a lens and paradigm of collaboration and teamwork. It takes many healers from many disciplines to truly attend to the holistic complexity of a single individual, couple or family. This is also true for ourselves as the individuals who are the healers needing the care of self. It is true of the many clients, consumers, and patients we serve. It is not only acceptable, it is preferred that we not go it alone, personally or professionally. Valuing and attending to our own unconscious processes and relational health can allow us to value efforts in developing safe spaces and communities, wherein each individual healer’s transference and countertransference can not only be acknowledged, but be openly explored and safely resolved, even as secure and safe attachments can be discovered, developed, and experienced.  

 

To be a psychotherapist, counselor, healer, and helper is a rich and wondrous calling. We can continue to enjoy our journey as healers and live vibrant lives throughout our many roles and relationships if we can heal relationally, become more conscious, balance our attunement to others with attunement to ourselves, and learn to live life in a manner that is relationally genuine, fulfilled, vibrant, and free. 

 

 

 

 

 

 

 

 

 

References

 

Crim, E. R., & Fitzpatrick, J. C. (2003). Clinical update: Childhood onset mental illness. Family Therapy Magazine, 2(5), 34–40.
Crim, E. R. (2009). Dancing the transference: Honoring the relationship between therapist and client. Clinical Update: California Society for Clinical Social Work, 38(8), 1, 9–12. 
Crim, E. R. (2012). Somatic transference: The body’s process in psychotherapy. LA Therapist Update: Los Angeles CAMFT Newsletter. Retrieved from http://lacamft.org/wp-content/uploads/2012/01/LA-CAMFT-Jan-Feb-2012-Newsletter.pdf
Crim, E. R. (2013). Yoga therapy for mental health: Understanding competence in the context of collaborative treatment teaming. YogaTherapyToday, 9(2), 16–8. 
Crim, E. R. (2015). Compassion fatigue and countertransference: A mindful continuum of identification, prevention, intervention. California Psychological Association: Division I Newsletter, 2(2), 1–2, 7. 
Figley, C. R. (Ed.). (2015). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Routledge.
Gelso, C. J., & Carter, J. A. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41(3), 296–306.
Hammer, D., Anderson, M. B., Brunson, W. D., Grus, C., Heun, L., Holtman, M., . . . Frost, J. G. (2012). Defining and measuring construct of interprofessional professionalism. Journal of Allied Health, 41(2), e49–53.
Katehakis, A. (2016). Sex addiction as affect dysregulation [Video file]. Retrieved from https://www.youtube.com/watch?v=ni-rbehd5jo
Kohut, H. (1971). The analysis of the self: A systematic approach to the psychoanalytic treatment of narcissistic personality disorders. Chicago, IL: University of Chicago Press. 
Ogden, P., Minton, K., & Pain, C. (2006). Attachment: The role of the body in dyadic regulation. In P. Ogden, K. Minton, & C. Pain, Trauma and the body: A sensorimotor approach to psychotherapy (pp. 41–64). New York, NY: WW Norton & Company.
Portnoy, D. (2011). Burnout and compassion fatigue: Watch for the signs. Health Progress: Journal of the Catholic Health Association of the United States. Retrieved from http://www.compassionfatigue.org/pages/healthprogress.pdf 
Rothschild, B., & Rand, M. (2006). Help for the helper: The psychophysiology of compassion fatigue and vicarious trauma. New York, NY: WW Norton & Company.
Schore, A. N. (2001). Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1–2), 7–66.  
Schore, A. N. (2012). The science of the art of psychotherapy. New York, NY: WW Norton & Company.
Siegel, D. J. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment relationships, “mindsight,” and neural integration. Infant Mental Health Journal, 22(1–2), 67–94.
Siegel, D. J. (2007). The mindful brain: Reflection and attunement in the cultivation of well-being. New York, NY: WW Norton & Company.
Stern, D. N. (2000). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York, NY: Basic Books.
Stolorow, R. D., Brandchaft, B., & Atwood, G. E. (1987). Psychoanalytic treatment: An intersubjective approach. New York, NY: The Analytic Press. 
Tucker, J. S., Friedman, H. S., Wingard, D. L., & Schwartz, J. E. (1996). Marital history at midlife as a predictor of longevity: Alternative explanations to the protective effect of marriage. Health Psychology, 15(2), 94–101.
Van der Kolk, B. A. (1994). The body keeps score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5), 253–65.