Self Care And Burnout Prevention: Cognitive Behavioral Strategies

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allceus.com counselortoolbox I'd like to welcome everybody to today's presentation on ethics, burnout and self care in Human services professions. Now I have to say that when I was gathering information for this class because I wanted to make sure that I was getting what is currently causing burnout and stress in different people's work environments in different states and you know, what have you, because I know my work environment and I know what the research says. But clearly I don't work everywhere. So I posted about this in a couple of my groups and within an hour I had 40 or 50 responses to that post in multiple different groups. So over the course of an hour I got almost 200 responses. A lot of them were people echoing the same thing. Which in a way is good because it's fewer things to address in a way is bad because so many people were were just verklemped with the amount of stress that they were experiencing. The objectives for today are very simple. We're going to identify signs and causes of burnout and explore techniques for burnout prevention. Let's start out with Is burnout a self care issue? Burnout is associated with suboptimal care and reduced patient safety. So instead of just pulling that out of thin air, you know, I try to go into PubMed and different places and actually get research and I found three meta analyses that show that yeah, it does contribute to suboptimal care and reduced patient safety in mental health as well as physical health care. High demands are associated with a greater risk of burnout regardless of level of other work support. And I thought that was interesting because think about our day to day work and if you're in private practice, you may have the luxury of managing your caseload. So it's at what you consider a quote, manageable level. If you are working in a clinic, private, for profit, nonprofit, whatever, a lot of times your caseload is thrust upon you and many times those caseloads can be very, very high. One of the things that struggled with when I was a supervisor was making sure that my staff had relatively equal caseloads in terms of effort. We would have some clients who were easy peasy, they were treatment compliant, they didn't have complex issues. You know, as far as treatment goes, they were sort of your ideal client. And then we had other clients that had multiple comorbid issues and had a Lot of problems. So I wouldn't want to take someone, have a client, have a Counselor working with 15 people who had substance abuse, mental health issues, comorbid personality disorders and physical health issues or something, you know, that is a lot more work and a lot more intensive than another counselor who had 15 people who had, if there is such a thing, simple addiction. It was important to me to balance that out. So when we had complex cases, a lot of times I had clinicians who really enjoyed those cases. I was lucky, however, they would have smaller caseloads because those people required so much more work. So we're going to talk a little bit more about demands. But I did think it was interesting that regardless of the level of other work support, if you've got a lot of demands on you, if you've got a really high caseload, even if you've got a great boss and you love your co workers and you can get time off occasionally that day in, day out, having to manage a caseload of 30, 40, 80 can get exhausting and oppressive. Suboptimal care can negatively impact the public's view of the profession and deter people from seeking treatment. Well, this is kind of that ethical issue of somewhere between beneficence, do what's right in the interest of the client. We want to make sure we're not providing suboptimal care, but also non malfeasance, making sure we're not providing suboptimal care. One study I found, and I thought it was interesting because I used to run a medication assisted treatment clinic and I can see how this would Happen, found that 26% of clinicians working in medication assisted treatment reported burnout. Now I would love to see documentation on the social workers that work at the va. I would love to see documentation on other cohorts out there because I know people who work in those settings and I know it is high demand and it can be very exhausting. But I thought that was really telling because that's more than a fourth. More than one in four counselors who work in methadone assisted treatment or medication assisted treatment are reporting burnout. We'll talk about more interventions later. Depersonalization happens when people start experiencing burnout. And that is an ethical issue because it's characterized by a loss of empathy. We quit seeing clients as other human beings and we start seeing them as numbers. They are our 26th billable hour this, this week. They are, you know, case number 4, 5, 32 1. Whatever it is, we quit having the ability to connect with them on A meaningful level because we're just out of gas, we're out of energy. What happens when we start getting burned out? Even mild, acute, uncontrollable stress. Okay, so mild and acute sounds like you know, you're having a bad day. But even mild, acute uncontrollable stress can cause a rapid and dramatic loss of prefrontal cognitive abilities. So if you're having a bad day, you know, whatever happens, you had a heaven forbid, you had a client commit suicide, you had a grievance filed against you, and you took it really personally. Whatever it is, you had a level of stress. It wasn't excruciating necessarily, but it wasn't something that you could control. What does that do? It affects our prefrontal cortex. It affects our ability to concentrate and make decisions and use higher order thinking. Prolonged stress exposure. Now think about your past three, six months at work. How many days have you had mild, acute, uncontrollable stressors? My guess is most of you are going. Most, me. Me, every day. So it's important to recognize that a lot of us are probably experiencing some cognitive changes. Prolonged stress exposure produces anatomical changes in the prefrontal nerve cells and amygdala enlargement. Now remember, the amygdala is fear processing, basically. And so your amygdala is getting bigger and going. There's more and more stress, there's more and more threat. Very, very oversimplified. But it's important to remember what effect does this have on our functioning? Our ability to focus and our attention goes down the tubes. Our self control of behavior and speech, you know that filter that we're supposed to have, it goes out the door too. Our ability to plan and organize, not so much. Again, focus and attention goes. Our ability to plan is probably going to go as well. And when you're thinking about organization, organizing your day, seeing your clients, getting your paperwork done, we do a lot of planning and organizing. Perspective taking goes out the window. Well, that's not really good when you're a clinician and you're needing to be empathetic and take somebody else's perspective and understand what life is like in their shoes. Our cognitive flexibility goes down. Well, this is one of those skills that we try to teach our clients every single day. So if our cognitive flexibility is going down, then what are we modeling for them? Our medical and other decision making becomes less accurate. Our ability to defer gratification may become more intense. So that desire when you wake up in the morning to go, oh, I think I'm calling in and taking a mental health day or have a cigarette or whatever it is that is your gratification that starts to become more prevalent. Our ability to estimate time goes out the window. So you know how you get through the day and you're just, you're struggling to get through the day. And some days it feels like that clock is creeping and other days you don't know where the day went and you still haven't gotten everything done that you needed. Your working memory is impaired. Well, your brain's not real concerned with working memory right now. It wants to fight or flee because it's experiencing this prolonged exposure to stress. But unless you're like one of those old fashioned clinicians from, you know, 50 years ago that sits there and takes copious notes throughout a session, you rely a lot on working memory to do your case notes and to engage your clients in sessions. It's important that we recognize this. And I said jokingly, I'm going to call in and take a mental health day. But it is important for us to recognize when we need a break because if we go in and we're just kind of half there, we're not going to be doing a service to our clients. In 1996, the National association of Social Workers updated the Code of Ethics to cover issues of professional impairment. And I'm just going to read it to you. Social workers should not allow personal problems, psychological distress or mental health difficulties to interfere with their professional judgment, performance or responsibilities to clients. Well, that's basically what we just talked about. So chronic stress, and even to an extent acute stress can impact our abilities. If you find out something, if you have this major stressor or moderate stressor impact you during the day, you may need to consider how well you're going to be able to provide services to your clients for the rest of the day and what you need to do. Social workers who experience these problems should immediately seek consultation and take appropriate remedial action. Hopefully you've got a mid level supervisor who is attentive and can help you navigate those things and has a sort of a drop back plan. Remedial action can include professional help, making adjustments in the workload, terminating practice, or taking any other steps necessary to protect clients and others. And finally, social workers with direct knowledge of another social worker's impairment should, when feasible, consult with and assist the social worker in taking remedial action. If you see that one of your colleagues seems to be experiencing burnout or impairment, it's important to talk with them about that. That's an ethical imperative that the code of ethics states for social workers, counseling has very similar verbiage in their ethics. We don't want to be going into sessions with clients when we are not able to give them at least 95%. I know some, not all of us, none of us is 100% every single day. You