“BOLSTERING Therapists’ Resilience at Work” with Dr Donald Meichenbaum

“BOLSTERING Therapists’ Resilience” with Donald Meichenbaum is part 2 of a series on essential ‘CBT Skills for Building Resilience‘ re-edited and re-published by Daniel Mirea on NeuroAffectiveCBT.com and Academia.edu with author’s permission for free use and clinical training – the content belongs exclusively to Dr Donald Meichenbaum (this material can also be found on the Melissa Institute and Roadmap to Resilience website)

These are authentic lecture notes and handouts written by Dr Meichenbaum, one of the CBT founders, they were intentionally not edited, so that when you will explore the material you would get a sense of ‘here and now’ as if you are at his lecture right now and he speaks directly to you. Enjoy… but not before you read part 1 of the series which is right here !

HOW TO BOLSTER RESILIENCE IN PSYCHOTHERPISTS AND HEALTH CARE PROVIDERS

INDIVIDUAL LEVEL

• Create A Formalized Way To Shift As You Leave Work: An Intentional Way Of Leaving Work At Work To Engage In Your Personal Life.
  • Walk
  •  Listen to a specific song
  • Taking a deep breath or two or ten as you leave. Envision breathing in _______ (peace/happiness/serenity etc) and breathing out ______ (stress/anxiety/COVID etc.)
  • Ceremonial changing of shoes/clothes envisioning leaving your work with what you change out of
  • Visualization or conscious thought as you leave: building/parking lot, that you are leaving work at work. Look in your rearview mirror and see it behind you.
  •  Write down the stresses you are leaving and put them in a box/envelop/folder that you literally leave at work to be picked up when you return.

• Replenish with physical and mental well-being activities and allow yourself to escape
  • Exercise or outdoor activities
  • Create a sleep routine including healthy daytime rhythms: Refer to “Roadmap to Resilience” in Appendix A for How To: Improve Sleep Behavior
  • Outdoor patios/backyards/parks
  • Cherish and foster connections, friendships and family

Reach out to them: virtually through interactive video calls etc. to talk, or do an activity while on the virtual call such as watch the same movie or a walk, electronically with email, text, message or comments on social media, write an actual letter and mail it: a letter to say hi, or a Thank You letter

• Maintain Healthy Life Balance, Allow Yourself To Recharge
  • Outlets and interests beyond work such as hobbies and social activities
  • Activities that have a concrete outcome to foster a sense of accomplishment:
    • Learn a language, instrument, or new skill
    • Volunteer work, write letters to nursing homes etc
  • Activities that allow you to create and express feelings
    • Garden, paint, dance, writing: poetry or journaling
    • Journaling
    • Writing your feelings to get them out, in a journal
    • Write a letter to someone or about something you’re upset or stressed about. Get all the feelings out in that letter and then destroy it. (tear it in to tiny pieces, burn it, wrinkle it up, and throw it away *Any combo of the three)

• Recognize You Are Not Alone – Repeat “I Am Not Alone”
  • Consciously pause, think about that phrase. Remember those words when you’re overwhelmed, before work, before you go home – Anytime you forget
  • If you forget. Reach out to a colleague or someone else in healthcare who understands the stresses. You can even create a “disaster plan” to have a sponsor where if you get in a dark place and feel alone, you both know you might reach out to say, I’m feeling alone or have a code word or phrase. To hear them respond with, I feel you/I get it/I’m here – will remind you.

“I recognize that others are going through this as well.”

• Develop And Cultivate A Philosophical Acceptance Outlook

The Serenity Prayer

“God grant me the serenity to accept the things I cannot change, the courage to change things I can, and the wisdom to know the difference.”

• Appreciate the positives
  • Commit to find one positive in each day. Create a list/collection of sticky notes, write them in a book. Have a physical copy, that you can look back on and see your progress and also to see there is hope when you can’t think of a positive during a dark moment.
  • Acknowledge and accept things that can and cannot be changed
    • Create a “To Do” list, of things that can be changed
    • Create a “To Let Be” or “To Accept” list – to help you acknowledge things you can and cannot change. Once you acknowledge, you can remind yourself they are things you cannot change. Identifying and reminding yourself, is an actionable step you can take towards acceptance.
  • Work on things you have the ability to change
    • Create a To Do List, of things you can change.
      • For each item in the list, create steps of what you can do.
      • For some of the items, create deadlines. Accomplishing goals gives you a sense of achievement.
  • Take pride in and recognize the privilege in being in a helping profession, especially in the setting of the stress of a pandemic
    • With co-workers, with patients, with family: You are all interacting in a vulnerable space. Look for the magic and privilege. Start a list of things you find in each day. Find one thing in each day. (Invite coworkers to add to the list as well. Have it be visible in a common area.)
  • At work, remind yourself in the moments of interactions with your patients/colleagues/visitors; you are in the helping position that allows you to, during their time of vulnerability, make a difference with simple kindnesses per your interactions of their visit/day.

