Self-care of the therapist working with traumatised clients of domestic abuse when dealing with moral distress

by Daniel Cleary

Domestic abuse can be described as a multi-faceted problem, and the people involved are from all social classes and positions (Gadomski et al., 2001; Hamlin, 1991; Mann, 2000; Sokoloff & Dupont, 2005). Studies involving domestic abuse have been carried out by many different researchers in various disciplines, including medicine, psychology, and social science (Ansari & Boyle, 2017; Chang et al., 2014; Gill et al., 2012). In these studies, as well as the practicality of working with victims and perpetrators experiencing domestic abuse, there arise different challenges, both for the people involved directly with the domestic abuse, and for the people working in this area, the domestic abuse therapists/practitioners. The author sees his work as a psychotherapist being performed in this context, and when faced with moral distress while working with traumatised clients, the need Image copyright William Pattengill 2021 for self- care becomes evident.

Domestic abuse

Domestic abuse is gender neutral. It includes all genders, races, ages and sexual orientations (Alejo, 2014: 82). Men and women can be the perpetrators or victims in heterosexual or same-sex relationships. In 2013, the World Health Organisation identified violence against women and their children as a human rights issue (WHO, 2013). Women’s Aid (2019) describes domestic abuse “as an incident or pattern of incidents of controlling, coercive, threatening, degrading and violent behaviour, including sexual violence.” In most cases it is perpetrated by a partner or ex-partner but can also be perpetrated by a family member or someone involved as a carer in the life of the family. Also, in most cases it is experienced by women and is perpetrated by men. Most female and male victims of domestic violence do not report their experiences of domestic violence (Watson & Parsons, 2005).

The impact on the domestic abuse therapist.

Working with victims of domestic abuse requires the therapist to be able to have a multifaceted response and trauma informed care and practice, in order not to re-traumatise victims (Alejo, 2014). The therapist will have to listen to and deal with the different impacts of domestic abuse on the family, especially on the victims. Cohen and Collens tell us that individuals who are working with traumatised clients can experience “secondary traumatic stress” and “vicarious trauma” in the context of trauma work (2013: 3). The therapist may also have to hear about the children who experience domestic abuse in their homes, and its impact when their parents are in a domestic abuse relationship (Carpenter & Stacks, 2009). The therapist may also encounter the perpetrator of the abuse and work with that person with a view to the perpetrator accepting responsibility for what they have done, as well as the therapist listening to the details of what has happened (Iliffe & Steed, 2000). The therapist will always have a focus on protecting the victims, including the children, as this is central to the work (Skyner, & Waters, 1999). The therapist will also be engaged in the work of change for/with the perpetrator of abuse, if the perpetrators are willing to engage in this work (Bowen, 2011). The therapist may have to address legal issues in their work, particularly in the area of child protection. This could involve the therapist being involved with Tusla, social workers who work in child protection, and the therapist may also have to be involved in the legal system in Ireland (Holt, 2011). Cohen and Collens (2013) draw our attention to an aspect of trauma work that is not often explored or researched, which is the “potential positive changes that emerge from trauma work” (3). Another possible impact on the therapist is that of moral distress. According to Cherny et al., moral distress “can produce feelings of frustration, anger and anxiety, and of having been devalued and marginalised” (2015: 254). The impact of moral distress on the therapist can be destructive and can result in the therapist, according to Cherny et al., having nightmares, headaches or possibly depression (2015). These authors go on to say that moral distress can have the impact of the therapist being/choosing to be isolated and also threaten the “self-worth” of the therapist (254). Moral distress can also “have the impact of burnout” on the therapist and “has been identified as a major risk factor” for people leaving their work. These authors tell us that a therapist could end up with “moral residue” due to a perceived sense of “seriously compromising” themselves or allowing themselves to be “seriously compromised” and if this re-occurs can lead to an impact on the practitioner’s “self-worth” (254).

Understanding a traumatised client.