know, some of those days you wake up, you're like, oh, you know, I'm struggling today, but you're still cognitively there. You may not be alert as normal, but we can make those judgments. Am I so impaired that I'm not going to provide ethical services to my client? So, signs of burnout. Let's talk about these, and then we'll start talking about some interventions. There's interventions in the last half of the presentation, but we're going to talk about some things that you do. Physical and emotional exhaustion. That's one of those signs of burnout. Your body can only stay in that fight or flee place for so long before your brain starts reining it in and going, you know what? It's not worth exerting any more effort or energy on this problem because I'm not going to win. There are some excellent articles if you look up the neurobiological effect of PTSD and hypocortisolism. Now, hopefully clinicians aren't getting to the point of hypocortisolism, but our brain is designed to protect us. It's designed to not run hot like that for extended periods at times. So we start feeling exhausted. That's our body going, you can't do that anymore. You got to back off. I'm not going to give you any more energy to focus on that. You've got to find a solution. Some of the things that we can do there for physical exhaustion are setting boundaries. And this is easier said than done. I know everything is easier said than done. So I want you to think about, how could you set boundaries between work and home? That's one step. And I know lots and lots of clinicians who take their work home with them. They have. They see clients all day long and they take their laptop home and then they do their notes. And Jennifer raises a good point. When you work at home, that's one of the reasons I love having an office now, because I always have difficulty when I'm working from home, separating work from home, because I always feel that I should be doing something else. The computer's right there. But I've learned over the years that I have to set a boundary in order to preserve my own Sanity and wellness and health and all kinds of stuff. So it's important for me to be able to let that go once the workday is over, whatever that looks like for me. And my husband's really good about reminding me, if I get home and I pick up my laptop and I start doing work, he's like, do you really need to be doing that right now? And, you know, he's right. So it's important for me to take that time to work in my garden, play with the dogs, spend time with the kids, do things that are meaningful, because that helps me emotionally recharge as well. If you're working at home, some of the things that you can do is close up whatever it is that you're doing, close up your office, your work office, and, you know, shut everything down so it is off for the night. It's too easy if you just put your computer to sleep to go back and start working on notes or something later. Now, if you are working in an environment, and I know a lot of people do especially well, that's not even true. I was going to say especially case managers, but that's not true. A lot of clinicians work in environments where they are expected to see clients all day long, but then they also have to do the notes. And one of the things that started doing with my clients and I had my staff start doing, which seemed to help immensely, is we would schedule that therapy hour for actually, oh, my gosh, let me hold on to your seats here for 60 whole minutes. But after 45 or 50 minutes, the therapist would pull out a worksheet and go over it with the client. And the therapist would say, okay, let's recap what we talked about today. Would make notes about what the client said, what they talked about, and what do you think that your three greatest accomplishments were over the past week? And the client would tell the therapist, again, theoretically, they'd already talked about that. Therapist would write it down. What are your goals for next week? Remind me what we talked about. Therapist would write it down. Anyway, the worksheet would get completed before the client left the office. The client would sign a copy, and the therapist would sign a copy and. Or would sign it. And then a copy was given to the client for them to take home so they could see their progress. The original was scanned into the electronic health record. Bada bing, the note is done. You know, there were a few checkboxes for the claim clinician for mental status stuff, but in large part, that accomplished the requirements for getting notes done for the Majority of my. For the majority of my staff. It doesn't work for everybody. But most clients really enjoyed that activity because it helped them see the progress they had made, and it helped them feel empowered to take charge of their. Their treatment. And they didn't have that question in their mind, well, why, you know, what is that person writing in the chart about me? What are all the secret stuff that she writes when I leave the office? When we start with any client or, you know, or when my staff would start with any client, we would explain to them ahead of time. We will spend the first 50 minutes, which is a normal therapy hour, doing therapy. But then the last 10 minutes, we're just going to kind of summarize and go over things so we're both on the same page. And, you know, we never had a client object to that. That helped staff get their paperwork done. So we were compliant for audits, which was always really important. It reduced stress because most of us, there are some people out there who love doing them, but most of us really hate doing notes. So that would get out of the way, which would reduce stress, because a lot of us would expend a lot of energy figuring out everything we could do besides the notes, and we would put that off, which is not good. But, you know, let's just be real about what happens. So anyway, that was one way to save a little bit of time and be able to leave the office at whatever time you got off, not have to take notes home or. And some of the suggestions on here from a couple of other people. If you work from home, you know, like I said, I said turn off your computer so everything's shut down. If you have a room that is where you do therapy or where you do work, walk out, shut the door, turn off the light, don't go back in there. And. And it's a little bit easier. It takes some discipline, but it is a little bit easier to do than if you just have your laptop and you're sitting at the kitchen table and you're working. Of course, the laptop is full disk encrypted, and nobody's around to read it, and all your HIPAA stuff is in compliance, yada, yada, yada. But that physical demarcation between work, home is really important, even if that just means work happens in this one room and home happens in the other nine rooms. Insomnia is another sign of burnout. And it can be because you're stressed about work. It can be because you're stressed about all the stuff that you're not doing because you're always at work. It can be just. It is, you know, you just have. You can't wind down to go to sleep. Well, let's think about why that might be. If you're under stress, your HPA axis is activated. So your body is on high alert for potential threats. It's on fight or flight standby, which means you've got stimulatory neurotransmitters going through your body. Not at a super high rate like if there was a problem standing right in front of you, but it's going through your body, which is going to make it harder. It's kind of like having a couple of cups of caffeine right before you go to bed. You wouldn't do that. Well, you've got to help your h. Whoops, sorry. You've got to help your HPA axis calm down. Which is why I saw somebody was writing earlier about practicing meditation and finding ways that work for you to help you reduce your stress. Response. Activation is going to be really important. Whether that's finding something to laugh about, you know, doing something that makes you happy, yoga, meditation, stretching, whatever it is that helps you relax is going to be really important to sleep. Insomnia can also be caused if you're working too many hours and you get your circadian rhythms out of whack. You know, impaired concentration or memory is another sign of burnout. And that's partly just brain changes that take place when you are under chronic stress. Physical symptoms such as heart palpitations or high blood pressure. You can have occasional heart palpitations, panic attacks, high blood pressure. You know, when your body starts reacting like this, obviously you know your doctor is probably going to be concerned, so you should probably be concerned. Appetite changes. This can happen if your circadian rhythm gets out of whack or you're just stressed. And when we're stressed, some people don't eat, some people eat to self soothe, depending on which one you are. If you notice that you're gravitating towards one end of the spectrum, that's what we call a clue. Increased illnesses doesn't have to be big things, but getting sick more easily, getting colds all the time. Now this doesn't hold if you have a kid that's in school, because if you have a kid that's in school, you're just gonna get sick all the time. But. Or if you're seeing pediatric clients, then it may not be a sign of burnout, it may be a sign of around children. But be aware of the fact that your immune system is reduced in efficiency when you're experiencing burnout, increases in depression or anxiety. Let's look at talk about depression first. Depression. I liken, if you will, to hopelessness and helplessness. When people feel depressed, there's a sense of apathy and anhedonia, if you want to go with the technical words, but they just. There's no motivation. It doesn't seem like anything they do makes a difference. They don't have the energy to try anymore. They're exhausted. You know, we've all heard those words. We've all experienced those things from time to time. You know, it could be for a day or it could be for longer, but noticing increases in depression. Let's encourage yourself to reflect and think about what might be causing my depression. What might be contributing to this? Am I not getting enough sleep? Am I eating poorly? Those are the easy ones to check. Do I feel hopeless and helpless about something at work? Do I feel overwhelmed and disenchanted because it doesn't seem like anything I do makes a difference? What is it that is prompting these