“The name of the game is IMPROVISE, ADAPT, OVERCOME. Be flexible by necessity.  Take one day at a time!”

• Spiritual Coping Strategies
  • Active involvement in a religion, online/TV  services, service measures to donate time/clothing/items of need, checking in on or meals for elderly neighbors
  • Each day converse or have a connection with your higher power, out loud on your way to or from work, in the form of a prayer, symbolistic jewelry/emblems as a reminder you are watched over, express gratitude, find purpose
  • “I do Nature Therapy daily. Go for walks- review my nature videos and pictures.  Appreciate the awe of nature.”
  • “I find strength in being altruistic – a higher purpose in life.”
  • “This pandemic is God’s way of testing us. I will meet this challenge and become stronger.”
  • “When I drive home, I am constantly talking to myself and to a higher power. I keep asking questions for which there are no answers.”
  • Refer to “Roadmap to Resilience” in Appendix A for Spiritual Fitness Coping Strategies

PEER/COLLEGIAL LEVEL

• Assess Your Social Support

“I rely on my “battle-buddy” – my fellow worker who keeps tabs on me and for whom I do the same for him/her. We check on each other frequently at work and at home.”

• Create an actual list of who would/could be emotional, informational, and or material support? (Might be different people for each type)
  •  Identify: family, friends, coworkers who are helpful. In what ways are they helpful?
  • Create a game plan, whether talking to them or having the list and knowing those are people you feel you could go to in those moments
  • Actively/intentionally maintain connections with peers and colleagues.
    • Set a goal. I will reach out to ____ # peer/colleague/friend each day. Can be verbal if you see them or a form of communication of your choice. Personalize the communication. Instead of just, “how are you?” “How are you doing with the pandemic/pandemic stress?” “How’s your family/cat/dog/kids/job/ holding up during all of this?” “How are you kids doing in school?” “What have you been doing to keep active/healthy/happy/_____?” “Good job on  _____ with that patient/staff/patient family etc. I think the way you (helped them calm down, helped them feel safe, taught them about _____) worked out well”
  • Ask yourself: Do I have the strategies, abilities, confidence and desire to cope with unhealthy, harmful relationships? If not, what can I do to protect myself? How can I learn, or who can I learn from?”

“There is no shame for asking for help. No one can do this alone. I realize I am not the only one with these problems. You do not have to try and do it yourself.”

• Can you identify a mission, cause, group of family or friends that you can engage with that will give purpose?
  • Can you identify individuals who value joy, improving the situation and who seek productive meaning-making?
    • Community coping efforts or support that generate a sense of hope, trust, solidarity, and connectedness
      • Public rituals, prayer circles, memorials, demonstrations, artistic expressive activities, theatre performances, reconciliation meetings, religious services, live music
  • Can you identify a role model or mentor?
    • What behaviors, actions or attributes do they have that caught your attention as someone to be a role model or mentor?
    • What behaviors do they have that stand out during these stressful times?
      • Can you ask them how they learned the behavior(s) that stands out to you?
    • What behaviors do you have, that are similar to theirs
    • What behaviors do you have, that would be helpful to change so you could develop behaviors similar to theirs?
    •  

“I nurture and invest in social relationships. I try to be useful to others. I can text, email, call, Skype, join Internet exercise and yoga classes and chat lines on the Internet, use Zoom, watch Netflix movies with others, schmooze on the phone in order to lift the dreadful cloud of COVID-19 for a little time.  You have to ‘give in order to get’.”

ORGANIZATIONAL LEVEL

• Regular Or Semi-Regular Team Meetings As A Form Of “Emotional Check-Up”
  • We don’t need to fix or solve the problems of their stress, but employees need to know we care. The simple act of stating that or phrasing it “We know we can’t fix the fact that we are in a pandemic right now and things have continuously been incredibly stressful. What we can do is create venues/opportunities for you to talk and be heard – on various levels.” * coworkers, managers, EAP have various parts

“People in deep grief (stress/trauma) want to feel that you have heard their pain. If you try to ‘fix it’, you may rob them of that passage. They often want someone they can trust…”.

• Training/Educational Opportunities To Learn About Resilience, Burnout, Wellness
  • Bring the interventions to staff (especially initially, in crisis/survival mode, they likely don’t have the mindset to begin, to seek out or know what they need or what would help)
    • Arrange for EAP to visit the units/departments
    • Workshops on building resilience to learn which: actions, behaviors and thoughts improve or hinder resilience
    • Create a campaign to initiate awareness for the concern for the resilience of staff

“… support a “mission” and accompanying activities to actively change the circumstances that lead to victimization. This may be done at the local, organizational, and national levels such as advocating for legislative reform and social action. Help workers transform stress into ways of finding “meaning” and “purpose”.

