Self-Care for BHA/Ps and Clients

There are many reasons people become BHA/Ps. Some of the most common reasons include:

• Being naturally inclined to help others who are in need.
• Caring about the health of your community and community members.
• Having a history of personal challenges.
• Knowing someone who was affected by mental illness.
• Having completed your own journey to recovery.

Whatever your reason for becoming a BHA/P, you have an important role in the health of your community and its members. Working as a BHA/P can be rewarding as you help members of your community improve and maintain their behavioral health.

Similarly, your work may be challenging as you are faced with your clients’ conflicts, hardships, emotional stressors, and traumatic and painful experiences. Exposure to such emotionally intense information can be stressful and difficult to process. When healthcare providers experience such work-related stress, it is often referred to as “burnout,” "compassion fatigue," “secondary trauma,” or “vicarious trauma.”

As a behavioral health provider, you have a number of other factors that may reduce or increase your work-related stress, including your:

• Role as the only behavioral health provider in your community.
• Access to reliable and regular supervision.
• Personal history, philosophy, and beliefs.
• Ability to regulate and manage your thoughts and emotions.
• Resiliency.
• Familiarity with your community and its members.
• Sense of responsibility and connectedness with your community.
• Access to the knowledge, skills, and resources required to treat your clients.
• Family and social support.
• Work/life balance.
• Clients' needs, crises, or deaths.
• Ability to set boundaries.
• Locus of control.
• Overall mental, physical, and spiritual health.

Admitting that you have been affected by a client’s case does not mean you are weak, nor does it mean that you are not good at your job. Being affected by your client’s life experience simply means that you are human and you have feelings too. It also means that it is especially important for you to have skills to reduce and prevent work-related stress by regularly practicing self-care and advocating for yourself similar to how you advocate for your clients.

Many of your clients' personal challenges and diagnosed conditions can also be positively impacted by self-care practices. As you learn about self-care, consider how you can apply these skills both in your own life and in your work with clients.

Stress can affect your mind, body, spirit, and overall ability to function on a daily basis. To reduce stress, you first must be able to recognize it in its many forms. You will not be able to avoid all stressful situations or eliminate every potential stressor, but being able to recognize stress will help you respond in a more effective and timely manner.

Physical responses to stress may include:

• Feeling tired much of the time.
• Constant tension in parts of your body.
• Headaches.
• Chronic back pain.
• Changes in sleeping habits.
• Stomach or indigestion problems.
• High blood pressure.
• Changes in eating habits.

Mental and emotional responses to stress may include:

• Feeling less control over your life and daily activities.
• An increased tendency to think negatively.
• Losing a sense of purpose and energy.
• Difficulty communicating with others.
• An increased desire to be alone.
• Losing your sense of humor.
• Feeling overloaded and unable to handle demands.
• Difficulty concentrating.
• Feeling mentally drained.
• Being triggered by a client who has had similar experiences to your own.
• Getting overly involved in client cases.
• Being challenged by your client’s presenting problems or personality traits.
• Reliving traumatic events.
• Increased anxiety or worry.
• Depression.
• Anger or irritability.
• Uncontrollable memories, dreams, or other reminders of stressors.

Recommended Interventions for Work-Related Stress

Spend a week or two observing and journaling your stress responses. Write down your stress triggers, your immediate symptoms, your immediate self-talk, and your long-term responses. Consider using the Stop, Breathe, Notice, Reflect, Respond approach when you pause to take notes on your stress responses.

For example, you might write down the following:

• Trigger: A client talking about struggling with her budget.
• Immediate symptoms: Faster heart rate. A little dizzy. Fidgeting.
• Immediate self-talk: I am really low on money right now. She is talking about her budget and I can barely make it week to week. Money has always been stressful for me.
• Long-term responses: I feel stressed when this client is coming in because I know money will come up. I'm less present with her because I enter her sessions already feeling anxious.

After a week or two of tracking your triggers and responses, you will have better information that will help you know when to use self-care strategies and mindfulness, meditation, and breathing. You can work on improving your self-talk when stressful situations arise.

In many traditional societies, prospective healers were identified in childhood and prepared for their roles and responsibilities. Today’s healers sometimes have only a few years of training. This is part of the reason that today's healers can feel overwhelmed, haunted by the things they see and the pain they hear about.