feelings of low motivation and lack of pleasure, low energy, all that kind of stuff? Because our body is telling us something. It's a form of communication. We need to listen. Obviously, you know, some people aren't burned out, but they may have increases in depression if they're experiencing hypothyroid hormone changes. There are a lot of physical things that completely aren't related to burnout. But in a lot of cases that we're talking about, we're talking about clinicians who are working in situations that are high stress. Even if you've got a moderate caseload, what we do from day to day can be considered high stress because we are hearing about people's stress and we're empathizing. So for a moment, we're down there with them experiencing that stress. And yes, we can get out of it because we're shadowing them in their shoes, if you will. We're not actually walking in their shoes, but it can be exhausting. So we need to make sure that we're taking care of ourselves and reflecting on the things that we do do that make our job worthwhile. And I encourage my supervisees to keep a journal every single day. And when they come in for session, I have them share with me that journal of at least one thing every day that went well. You know, one good session or even a good moment in a session so they can look back. And I would encourage them to keep a log. You Know no phi, but keep a log of their clients and the progress that they're making. So because a lot of times we focus on the clients that drop out or the clients that are not doing well as opposed to focusing on the clients that are doing well. So you may have 80% of your caseload is just, you know, rocking out, and there's 20% that is having difficulty. Which one do you tend to focus on? So it is important to focus on that absence of positive emotions kind of goes with depression or anxiety, cynicism and disillusionment. And I see that a lot in people who've been in the profession for a while as reimbursement changes and as it's harder to get clients, as clients come in and are not motivated to do what the clinicians want them to do. So we need to maybe back up and look at it from a different perspective. Why did you get into this profession because you want to help people? That's my assumption. Probably wasn't to make a ton of money. Okay, so you wanted to help people. How can you focus or how can you conceptualize what you're doing to help people? You may have clients coming in. When I work with involuntary clients, you know, I want them to recognize their substance abuse and quit using substances and be happier and healthier and blah, blah, blah, blah, blah. And that's great, but most of them don't want to do that. They don't share my same goals. So it's important to find mutually acceptable goals between you and the client. So if the client wants to get off probation. All right, well, in order to do that, you need to be clean. So it's a win win for both of us. Creating goals that are win, win. Find the client's goal and figure out how you can make that a win in your column because it's a step towards getting them happier and healthier and all that kind of stuff. Lack of patience. And this can get, you know, pretty prominent. And it can be lack of patience with your co workers. It can be lack of patience with the expletive, expletive computer, or it can be lack of patience with clients that seem to, quote, refuse to make any positive changes. And remember, resistance in clients is just their way of saying what you're suggesting just doesn't sound as rewarding as what I'm doing already. So we want to back up and go, okay, why? You know, is what I'm suggesting too scary and you would rather stay with what you're doing? Because at least that's predictable. Or you know, what am I missing here? Lack of resilience. Everything can be a crisis. You get a new client on your caseload that you weren't expecting and it's a crisis. You have a client call out and you know, not show up for, for their session and it's a crisis. If anytime there's a change in your schedule, there becomes a crisis, then you may be experiencing burnout. Substance abuse, relationship deterioration, and foregoing important personal activities. Those are all also signs of burnout. If you just, you come home and you're leaving the office at 5 o' clock and you come home and you put your stuff down in the foyer and you go into your living room and you plop down on the couch and you just don't have the energy to move until it's time to go to bed. So you're not doing the things that you enjoy doing. That's what would probably be a warning sign at the very least that you may be experiencing burnout. Now we all have those days, you know, know when you're preparing for an audit or an accreditation survey. You're going to be full bore while you're at the office and you're going to come home and you're just going to be like, I just want to sit here and drool on myself for the next 30 minutes. And that's okay. But if it's all the time, then it is a problem. The Melash Burnout Inventory is the most commonly used self assessment tool for burnout. It explores three exhaustion, data depersonalization and personal achievement. So SAMHSA has an abbreviated version online that you can take or you can look at the full Melosh Burnout Inventory with this link. We're not going to go into that right now, but if you're interested in doing a self assessment, if you are a supervisor, clinical supervisor, or administrative, I strongly suggest you have your supervisees taking this burnout inventory at least once a quarter. And you may not need them to share it with you or you may choose to however you want to do it. But it's important for them to remain self aware of their level of potential burnout. So causes of burnout. We just talked about the effects of it, excessive workload. And I've seen a lot of things going on in the chat room while I've been talking, especially about concurrent noting and concurrent noting is if you're going to do notes with clients in the room, then I would feel, you know, if I were the client and you know, we've always done it where we discussed it with the client ahead of time. We told them this is how it goes and they were cool with it. But I would feel that it probably would be a much easier thing to have happen. If you discuss it with the client at intake and let them know this is what we do and, you know, bada bing, then they don't. Then they're not surprised when it happens. They know they're getting something to take home. So it's, you know, it's something you're doing for them, if you want to phrase it that way, or frame it that way, so they can track their own progress. Like I said, I have used it with hundreds of clients. We've never had any blowback from it. Using check ins is also a good thing to do. We do this a lot when we do group work. But I can see how it could be beneficial for individuals where when the client's waiting in the waiting room or waiting for their appointment, they fill out a check in sheet about what goals they worked on, what their successes were, what their challenges were, and what their hopes are for the session or something. But that way again, you have, not only is that documentation written, so you have, you know, proof that you met with the client, but it's also written in the client's handwriting, which auditors tend to love because it shows that you're actually working with the client. You're not writing the treatment plan for them. You're not just writing your own note based on what you assume was going on in the client's mind. You are actually communicating with them and collaborating, which can be excellent in terms of, you know, both increasing credibility and collaboration with the client. Emotionally draining work. Well, let's go back to excessive workload. Depending on where you work, you may not be able to do anything about this, and that's a shame. However, it's important to point out in some States, Florida, for example, 65D30 is the statute. I know it well. That tells you how many clients can be on a caseload for intensive outpatient, how many clients can be in a group for this, and et cetera. So 65D30 in Florida does a great job of giving objective meat, if you will, for clinicians to go to supervisors and go legally, I'm not allowed to have any more than this number of clients on my caseload. You can look up best practice guidelines for, for how many clients on a caseload. Now, clients on a caseload is kind of arbitrary because like I was talking about earlier, you can have 20 clients that are high intensity clients or you can have 50 clients that are low to moderate intensity and maybe the low intensity clients you're only seeing once every two weeks. We want to look at maybe billable hours. You know, how are you conceptualizing this workload? In addition, what else do you have to do besides see clients? You know, that's why we got into it. But we also have to do notes. Okay, what else do you have to do? Do you have to pinch hit if the assessor doesn't show up? Do you have to do orientation for people? What else takes up your time? Would. You'll see the efficiency chart in a little while. But I would regularly go through my departments and try to figure out what was taking up everyone's time in order to try to help them balance their energy. Emotionally draining work. What we do is emotionally draining. That's just what it is. We can't get away from that. Otherwise we're probably not seeing clients who are in crisis or, you know, struggling for some reason, which means we're not probably doing counseling or doing psychoed or something. Emotionally draining work is part and parcel. So how do we recoup from that? And that's an individual. Every individual is going to be different in how they deal with the energy and the emotional drain from seeing clients every day. In private practice. Now that I'm not working for an agency, I personally choose not to see any more than three clients on a day. You know, that's just, that's my choice. And you know, from a financial perspective, if that's all I was doing, that would probably not work so well. But I choose to not see any more than three clients a day because I feel like after three hours of one on one, I'm not as efficient or effective. That's my feeling now. Can't have I done six in a day? Sure. When I used to work in community mental health, we had a minimum of 30 billable hours per week. That was non negotiable. So yes, I have done it