Trauma can appear and be understood in different ways; Herman (1992) describes trauma as an affliction of being powerless, where the victim is in a state of being helpless. In addition, this is the experience that the person has, when everyday ordinary systems of care that give that person a sense of control, connection and meaning are also overwhelmed. Herman also informs us that any traumatic events are extraordinary because they overwhelm the ordinary interactions of the person with their everyday environment. Herman (1992) also said that people who have endured any kind of difficult/ horrendous events will suffer from some expected psychological distress or trauma. He tells us that there is a wide range of traumatic disorders and these can go from the effects of a single, one-off overwhelming event to the more “complicated effects of prolonged and repeated abuse” (2), as in the case of domestic abuse. When it comes to domestic abuse and to the victim in the situation, Herman says that the victim (the woman) who has been given some kind of diagnosis, especially a severe personality disorder, has been generally failed in the recognition of the impact of “victimisation” (2). Herman (2001) also tells us that “trauma is the result of the bodily system being flooded, with the result that the body’s self-defence system becomes disorganised” (122). For him, these are the responses or parts/aspects that a person had in their normal day-to-day responses to danger that were useful or beneficial to the person and are now always in “an altered and exaggerated state” (122), even though the event or danger has long passed. Berclaz (2009), when referring to Herman’s understanding of trauma, says that traumatic events can involve anything from threats to life, to threats to a person’s autonomy and self-determination over their own body, or a close encounter with violence and/or death. A person who has these experiences is confronted with the “extremities of helplessness and terror and evoke the responses of catastrophe” (28). According to Nijenhuis & van der Hart (2011), the word trauma means wound or injury. From this perspective, we must see the traumatic event as “a psychobiological wound” (417) and not an event. This psychobiological wound is understood as something that has come about because of “psychological, biological, social, and other environmental factors” (417). Van der Kolk (2015) informs us that trauma is specifically an event and that it overwhelms the person’s central nervous system, altering the way in which that person processes and recalls the memories of the event(s). Van der Kolk (2015) states the following;

Traumatised people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs; in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from their selves.

(van der Kolk 2015: 97)

Van der Kolk (2015) also tells us that trauma for the person is not just about what happened in that event in the past; it is also about what is left for that person because of that traumatic event, and this is the pain, horror, and fear that is now living inside of the body.

Trauma and domestic abuse

The impact of domestic abuse on victims can be short or long term. Victims of domestic abuse are at an increased risk for many chronic health problems, health risk behaviours and mental health issues (Macy, Ferron & Crosby, 2009). The therapist will, in their work, hear all the experiences of the family, adults and children. Domestic abuse impacts the overall ‘quality of life’ for a victim (Hanson et al., 2010). The traumatic impact on adult victims who experience domestic abuse depends on different factors, and these include the person’s response to trauma/stress, age, frequency, and the severity of abuse (SafeIreland, 2020; Watson & Parsons, 2005: 105-122). Some victims will display criteria associated with Post Traumatic Stress Disorder (PTSD), and others will exhibit resilient responses. Traumatic responses often are different because individuals react differently to trauma. The obvious impact on victims is physical injury, life threatening injuries or death (Karakurt et al., 2017). Other impacts include the psychological/emotional injury (stalking, threats, harassment, coercive control, isolation, intimidation etc.); also, there are common emotional and spiritual effects of domestic abuse which include: hopelessness, feeling unworthy, apprehension, chronic stress, being discouraged about the future, inability to trust, fear of intimacy, questioning and doubting spiritual faith and feeling unmotivated. The destruction of personal property and family property, and the threat of same have a negative psychological and emotional impact on victims. The impact of domestic abuse can also include economic and financial factors or technologically facilitated factors (Al-Alosi. 2017). The abuse can affect a person’s parenting capacity, identity and parental role (Cort & Cline, 2017). Victims suffer negative social effects from domestic abuse, and the therapist will also hear about how the abuse has harmed family bonds and family relationships (Meyer, 2017). Children also experience domestic violence with all their senses, and it negatively impacts their everyday functioning, and even their very being. It is understood that children are acutely aware of and impacted by domestic abuse (Devaney, 2015).