When you experience your clients' pain, it can spill over into your own journey and affect you in many ways. This effect is called empathy fatigue, vicarious or secondary trauma,or burnout.

The symptoms of compassion fatigue (vicarious trauma) vary widely and are similar to those of chronic stress. They include:

• Chronic tiredness.
• Trouble sleeping or sleeping too much.
• Feeling disconnected or feeling hypersensitive.
• Wondering if your work is making a difference.
• Uncontrollable thoughts or mental images related to a traumatic event.
• Difficulty with personal relationships.
• Seeing danger everywhere.
• Stress-related physical ailments (headaches, stomachaches, more frequent sickness, chronic fatigue syndrome, etc.).
• Substance abuse.

If you think that you are suffering from compassion fatigue, you are probably right.

Recommended Interventions for Compassion Fatigue

The first step to recovering from compassion fatigue is to become aware of your feelings and the source of them. Take some time to journal about your feelings or talk with your supervisor and list the causes. Once you've done that, the next step is to practice self-care.

Gratitude is also a helpful way to fight compassion fatigue and improve your overall wellbeing. Gratitude has been shown to increase life satisfaction, decrease stress, increase your sense of social support, make you more optimistic, and increase your sense of effectiveness at work.

Improve your own sense of gratitude through these strategies:

• Start or end your day by listing three things you are grateful for.
• Pause during each work day to write down a positive experience you had in the past 24 hours.
• Write a message thanking or praising a coworker, family member, or friend each day.

Historical trauma is the unresolved emotional and psychological injury caused by the cumulative effects of colonization, epidemics, boarding schools, and racism. It occurs across generations as a result of widespread traumatic experiences shared by groups of people, often based on their ethnicity or culture. Examples range from young children being removed from their families and sent to boarding schools to famines and wars that kill entire generations. This trauma is a kind of "psychological baggage" that, unless healed, is passed down through generations. While Alaska Native people share a past of trauma-related colonization, different regions had very different experiences and periods of exposure to newcomers and their ways of life.

Historical trauma is likely to be present in the people you treat, especially those who are depressed, addicted to alcohol or other substances, or victims and perpetrators of violence. Similarly, tribal health care providers can also be affected by historical trauma. It can affect people's self-confidence at home, at work, and in the community.

Personal trauma can sometimes get in the way of us helping our clients. For example, a BHA/P who has experienced domestic violence herself may encounter a patient or client who has been battered. When a client’s issues and experiences seem to mirror our own, the boundaries may become blurred and our own emotions stirred. This is when we are “triggered.”

The sensations of getting triggered are similar to being stressed.

Recommended Interventions for Historical and Personal Trauma

Focusing on the strengths that Alaska Native peoples have shown over the millennia can help to address historical trauma. Connecting with history, traditions, and "original instructions" as humans can help, too.

When personal trauma is triggered, an effective way to become calm and refocused is to pay attention to your breath. Here are a few suggestions for when you start to feel triggered:

• Pause for a few seconds.
• Breathe deeply and slowly several times.
• Refocus on what needs to be done.
• If you need to pause in your communication with clients to regain your focus, you can say something like:
  • Let's take a moment to calm ourselves so we can communicate better.
  • Let's pause together to get ready to work on this.
  • This is really important, but I need to excuse myself for a moment. I will be right back.
  • This is really important, and I need a moment to think about how to best respond.

See: Trauma and Posttraumatic Stress for more information on personal trauma.

Having positive connections to your community and its providers is essential to prevent compassion fatigue.

Longtime BHA/Ps find that a critical part of their happiness and success at work is forming relationships with other providers to build a strong team. These relationships can help you support your clients and community, but they can also support and encourage your own self-care. You can talk with your team about important issues for providers such as boundaries, wellness, and approaches to self-care.

You are better equipped to succeed if your community is supportive, and your clear boundaries will help them support you. Boundaries not only protect you; they help community members know that you are a safe resource who won’t gossip about their behavioral health problems or treatment.

Leading community activities, such as fun runs, traditional activities, or educational activities, can establish you as a resource and create more support for you and the other providers in the community.

Establishing a good relationship with the village council is also helpful. You can present briefly at the council about your services (without breaking confidentiality), work with the council on community events, or ask the council to recognize a colleague for good work.