and I can do it. But I prefer for my own sanity to only only see three clients a day. So the question is, if you decide that clients are emotionally draining, which again, they are, it's not their fault. It's just, it's part of the job. And you choose to lower your caseload like I did, what are you going to do to make up that financial downfall, that financial deficit from not seeing 30 clients in a week? And that's going to be, you know, something, You've got to figure out how you want to Handle it if you want to adjunct or if you want to consult or you want to get a contract somewhere to do psychoeducation or whatever it is that you want to do. But there are a lot of alternatives to just doing straight up, one on one counseling, lack of support. And this can be in a lot of things. And I see somebody was talking about electronic records. Oh goodness. One of the agencies that I used to work for, the electronic health record was so cumbersome and overwhelming and difficult to navigate. It took two or three hours to do something that you could handwrite in 45 minutes, no joke. And most of us, I consider myself relatively computer literate. I failed the class the first time I went through. I still couldn't figure out how to input a client into the electronic health record. And so I actually encouraged my boss to go, who was the vice president at the time. I'm like, Richard, you got to go sit through this class. You know, it's, it's important. And because he kept saying that my staff just wasn't trying and they were just being lazy and da da, da, da, like you got to go sit through it. So he sat through all of one day of the class and, you know, did the activities and everything and struggled at least as much as I did. And he leans over to me after lunch and he goes, now I see why you had me come in here. And I said, yeah, now you're getting it. And he had a lot more empathy. We couldn't change it at that point because the agency had invested like seven figures in this electronic health record. But he did have more empathy for how much longer it was taking and why billable hours were down, especially in my outpatient clinics. So we need to have support not only for our one to one interactions with clients, for being counselors, but we need to have support in our work environment to make sure that it's collegial. And we need to have support in our technology environment or our health record environment, whatever you want to call the other stuff that we do that's not person oriented. We need to make sure that we have support and the resources we need to do our job. Lack of rewards is huge. And I am guilty as a supervisor of not giving enough or not noticing enough when employees are doing the right thing. And I hate to say rewarding good behavior because it sounds like I'm talking about a child, but. Working with supervisees and making sure that they feel appreciated and they know when they did a good job. I had to work very hard to write, remind Myself because I'm not one of those people who, I'm not a warm, fuzzy, gift giving, card sending person. It's just not me. And that's at home as well as at work. It's just that's not me. So I had to work really hard to remind myself every week to notice something positive about each one of my employees and you know, leave a sticky note on their computer or give them a shout out in staff meeting or whatever the case may be. It was important for me to make sure that I recognized them. Generally I tried to do every week, didn't always happen. But rewards are really important. If your supervisor doesn't give you rewards, reward your own self. Remind yourself when you do a fantastic progress note or when you have a great, great session with a client, give yourself a pat on the back, allow yourself to go to Starbucks or whatever it is that you do to reward yourself and recognize what you're doing as a job well done if you can. You know, sometimes your supervisors just aren't on board, but a lot of times your colleagues are so you can form your own community if you will. And maybe during lunch or you know, once a week after staff meeting or whatever, get together and share good things that happen so you can all congratulate each other. So you've got this feeling of mutual support, a lack of a control or a sense of say in what goes on. We see this in a lot of agencies that are top down. One agency that I worked for had a very top down management style. The CEO went as far as to say that she encouraged all of the C level executives and the vice presidents to be on campus as little as possible because they didn't want to get caught up in the line staff issues. And they would make decisions, they would go on retreats and make decisions that affected the whole company and come down and just bestow it upon us. Which was kind of oppressive to a lot of the line staff who are going, we can't do that. You know, there's just absolutely no way. And so staff would get very frustrated very easily and well, not easily, but frequently it was important for us middle managers to act as the go between. And I was very blessed to have my supervisor at the time who could, I think he's part politician because he could play both sides of the fence and I could go to him and I could go, this ain't going to fly. There is no way this can happen. And here are all the ways that I've tried to figure out how to make it happen. It just is not going to work with him. I always had to propose a solution, though. You don't just go to him with a problem. You always have a solution. So I would propose a solution most of the time. Then sometimes things would come down that there just was no solution to. Really. Like, they chose at one point to put cameras in all of the group rooms. And, you know, they said it was for a safety feature or whatever, but the clients were very appalled by that because they felt like their confidentiality was being breached in a big way. And I can see where they felt like that. So that ended up becoming a big hubbub. But we had to encourage staff, or I had to encourage staff to state their opinions instead of just being angry about it. You know, what can we do to model for clients the best way to handle this? And so staff started writing notes to senior management about what was going on. When that kind of fell on deaf ears, staff said, okay, y', all, the clients are unhappy with this, and you feel it's a breach of your confidentiality. Let's start filing grievances. And by the time, you know, 50 or 60 grievances came in, this was a pretty big program. Senior management, you know, suddenly started to go, okay, let's, you know, back up and think about it. It's important if you can convince your agency to have at least committees that allow representatives to be on them so you have a sense of say of what's going on. So you have the ability to speak up and say, these caseloads are getting out of control instead of it getting to the breaking point. And half the department quits within a month. Unclear and ever changing requirements. Encouraging. Senior management, when possible to be clear about what the requirements are, write them down and not change them too often. Is usually good. At our agencies, the ones, the agencies that I've worked for, our dashboards, our requirements would be evaluated once a year, so they didn't change that often. And the only other time we would have changes is if an auditor came in and found some sort of deficiency and we had to file a corrective action. But that was few and far between. Thankfully, it was a pretty established program. Severe consequences for mistakes. And I have to say, my supervisor was amazing because. And, you know, I made mistakes. I worked my way up from line clinician to supervisor there. And initially I had no clue what I was doing. I will be frank about that. And I made some mistakes with him. I knew, though, if I went in and I said, richard, I screwed up, and I was honest about It Every time I did that, he would just kind of sit back in his chair, fold his hands over his stomach and go, yeah, you did. How are we going to fix it? And that was that. You know, there was a problem, I identified it, we moved on. When there are other mistakes, sentinel events, we would have those. Yes, it would go before the quality assurance board and there would be a review of what happened. But to the best of my knowledge, there were never any severe consequences for those mistakes because the clinicians didn't really do anything wrong. There may have been a fault in the system, but the clinicians didn't do anything wrong. So when clinicians are afraid that, you know, oh my gosh, I made a mistake, I forgot to put this note in and I'm going to get written up or I forgot to do this and I'm going to get fired. That contributes to burnout. Clinicians need to know that as a different supervisor, I had once said, as long as you are doing what is in the best interest of the client and doing your best to try to meet the other requirements, I'm going to be happy. And he followed that with Auditors are paid to find mistakes, so you know they're going to find something, don't worry about it. But that helps me feel calmer and gave me a different approach every time auditors came, because we had auditors every other month in the program that I worked for because we had so many different funding sources. Making sure that your staff feels buffered against consequences and mistakes. If you are a supervisor and if there are seemingly overly penalizing consequences for mistakes, consider taking it up with human resources and talking about the impact that has. If people are afraid to report mistakes, then mistakes are going to get hidden and. And bigger problems are probably going to emerge. Work life imbalance. We already talked about that. Perfectionistic tendencies. Nothing is ever good enough. If you are one of those people who feels like all of your clients should love you, all of your clients should get better, and all of your clients should successfully complete treatment, you're going to get burned out because it ain't going to happen. And that's one of the things I try to drive home to my supervisees with regularity. And whenever there's an auditor that comes, I'll say that again. Auditors are paid to come in with a fine tooth comb and find mistakes to help you improve. They're looking for ways to help you improve. And when you develop a collaborative relationship with auditors, it's a whole lot easier when they come in