• Community/Team Building Initiatives

• Ongoing Supervision, Checking In On Staff

“We have end-of-shift ‘campfires’ – a kind of debriefing where we can give voice to our experiences, vent and problem solve.  We have created a kind of social support group.”

• Create And Ensure A Psychologically Healthy Workplace In A Way That Is Actionable And Visible And Ongoing
  • Psychological health includes the need people have for feeling connectedness and sensing belonging

And finally the difficult part… how much time do you spend evaluating your work and if so how do you do it, are you being too critical, or avoidant, or scared to find out what your patient really feels about the therapeutic process and about you… what are the questions that you need to ask in order to improve your approach?

SELF-EVALUATION OF YOUR LEVEL OF PSYCHOTHERAPEUTIC “EXPERTISE”

On a Scale from 1 to 5, where 5 indicates that you are very SKILLFUL at doing the therapeutic’ activity (even can teach it to others), and where 1 indicates that you still consider yourself a NOVICE, Rate yourself. A Rating of 3 indicates that this therapeutic activity is still a BUDDING SKILL.

___  1. AGENDA SETTING — At the beginning of each session. you and your patient together can establish an agenda to discuss and explore specific issues and patient concerns.   

 ___ 2. PATIENT FEEDBACK — On a session-by-session basis you routinely elicit both your patient’s positive and negative reactions to all aspects of the therapy session. You may use some form of Rating Scale and discuss the patient’s choices and reactions, or you can use the Art of Questioning to elicit   such patient feedback.

___ 3. COLLABORATE WITH THE PATIENT — You are able to establish a collaborative relationship with your patient when establishing Treatment Goals, when selecting “Homework” activities (Commitments to undertake personal     experiments). You can include a Treatment Rationale that increases the            likelihood that your patient will be actively engaged in the therapeutic              enterprise.

___ 4 USE GUIDED DISCOVERY AND THE ART OF SOCRATIC QUESTIONING — Help patients better appreciate the interconnections between their feelings’     thoughts and behaviors. (USE THE CLOCK METAPHOR). Help patients           better appreciate how they inadvertently, unwittingly, and perhaps,                   even unknowingly, emit behaviors that trigger reactions from others                 that reinforce their views of themselves, others and the future.

(Remember “There is no situation so bad, that by your own efforts you can make it worse.”)

___  5. USE ACCURATE EMPAHTY — You can communicate an understanding of your patient’s feelings and thoughts and address any ambivalence the patients have about changing their behaviors. Convey that you are trying to see the world through their eyes. Validate, normalize, and even help reframe your      patients’ reactions.

___  6.  ELICIT YOUR PATIENTS’ STRENGTHS— Help patients access and appreciate the resilience and Islands of competence that they bring to therapy with them, Ask HOW and WHAT questions concerning these “In spite of behaviors”. Help patients develop a RESILIENT MINDSET.        

___  7. CHALLENGE YOUR PATIENTS TO UNDERTAKE PERSONAL EXPERIMENTS — Encourage your patients to engage in between session activities in order to test their hypotheses and expectations. Help them achieve a “new positive ending ” to an old issue or conflict.”  Ensure that your patients take these results / data as evidence to unfreeze their beliefs.

___ 8 . USE CHANGE TALK, THE LANGUAGE OF POSSIBILITIES AND BECOMING — Ensure that your patients take credit for any behavioral changes. Ask patients for examples as for how they were able to (USE RE Verbs RE-connect, RE-prioritize, RE-author etc.) engage in Meta-cognitive personal agency activities (“Notice. plan, choose etc”). Not allow their emotions to HIJACK their Frontal Lobe Executive TYPE 2 thinking processes.

___ 9. PACE THE SESSION APPROPRIATELY — You use the therapy time effectively, combining the patients’ concerns and desire to connect with you and the eeded focus on ways to achieve the agreed upon treatment goals, Continually explore how what is being addressed in therapy can be applied by the patients in their everyday experiences?

___ 10.  STRATEGICALLY AND SKILLFULLY EMPLOY THERAPEUTIC            INTERVENTIONS — Select from an array of Cognitive behavioral and Constructive Narrative interventions those treatments that best meet the clinical needs and patient preferences. Meet the patients where they are at. Build in generalization guidelines, no matter what treatment approach you adopt.

“REMEMBER THE QUALITY OF THE THERAPEUTIC ALLIANCE AND THE LEVEL OF GROUP COHESION ARE THE BEST PREDICTORS OF TREATMENT OUTCOMES“

“MAINTAIN PROFESSIONAL SELF-DOUBT“

“LOVE YOURSELF AS A PERSON, BUT CONTINUALLY DOUBT YOURSELF AS A THERAPIST”