Having personal boundaries and practicing regular self-care are some of the best ways to take care of yourself and keep yourself healthy.

As you establish and enforce your personal boundaries, it may be helpful to remember these tips:

• Regularly consult and communicate with your supervisor.
• If you have a hard time setting boundaries with clients, consider consulting with your supervisor or another team member for guidance or support. Remember: You are not alone. See: Supervision and Support.
• When you recognize symptoms of stress, reach out for your own support.
• Discuss with your supervisor or your own mental health clinician how work-related issues have affected you and what you might be able to do to lessen their impact on you. Work with this person to explore and develop a stronger internal locus of control.
• Take time to understand your reactions to situations that arise at work and in your community.
• Identify ways to address your symptoms of stress. See: BHA/P Services and Common Interventions for concrete ideas.
• When working with clients, always be aware of your safety and the tone of the sessions. See: Working with Difficult Clients.
• If you find yourself becoming emotionally drained, too emotionally invested, or overly involved in the case, consider referring the client for services with another provider.
• Remember, how you see the challenges you've faced in your own life will affect how you see your clients' challenges. Healthy boundaries include a distinction between your life journey and your client's; in other words, keep in mind that what worked well for you may not work well for the client. If you are feeling triggered and the triggering feelings are affecting your ability to provide care, consult your supervisor.

Your locus of control is the degree to which you believe you have the power to change or control a situation.

People with a high internal locus of control believe in their own ability to control themselves and to influence or change situations. They are able to change the way they look at situations and often find positive aspects even in negative situations. People with a high internal locus of control see their future as being in their own hands and know that their own choices lead to success or failure.

People with a high internal locus of control know that sometimes things happen in their lives that they cannot change. They know that even when circumstances are out of their control, they can still choose how they react to the situation.

People with a high external locus of control believe that control over events and what other people do is outside of them, and that they personally have little or no control over such things. Rather than being able to reframe a negative situation, they are more likely to adopt a “poor me” or “victim” attitude.

As a BHA/P, you can lay the foundation for self-care by working to develop an internal locus of control. With a strong internal locus of control, you can reframe almost any situation to help you see the positive and to set healthy boundaries.

Self-care is the ability to focus on yourself and your mental, physical, and spiritual health in positive ways. Practicing good self-care will help keep you healthy and energized to remain supportive to others. Self-care is also an important tool for handling stress.

When you experience compassion fatigue or feel historical or personal trauma being triggered by client sessions:

• Talk with your supervisor or your own mental health clinician to discuss how these issues have affected you and what you can do to lessen their impact on you.
• Keep in mind that healing takes time, both for you and for your clients.
• Observe whether your symptoms are brief or if they are persistent (if they continue into the days or weeks after the session). Also observe whether they are disruptive, which means they make it difficult for you to live your day-to-day life the way you usually do. Seek additional help if your symptoms are persistent and/or disruptive.

Examples of healthy self-care practices:

• Seek supervision and discuss matters on your mind.
• Try not to own, dwell on, or carry a client’s problem with you.
• Be confident about your scope of practice.
• Be honest with yourself and your clients, supervisors, and family members.
• Take care of your health.
• Go for a walk or get exercise by doing simple things like jumping jacks. Try to do this between client sessions to rejuvenate you.
• Take periodic stretch breaks to improve blood flow and concentration. You can use this audio file to guide your stretch breaks.
• Use this audio file to do a body scan and relax tense muscles.
• Spend time outdoors and in nature.
• Go fishing or hunting.
• Strive for balance by getting eight hours of sleep, eating healthy meals, and drinking enough water.
• Spend quality time with family and friends.
• Talk with a friend or trusted coworker about your emotions. While you can't break confidentiality, you can share your feelings and process them with someone trustworthy.
• Take a break or vacation when you need one.
• Participate in an activity you enjoy.
• Spend quiet time praying, meditating, or simply imagining a peaceful setting.
• Practice relaxation techniques and breathing exercises.
• Seek support from a spiritual advisor.
• Be able to laugh and maintain a sense of humor.
• Read a book.
• Take a steam.
• Listen to music.
• Practice beading, painting, carving, or basket weaving.