and I had a great auditor with the Department of Children and Families and I remember one time he sat down and he taught me the KSA format for treatment planning, which is how they wanted to see it. And that's fine. And it totally made sense. First you teach knowledge, you teach about substance abuse, then you teach skills. You know, you teach about identifying relapse triggers and relapse warning signs and ways to handle them. And then you teach them how to take those skills and actually use them in the real world. That's abilities. And he's like, that's what I want to see on the treatment plan. I said, oh, okay, I can plug and chug. So instead of, you know, marking us down and saying that our treatment plans were just crap, which they weren't the greatest, he looked at it and said, I can see you guys are trying here. This is a better format to do it or this is how I want to see it. And it was great. I didn't take it as, you know, I didn't take it negatively and I tend to be somewhat perfectionistic, but it was helping me grow instead of telling me I was, you know, ineffective. So that was, it was a great relationship. If you have a pessimistic view of yourself and the world, then you're probably going to have burnout. But a lot of times clinicians start out with this optimistic, wide eyed view. They're going to save the world. And then when burnout sets in is when the pessimism sets in. And I can think of at least three clinicians I've worked with who I saw them erode from optimism to pessimism. If you have a need to be in control and reluctance to delegate to others, you going to get burned out. Because that means you're probably doing for clients what they need to be doing for themselves. And you're probably going to be trying to control everything in your agency because you think you can do it better. Sometimes you just got to back up and go, all right, you know, what is my goal here? Why am I doing this job? To help people. Okay, if I want to help people, I can help my people. Now if I focus on this paperwork change over here and I expend a lot of energy on it, could I be using that energy to help my clients? You know, is it going to help my clients markedly if I focus my energy over here? If not, let me delegate that to the administrative team and I'll just take whatever they give me. If you are a high achieving type A personality, we know those people tend to burn out. If you have a poor work person fit, then you may find yourself burning out faster. I saw some people talking about long travel times and travel. I also saw some people saying, that's when I decompress, is when I'm driving home from work. It can be great decompression, but it can also be exhausting. There's a fine line and I found for me, 30 minutes is about it. You know, any more than 30 minutes and it starts getting tedious and exhausting. But for the first 30 minutes, I'm decompressing. So if you're working somewhere and it's an hour, I know some people around here drive an hour and a half each way. That can cause burnout. Or if you're working in an environment that is not a good fit for you, for whatever reason, you're working in a prison and. And that's not a good fit for you, or you're working with a pediatric population and that's not where your heart is, then you could experience burnout more easily. If you have value conflicts with what's going on, and a lot of times value conflicts can be centered around whether you discharge a client or not. You know, your boss may be going, that client needs to be discharged, and you're going, no, not yet. Or vice versa, but generally that's the way I've seen it happen. Or you have value conflicts over billing. You know that some of the billing going on is a little bit shady, but if the shady billing doesn't go on, then the clients can't afford to seek treatment. So what do you do? Lots of value conflicts and ethical issues that come up. Have a colleague that you can talk with. And a lot of our state boards actually have an ethics hotline that you can call and just run things by them and say, I've got this going on. You can also, if it's a legal, ethical issue, if you've got something like prepaid legal, you can call. Most of those services are really inexpensive. On a monthly basis, you can call and get input from an attorney about what the best course of action is to do. If there's a lack of debriefing in your agency, whether it's a debriefing after somebody quits or after a client leaves against medical advice, or after a critical incident happens, any of those things can be very traumatizing or exhausting. I remember one time I came in after a long weekend and. And there was an envelope on my desk and I opened it, and one of my clients that I'D been seeing for about three months. The note just notified me that he was dead. And I was like, whoa. He had died of gastric cancer, but it had nothing to do with suicide. But it still threw me back because I really connected with my clients. And all of a sudden that person was gone. And I was like, okay. Well, that came from out of left field. And everybody in the office was just kind of going about their merry business. And, yeah, he's dead, you know, now you've got an opening on your caseload. And I was like, what? No, no, no. We need a grieving period here. The book Restoring Sanctuary by Sandra L. Bloom. It's really, really a must read. If you work in a burnout sort of environment, if you are a clinician or a supervisor, it can give you a lot of good ideas for things that you can implement. Either if you're a clinician, between you and your colleagues, you know, sometimes you gotta do it at the ground level, or if you're a supervisor for your department, the whole agency may not get on board. That takes a lot of doing. But there are a lot of things that you can do to reduce stress and burnout and trauma within your. Within your little area. An unpleasant environment. This was one of the ones that came up on in some of my groups, and I know we're pushing the end of the hour, so I just want to finish up this slide. But people who don't have access to natural light, and I used to work in one of those offices, so I could really relate when the person said this. I would go into work, it would be dark, and I would work all day, and I would come out and, you know, three quarters of the year it would be dark again. And my circadian rhythms were like, did the sun ever come up? It's important to be able to have. To have natural light, to have bright light, to have pleasant environments. You don't want to be in this environment that's completely sterile and, you know, puke green on the walls and smells very institutional, and you're not allowed to have any personal effects. You know, that can be really a downer, and it can cause a lot of burnout if it's. If you're not enjoying where you're at and you want to think about all your senses. What are you smelling? What are you seeing? What are you feeling? You know, is it too cold, too hot, too musty? You know, taste doesn't really affect it. And the people that you work with are the people that you work with in general. You know, relatively agreeable, or are you working with a bunch of people who hate their job and hate each other? And it's a very argumentative, unpleasant sort of environment. All of that, clients aside, can create a sense of burnout and cultural differences can also cause burnout. Cultural differences among clinicians on a personal levels, but also on clinical levels. If you are in a team, and I was really, really lucky to be on a team. We had psychologists, social workers, rehab counselors, addictionologists, and our attending psychiatrist was awesome, and our nurse was awesome. We had people from just about every behavioral health discipline you could think of on our team. And when we would do case studies each week, you know, everybody would put out their own opinion about, you know, what might need to happen with this client. But we respected one another, and that's really important to recognize. Anyway, burnout and difficult clients is where we're going to start here. And this is the second half of the ethics and burnout and self care presentation. The client that you may be dealing with that is considered, quote, difficult may be having psychiatric issues, may have low resources or inability to support their own self care, so they have difficulty being treatment compliant. Remember what I've said over and over again about people's resistance. Their behaviors are a way of speaking to us. People generally choose what's most rewarding or least threatening when given two options. So we want to look at why is this person, what is this person trying to communicate to me through their behaviors? They may have low motivation. Again, if their motivation is low, then we need to ask why? What are they motivated to do? I'm going to have a hard time getting them motivated to do something they ain't motivated to do, but likely they are motivated to do something. There was a book by McFarland, I think her name was Barbara McFarland, on brief therapy and eating disorders. And she recounted a client that she talked with who was anorexic and didn't want to go to the hospital. And Dr. McFarland wanted this client to eat and gain some weight, but the client didn't want to eat and gain weight, but the client didn't want to go into the hospital. So it came down to Dr. McFarland saying, you know, at a certain point, I'm not going to be able to, you know, the team is going to decide that you need to go to the hospital. I'm not going to be able to keep you out of the hospital, nor am I going to try. So if you want to stay out of the hospital, let's try to Figure out a mutually agreeable goal so we can show that you are trying to put on weight, you are trying to comply with your nutritional plan, and that will help keep you out of the hospital. And from there, from that point on is when I started saying, okay, let me look at. Instead of what I want, let me ask the client, what is it that you want? What are you motivated to do when it comes to treating things like depression? You know, some clients may be really motivated to come in for talk therapy. Great for us. But they may not be motivated to start exercising or vice versa. You know, some of the clients I work with aren't real keen on the whole talk therapy thing, but they're interested and willing to come in and talk about lifestyle changes that may help them feel less fatigued. Okay. Either way, we're saying the same thing. The client may be sensitized to perceiving or expecting inadequate care. So they become difficult. They come into your office. And I had a client who was like this. She came in one day, and I'd never met her before, didn't know her from Adam's house cat. We did the assessment, and I'm finishing up writing the assessment and getting ready to start talking to her about what my recommendations are. And she stops me. She's like, before you start, let me tell you, I am not going to any of those meetings. And she meant 12 step meetings. And I said, okay. And she repeated herself, and I repeated myself. I said, okay, you're not going to those meetings. Tell me what you're going to do instead. And she sat there sort of dumbfounded for a second. And let me tell you, this was the only time that client was ever dumbfounded. She had a lot to say, God love her, but she was so used to expecting people to tell her, this is the way it has to be done. You have to do this. Instead of hearing what she wanted, that she came in and she had an attitude, no denying that. And she was already prepared to fight. And when I didn't engage her, it was a whole different experience for her. So we do want to be aware that clients may come in and be difficult because they've had bad experiences before and they expect to have to fight. And they may have what's called entitlement amplification because of all the patient satisfaction surveys and healthcare reform, and they feel like they're entitled to so much stuff. This happens a lot in residential. I haven't seen it nearly as much in outpatient, but the author who wrote Clinician Burnout and Dealing with difficult patients actually did cite this as a big source of challenges with clients, especially in the medical field. So then we move over to the clinician when you have clients, especially difficult clients. But when you have any clients, the client characteristics can seem even magnified. If you're already overworked, burned out, don't have sufficient training or supervision, have low levels of experience with particular issues or cultures, or are overly paternalistic, all of those things can contribute to an adversarial relationship and an increase in burnout. It's important to check yourself and check your stuff. Make sure. If you don't feel like you're getting enough training or supervision, seek it out. If you can't get it at your agency, find it somewhere. There are places, the forums that I'm in, I am more than happy to consult with people and I try to avail myself to the professionals that are in my groups on Facebook and LinkedIn and stuff, if they ever want to just bounce ideas, you know, I may not have all the answers, but you know, no, I don't. But I can listen and potentially provide a different perspective. Or if you've got low levels of experience, seek out continuing education. And if you can, get supervision. If the organization you're working in has a lot of productivity pressures, we've talked about that. If there's a value schism between administrators and clinicians, you see that a lot. Clinicians want to provide the best treatment for their clients, which may mean they want to see their clients for more than 10 sessions. And the organization and the insurers may say, you got 10 sessions and that's it, then you're discharging. So there can be a disconnect there and the clinician feels hamstrung if there's poor work design and poor workflows and electronic health records that that aren't effective. And reading in some of the comments, there are some people who've worked with some really awesome EHRs. So that's wonderful. And I find that EHRs are as unique as individuals because every agency has their different requirements for billing, unfortunately. So it's not that you can just give a name of this EHR is wonderful. It may be wonderful in one setting, but not in another. Important for your tech people to involve the clinicians when choosing an ehr. And poor clinician management can also contribute to burnout if you've got a high turnover rate. I know where I used to work when somebody would quit their caseload got redistributed among everybody else and sometimes me. So it can Contribute to burnout because people are getting overworked. Sometimes we have reactions to difficult patients, including anger that we have to even see the client when there are other people who want your help that you could be seeing. It's like, why do I have to see this person? They are just. They're going to sit there and, yes, but me for an entire hour. And I would really encourage you to, you know, again, try to find the meaning behind their behavior. See, seek consultation. Sometimes you're so in the middle of the forest that you can't see your way out because you've got these notions, preconceived or otherwise, about the client. So ask a colleague, what do you think might be motivating this behavior? And that's one of the things I used to love about our case consults, because we would be able to get four or five different people's opinions. A lot of us struggle occasionally with guilt if we truly dislike a client. And it happens, we have clients that just. Whether it's a counter transference issue or it's just something about that client that we don't get along with as well, it can be frustrating. Now, obviously, we have to keep that in check and keep our professional boundaries. Fear that you won't be able to deal with the problem if you have a client. And I can remember two clients in particular that I've worked with in my career. One had very clear borderline personality disorder, among other things, intermittent explosive disorder. And the other one had cognitive impairment, borderline personality disorder, hiv, and something else. And she. When she would get upset, she would get violent, and she would try to bite people and spit on them. So it. Working with her was always, you know, I was challenged because I didn't know if I could help her at all, given her cognitive limitations as well as her behavioral issues. Yet my supervisor told me or told us that we had to see that client. We were not allowed to refer her to a different program based on her special needs. So I always had this fear that we weren't doing her justice or that I wouldn't be able to cope with it. And, you know, turns out I was able to deal with both of them. But it was a learning curve, and there's a sense of failure if you cannot engage or help the client, no matter how hard you try. And I've had some of those clients, too. Working in substance abuse, that's not all that uncommon. And however, I had a supervisor that worked with me one time who said, if you're familiar with Prochaska and Declemente's stages of change. It's pre contemplation, contemplation preparation, action, and maintenance. And I used to have clients come in and they were involuntary. They were in pre contemplation and they would stay with us for 30 days and they wouldn't be fixed. And I had the sense of failure when they would come back to detox, you know, three months later. And finally Mark pulled me aside and he said, if you can get them increased one level on that readiness for change, from pre contemplation to contemplation, you have done your job. If you can do that in 30 days, you have more than done your job. You've planted the seed. And that helped me get a different perspective on what was going on. So if you can plant the seeds, if you can give the client a good experience and leave the door open, then you're one step closer to helping them achieve sustained recovery. Clinician strategies to consider when dealing with challenging clients, Be aware of your negative feelings. Turn toward certain types of clients and seek supervision if needed. If there are certain types of clients that you have difficulty dealing with, such as child abusers or whatever your issues are. I have difficulty working with child abusers, then it's important to seek supervision. Whenever I would have a client come in who had egregious child abuse, and most of my clients were involved with Department of Children and Families, but there were a couple that I had a really hard time working with because the abuse was so severe. Identify what upsets you about these clients and remember that you're not a bad clinician because you have difficulty having positive feelings towards every single client. And recognize that you're not alone. All of us have certain types of clients or certain issues that are really difficult, if not impossible in some cases for us to work with. And when I say impossible, I mean from an ethical standpoint. And remember that all behavior is a form of communication. So change the dialogue from why are you doing this? Or why aren't you doing this? To what happened to you that is causing this behavior? What is motivating this behavior? Patient strategies to consider with challenging clients Reassure the client that you know we're going to get through this step by step. Let's talk. Forming that collaborative relationship and rapport is so important, especially with challenging clients, because until you can get that dialogue going, you're not going to be able to understand what's motivating the behavior. Encourage your clients to discuss fears and irritants in session. Set and maintain emotional, physical, and social boundaries with clients, you know, what's going to happen when we see each other at the Walmart? What's going to happen when we see each other, you know, somewhere else or if you see me online. What are the boundaries and how do we maintain those Reward independent and self empowered actions, including treatment plan compliance. You know, make sure to highlight the good things. Give clients choices to let them increase control and optimism. If they don't feel like you are doing something to them, if they feel like they're empowered, then they're going to be less likely to be resistant or argumentative or in that fight or flight phase. Foster a collaborative approach with the client as the expert on himself or herself, because they are, they've lived in their skin for a whole lot longer than you've ever known them. They know what their triggers are. They may not be able to articulate them yet, but you don't have any idea. If they start to think back, they can start identifying their triggers and things. So they're the expert. You've got the tools. Between the two of you, you can come up with a plan. Resist challenging entitlement. When they say that, you know, they're