In mindfulness, we focus our attention on what’s going on right now. Practicing mindfulness means quieting yourself and noticing all that is happening around you. Mindfulness improves your focus and helps you to feel grounded in your present experience.

• You can practice mindfulness throughout your workday by immersing yourself in the flow of your work and creating a space that supports mindfulness.

In meditation, we are also focused on the present moment but in a more personal, inward way. Meditation relaxes and calms the mind by bringing attention back to the present. Meditation is a valuable form of self-care and there are many ways to meditate.

• We may practice meditation before and after seeing a difficult client or at the end of a long workday to keep the stresses of work from spilling into our home lives.

Deep breathing is one of the simplest ways to relax, reduce stress, decrease anxiety, and even enter mindfulness or meditation.

• One method is the Three-Minute Breathing Space. Taking just three minutes to quietly focus on your breath can calm your mind, clarify your thoughts, and relax your body. Set a timer so you aren't worried about the clock. Close your eyes and begin to inhale and exhale deeply. First focus your full attention on your breath, then tune into your body as a whole. When you are done, take a moment to notice how your body and mind feel. You can do this several times per day and can do it anywhere.
• Another is Measured Breathing. Try making your breathing deep and regular by counting as you breathe. Breathe in for 4, hold for 4, breathe out for 4, and hold for 4. Repeat this ten times. You can also try breathing in for 4, holding for 5, and breathing out for 7. Vary the time breathing in and out and holding your breath to see what feels right to you.
• If you’re viewing this manual electronically, use this audio exercise to help you be with your breath.
• Consider downloading a free app to your smart phone or computer to help you practice deep breathing or finding guided breathing videos on YouTube.

You spend a significant portion of your week at work, and your physical setting matters to your wellbeing.

Personalizing your work area can give you a stronger sense of ownership and connectedness to your time at work. Bring in small decorations that express your personality. Use headphones to listen to music you find soothing or that helps you focus. If your work allows, bring in some photos of beloved family members or pets.

In addition, having open, honest, respectful communication with your coworkers about how each of you is affected by noise, lights, and organization can help.

When conflict arises with a supervisor, coworker, client, or community member, it's tempting to respond immediately. However, our first reactions to conflict often aren't productive or helpful and can make the conflict worse. Instead, it's best to take a more measured, calm approach to challenging situations. You can help turn conflict into collaboration using the SBNRR approach:

• Stop yourself from acting on your first impulse.
• Breathe in and out deeply. If you have time, use the Three-Minute Breathing Space technique.
• Notice and name your thoughts and feelings.
• Reflect on how you can respond in a way that will move things forward.
• Respond only after completing the first four steps.

For example, imagine that you recently had to take an unexpected day off for a family emergency. A coworker does not know what happened and writes you an angry email about how she had to take on your work during an already busy day. Your first instinct may be to fire back an angry, defensive response. You start typing your angry thoughts in an email response, but instead, you:

• Stop yourself from hitting "send."
• Breathe deeply in and out until your heart stops racing and you feel grounded.
• Notice your thoughts and feelings, recognizing that you feel defensive and hurt.
• Reflect that your coworker is generally a good person but has been under extra stress lately due to her increased workload.
• Respond by empathizing with her frustration and explaining that you had a family emergency but will help her catch up today.

Changing your "internal dialog," or how you mentally talk to yourself, can change your feelings, perceptions, and behavior. Negative self-talk and thinking will not help you or your clients, whereas positive self-talk and thinking bring energy, hope, and new perspectives to a situation.

Steps to change your self-talk:

• Tune your attention to your self-talk. Being aware of your thought patterns is the first step in changing them. Monitor what your inner voice is saying and consider writing notes as you observe your thoughts. Is your self-talk mostly positive or negative?
• Practice thought stopping. When negative self-talk takes over, say or whisper "STOP" aloud. It may feel silly at first, but this technique helps to combat negative thought patterns.
• Change your negative thoughts to positive ones. Shift your focus to what you like versus what you don’t like. Focus on what you value and appreciate about yourself, others, and the world around you. You can think about the positives of a challenging situation, consider what you'll learn from it, or focus on other good things in your life to put your current struggles in context.
• Practice positive self-talk. The words you use matter and will shape your thought patterns over time, so continue tuning into your thoughts and shifting your focus whenever you notice negative self-talk.