your best client or they need to have two sessions a week or whatever it is that they think they need to have, you know, okay, I hear that this is what you feel you need right now. We don't, you don't want to get into a power struggle over this. You may be able to explain to them that there's just no way to make that happen. But avoid challenging their entitlement and validate their feelings, thoughts and perceptions as their reality. However they feel like it's going. If they feel like the front desk staff is rude and horrible and what have you, that's their perception. And you know, as a supervisor, I would go out into the lobby after the patient was gone and just observe for a little while to see what they saw that might have led them to that impression and try to understand it from their point of view. Individual interventions to reduce burnout in the short term take tend to only be effective for six months or less. So if you're working in an environment that is just high stress, high demand, conflictual, whatever, and you are doing everything you can to keep yourself happy, that's going to be helpful, but only to a certain point. After about six months, something's got to give because that constant input of stress and negativity eventually is going to erode your walls. A combination of both person, organization, directed interventions tends to have longer lasting positive effects. Usually more than 12 months. Which is another reason that agencies really need to get involved in understanding the challenges. So system strategies. And again, I don't want to say that agencies are just going to be eager to jump on the bandwagon because they ain't. However, some supervisors will. And you can work, as Jacob pointed out, even if you don't have a committee of your peers together that can work together to support one another, you can create a buddy system so you don't feel like you are just out there floating in your own world. So system strategies provide adequate supervision. If you don't have that at your agency, talk about having meetings with your colleagues periodically where you can provide each other consultation and then have a buddy if you can. And I used to pair my clinicians up so they always had someone they could go to if they needed to get, you know, that consultation about, you know, do I need to refer this client? And they couldn't find me. So they always had at least two or three backups paid time off needs to be accessible, it's great to have it, but if it just sits there on the books, it's not doing any good. I saw one of you said that you regularly take three day weekends and periodically take four to seven day vacations or staycations. That's awesome. We need to do that because we, we do need that time to recharge. Increased staff wide get togethers for community building is really helpful, a fun thing. And some one of you said that you like to have your lunch by yourself because that's your downtime. Great. You know, that's awesome. Community building doesn't, we don't want to encroach on people's downtime, especially people who need that regrounding time every day. But we do want to have occasional get togethers during the workday. We don't want to detract from their home life to help people, you know, establish some rapport with one another, increase staff input on changes and decisions, even if it doesn't go anywhere. If you work together as a team, and I'm assuming supervisors are just not on board, you know, making that assumption. If you work together as a team and present a United States letter or memo to the next level supervisor about changes, decisions, needed resources on a semi annual basis, you know, that might help people start getting what they need. Or if you have a point person that's willing to go to that first level supervisor and negotiate and say, you know, staff is saying they need these things or what do we need to do? To make that happen. Most of the time things can be achieved. Improved communication so you're not just getting the memos shot at you all the time. Reasonable caseloads in terms of size and complexity. Efficiency audits, we're going to talk about those in a minute. Let staff maintain work life boundaries. It drives me crazy when I hear supervisors say, well, if you can't get it done here, you need to take it home and get it done. Oh gosh, no. You know, for multiple reasons, HIPAA aside, we don't want to encroach on people's work life boundaries if possible. We don't want to be emailing them at 10 o' clock at night, or calling them or texting them when they're at home, unless they're on call or what have you. And if there is an on call at your agency, making sure that that on call rotates because it gets exhausting being the one on call 24, 7, 365. Positive recognition, like we talked about before, goes a long way, even if it's just peer recognition and making sure that there's an effort, reward, balance. If you are putting forth X effort, then you need to get X rewards. You get paid or whatever, but if you're doing something more highly intensive or highly skilled, ideally you would get paid more. Efficiency audits, I've mentioned those several times. Have each staff member or yourself if you don't have staff members. Track what takes time for a week. Identify common reasons for time loss. When I worked in residential, we did this and my staff identified drop in clients and interruptions from email and phone caused them a lot of time loss. Because just stopping what you're doing, handling this and then going okay, now what was I doing? And yada yada, you lose a lot of time. Problems with the electronic medical record, problems getting notes done, lengthy assessments. They started using this one assessment tool before I left that turned a 45 minute assessment into easily two and a half hours. But you could only book an hour and bill for an hour. So it was kind of counterintuitive. Repetitive orientations. If you have to be the one doing orientation every single day for the new clients, weekly treatment plan updates and driving between home visits. So what did we do? Well, drop in clients and interruptions. We set a rule that all the clients for each clinician met with each clinician every morning for 30 minutes. That's the time that they told their clinician if they needed a day pass, if they needed to see the nurse, yada yada, anything they needed they handled during that 30 minute session in the morning. And then the clinician throughout the day would be doing group and individual and whatever they needed to do. They'd shut their door after lunch, which was the quiet time for this for the residents. They would do their notes and they didn't have people coming and knocking on the door because clients knew that what they needed to say, they had to say at that, at that morning meeting unless it was an emergency. And if it was an emergency, we had milieu monitors that generally were able to handle it. That stopped a lot of interruptions and greatly increased efficiency problems with the emr. Well, those never went away. So we did raise those issues, but those never went away. Getting notes done. We started using the check sheets and, and doing notes in session with groups. The clients would do a similar worksheet at the end of group. They would identify what they got out of group and a few other things. It was a very short worksheet. And then they would hand it into the counselor so the counselor didn't have to think about okay, now what did John say in group today? Da da da da. It would be right there. Lengthy assessments. We ended up. Staff ended up showing that it was taking way more time than the company that sold us the assessments that it was supposed to take. And that assessment ended up getting scrapped. Repetitive orientations. We started scheduling those and I actually had techs start doing the orientations. There was no reason for clinicians to be doing that. Weekly treatment plan updates Again, we went to a worksheet format where clients would review their treatment plan and they would answer questions on a worksheet and then they would talk about it in a group. We would have a group every Friday where clients would meet with their clinician and go over their treatment plan and talk about their successes, but also talk about any challenges that they faced meeting their goals for that week. They would get support from their peers. They would brainstorm any changes that were needed. They would get any referrals. We'd write it up. Bada bing. Weekly treatment plan update done. And then for my outpatient people driving between home visits, it was just a matter of planning. So you were going in a logical format instead of zigzagging all over town. That was about the only way to improve efficiency there. But there are a lot of. You just have to get creative and think about how can we make this happen in a way that best serves the client. You know, we don't want to take away from client service but also is more efficient for the clinician. Identify factors inherent to the job that impact morale, such as client attrition, non compliance and secondary traumatization and start addressing those with the clinicians. Talk about, you know, maybe if you have a client attrition problem, you may want to start figuring out why that is and addressing it. Continue to address resistance and non compliance. Shifting that conceptualization to the client is not motivated to do what we're asking them to do. So let me understand why. If you are in a job where you're hearing about people's traumas, you are at risk of secondary traumatization. You are more likely to be secondarily traumatized if the person you're talking to, if you're similar to that person or you've had a similar experience. So if you're talking to a client who's been raped and you have a history of rape, then you're at risk for second, higher risk for secondary traumatization. If you have a lot of stressors in the previous six months, so you're already worn down or you're burned out, then you're more vulnerable to secondary trauma. And if you're dealing with substance abuse or mental health issues or have had those, then it's easier to for traumas, for hearing about traumas and secondary traumatization to potentially trigger those issues to recur and, and they kind of trigger each other. Just be aware the similarity, the stressors and the substance abuse or mental health issues can make you more at risk for secondary traumatization. Doesn't mean you can't deal with those things. It just means you need to be aware of them. And if you're seeing a client that is traumatizing in some way or you're dealing with an issue with a client that is, you know, hits close to home, making sure that you're getting adequate self care and support. Individual interventions. Conduct periodic self assessments using the Melash Burnout Inventory or any old burnout inventory. You want to listen to concerns of colleagues, family and friends. If they say, you know what, you seem like you're getting pretty run down. Pay attention. Engage in pleasurable activities. I shouldn't have to say this, but I do because too often we get so caught up in the day to day grind that we forget to do things that make us happy. Exercise releases serotonin, releases endorphins. It's a great thing to help with mood. It doesn't have to be arduous. Take breaks during the workday. Reduce isolation by maintaining regular supervision and networking with colleagues. Take needed mental health days. Use stress Reduction techniques. Arrange for reassignment at work. Take leave and seek appropriate professional help as needed. Develop support, whether it's with co workers, with peers, other clinicians that work elsewhere in the community or your supervisor. Know and ask for what you need in time in terms of resources. If it is, there's no reason you can't ask. If you don't ask, you're definitely not going to get it. Create work life balance by developing and nurturing relationships. Schedule it in if needed. Do what we tell our clients to do. For goodness sake, leave work at work. And I say sorta because there are some of those cases that are gonna you need to debrief after work or decompress in some way. But after a certain time, you know, you want to try not to let your monkey mind go back to the office. Keep work out of your personal social networking. What I mean is, you know, I love my professional groups, but I try not to get in there during my off time because I see stuff that, you know, things the people are stressed out about or burnt out or needing consultation or this or that. And then I put on work hat again. So I try to stay out of those groups outside of my working hours. Take time for self care and relaxation. Eat healthfully. Check your need for perfectionism and control. And as y' all are talking about in the chat room, check your guilt if you feel guilty taking time off, you know, what would you tell a client who said that to you? Well, I could, but I feel too guilty taking time off. I know, you know, I could relax on the weekend, but I feel so guilty if I'm not up doing housework. You know, that's one of my big things, you know, Yes, I could sit on the couch and watch movies, but I feel so guilty. And you have to check your own guilt because guilt is you telling yourself you should be doing something. Well, there are things you could be doing, but what do you need to be doing in order to take the best care of yourself? And Mark, you, you know, is just one step ahead of me. In acceptance and commitment therapy. We talk about living in the and being able to feel guilty and do it anyway and eventually that guilt kind of subsides and you realize, okay, this isn't so bad, I deserve this. Describe why you got into the field and visualize that intention. Make it in a collage, whatever you want to do, whether it was to earn money, to help people, for the adrenaline rush, for status, power, whatever it is, you know, and adrenaline rush. We don't seem very often in Counseling, but in the emergency department. You know, sometimes ER physicians really like that adrenaline. But whatever reason it is, envision why you got in there. And then every day you go to work, ask yourself, am I getting out of the job what I wanted to get out of it? If not, how can I use psychological flexibility? Ask yourself, or define for yourself what a rich and meaningful life looks like. And regularly ask yourself, is what I am doing, thinking or feeling right now helping me move towards a rich and meaningful life? You know, is being upset because I've got to go to this store stupid staff meeting in 20 minutes a good use of my energy? Probably not, because you can't change it. If not, what can I do to improve the next moment? Can I take a different perspective? Can I make a decision? Can I use some coping and emotion regulation tools? Practice assertiveness. Take a moment to relax or cognitively restructure. Change how I'm thinking about it, whatever it is. How can I use that energy in a more effective way? Identify the strengths and resources you do have and practice mental agility. Trying to look at situations from multiple perspectives. When something happens, look at it from the client's perspective, then from your perspective, and then from your supervisor's perspective to understand why each person is is saying or doing what they're saying or doing. Practice mindfulness on the daily, preferably multiple times a day. Check in how you feel emotionally and where that's coming from, how you feel physically and what that means to you, and what are your current thoughts and your attitude and where's that coming from. Be aware of your trauma triggers and take regular squeegee or cleansing breaths. Add in the positive. Every day, do something that makes you happy. Set smart goals for work. Specific, measurable, achievable, relative or related, and time limited. Brainstorm ways to work smarter, not harder. Each day. Identify three to five things that went well. If you can do one, that's good. But ideally, shoot for three to five. Keep a scrapbook or journal of your positive experiences without phi. And you can do that. Some people will have a perennial garden and they'll plant a new plant for everything that goes well. You know, if they had a client successfully graduate, they may plant a perennial plant that comes back year after year. So eventually they have this huge, gorgeous garden and they can see, they can visualize what they've done. Ornaments, wind chimes, stepping stones or backsplashes, backsplash tile walls that each tile reminds you of something or someone that was a positive experience. Limit your contact with negative people and Connect with a cause or a community group that's personally meaningful to you. Develop resiliency. You know, this ball is pretty resilient because it's not giving in under the weight of the elephant. You can do this with the acronym Godiva, which is a really good chocolate too. But I digress. Gratitude. Be grateful for what you have. Be grateful for the clients, the progress that they're making. Be grateful that they showed up. You know, maybe they didn't do everything you wanted, but they came back okay. I'm grateful for that. Use an optimistic explanatory style. Notice the positive and look at it from a positive point of view and focus on what you can control and take purposeful action. What can I do to help improve my situation? Use distress tolerance skills. Go back to DBT and look at the Accept and Improves acronyms. Focus on using integrity every day, because if you're working against your values, you're probably going to be very stressed. Practice vulnerability prevention and mitigation. You all know that for me, that goes back to eat a healthy diet, get good rest, practice pain management and have good social support, and be accepting and aware of what you can and cannot control so you can live in the and putting the pieces together. Pieces stands for physical, interpersonal, emotional, cognitive, environmental, and spiritual. So take this worksheet, you know, print it out or write it down and ask yourself, for me, when I'm at home, what can I do to reduce or prevent stress? Physically, interpersonally, emotionally, cognitively, environmentally and spiritually? And after a stressful event happens at home and it happens, you have a dog die, you have a roof leak, whatever it is, what can I do to recharge physically, interpersonally, emotionally, cognitively, environmentally, and spiritually? What things can I do in each area to help me recharge and then go to work? What can I do when I'm at work in each one of those areas to reduce or prevent stress? And when stressful things happen at work, and they will, what can I do in each one of those areas to help me recharge? And then on an organizational level, this is your wish list. What can your organization or your supervisor do to help you reduce or prevent stress? You can make a wish list. There ain't nothing wrong with that. And what can your organization do to help you recharge after stress? Burnout. Work environments are a reality, but burnout doesn't have to be. Burnout causes problems in health, mental health, relationships, work environment, and employee retention and ability to provide good client services. Develop resilience and identify the sources and interventions for your burnout. So you need to know what causes your burnout, what is it? Which people, which places, which things, which activities are stressing you out and how can you handle it? What creative ways. And come from the perspective of anything's possible. Brainstorm any solutions, suggestions, get ideas for how other people handle it and then figure out what's going to work for you. Now, somebody. Had a suggestion. There's a acceptance and commitment therapy book for work workplace burnout called the Mindful and Effective Employee. I've never read that book, but it's recommended by one of your peers, so it might be something to check out. And somebody else said, in terms of guilt, his mother always said, I don't take any trips I don't pay for. And that's true. If you want to put yourself on a guilt trip, you're going to pay for it. And I'm kind of frugal. I don't like to pay for stuff, so I'll keep that in mind. But it's definitely important for us to do what we can to reduce our burnout and to try to do the next right thing. You're not always going to be able to do it. You're not always going to be able to change your. Your environment. You're not always going to be able to change what your supervisor does. But you can step back and figure out, okay, well, I can't change the organization's policy that I vehemently disagree with. What can I do to reduce my stress surrounding this particular thing? Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend Therapy Notes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of TherapyNotes by just using the promo code CEU when you sign up for a free trial at therapynotes.com.