Moral distress

The idea of, and need for understanding, ‘moral distress’ with professionals has its origins in nursing ethics in the 1970s and 1980s. During this period, ethics faculties in America “recognised that nurses and nursing students displayed a strong interest in the study of ethics” (Jameton, 2013: 297). Hamric et al. (2012) tell us that “moral distress is increasingly recognised as an important problem that threatens the integrity of health care providers and health care systems” (1), and they go on to say that there are very few reliable and valid measures of moral distress in use, and this would include everyday practices for professionals, as well as in research. Austin (2012) tells us that moral distress is used to refer to “experiences of frustration and failure arising from struggles to fulfil the moral obligations of professionals”; she goes on to say that “we need to pay attention to these experiences’” (28). Moral distress/moral problems are described as common experiences with complex phenomenon (Jameton, 2013; Hanna, 2004). These common experiences happen for individuals and for societies “when individuals have clear moral judgments about societal practices but have difficulty in finding a venue in which to express concerns” (Jameton, 2013: 297). But there is a difficulty with having a “clear complete definition” in spite of these moral distresses/problems being experienced by professionals worldwide (Hanna, 2004: 73). Some authors who suggest that moral distress is understood by how it arises i.e., a professional struggling to make a decision because of what the organisation they work for demands, or what society looks for. Sunderland et al. (2010), however, understand it to mean the “particular phenomenon of moral distress,” or “feelings of helplessness to act in accordance with one’s moral values due to systemic or institutional constraints” (78). Camp & Sadler (2019) tell us that moral distress happens when a professional chooses an ethical response to the moral distress, but for whatever reason, cannot do it. Cherny et al. (2015) tell us that professionals who experience moral distress do so when they are asked to “carry out acts that run contrary to their moral compass” (246). Perhaps a more helpful understanding of moral distress comes from Russell (2012) when she says that “The term ‘moral distress’ is not a word, but rather a phrase that is often given different meanings by different literature” (15). Russell (2012) tells us that when it comes to understanding moral distress, looking at its common use in the literature is insightful, and tells us that “four comprehensive attributes were formulated to describe moral distress: negative feelings, powerlessness, conflicting loyalties, and uncertainty” (23).

Self-care

Professionals in any/all caring professions run the risk of experiencing stress, burnout and exhaustion (Bressi & Vaden 2017), secondary or vicarious trauma (Bober & Regher 2006), and/or compassionate fatigue (Sansbury, Graves & Scott, 2015). Wise et al., (2012) tell us that professionals who are committed to caring for others may neglect having a balance between “caring for our clients and caring for ourselves” (487- 488). They go on to say that they understand self-care as “enhancing positive well-being”. Self-care for social workers, according to Bloomquist et al., (2015), is the way in which these professionals will be able to “protect” themselves “against the many stressors” (293) of their profession. Self-care can also be understood by practicing actions that are intentional and done on purpose by people and organisations, and these actions can contribute to the wellness of the professional and reduce their stress (Alkema, Linton, & Davies, 2008). Two ways in which a therapist working with traumatised clients can practise self-care is by using their values and/or the values of the organisation they may be working with, and also by attending supervision.

Values

Organisations have different values and use these in showing the vision and mission that they have. These organisations ask the people involved in the organisation to commit to these values so as to engage in the work of the organisation. For some organisations, the focus is on ‘how’ you do what you do so that the clients will experience and see their values at work. Values according to Mowles (2008) create the conditions for solidarity among staff. Mowles goes on to say that values “are emergent and intensely social phenomena that arise daily between people engaged in a collective enterprise” (5). Values and beliefs can also be used in an organisation so as to enable an individual, group or management to make ethical decisions (McEwan, 2001). Bissett (2014) tell us that if there is congruence between the therapists’ values and their perceptions of organisational values, then there is the possibility that the practitioner will experience job satisfaction, work engagement, inclusion and resilience.

Supervision

Berger & Quiros (2014) tell us that supervision for those who work with traumatised clients is “designed to enhance the knowledge and skills of practitioners who provide this service” and they go on to say that supervision will “foster the professional and personal growth of practitioners and enhance their mastery of trauma-informed care” (296). The role of the supervisor is to support the therapist emotionally, modelling ethical, safe practice, and promoting effective practice interventions which would need to be informed by evidence-based theory and research (British Psychological Society, 2007). Many involved in different aspects of social care, social work, therapy and/or counselling believe that supervision is necessary for them professionally as well as for good self-care. This self-care in supervision is so that the therapist will be able to find meaning in the work that they do and so that they will have resilience and allow themselves to be open to the potential of transformation (Thompson et al, 2011: 159).

Conclusion

In a family where domestic abuse is an issue and everyday reality, all members will experience and be impacted by traumatic events. These traumatic experiences will have a long-lasting effect on the person, even if the experience was a one-off event. Therapists working in the area of domestic abuse then will need to be aware of the possible situations and experiences they will find themselves working within, in order that they can best address and work with those involved to ensure safety for the family and themselves as therapists. In their work as therapists in this area, they may find themselves addressing moral dilemmas and trying to work with and manage these as they go about working with their clients. The tendency here is to experience moral distress, whereby the therapists may find themselves unable to continue to work with traumatised clients. Therapists will need to be able to avail of appropriate self-care in order to be able to address any issues that arise, and they will need to be aware of issues like stress, burnout, vicarious trauma, secondary trauma, compassion fatigue, supervision and the values of self and/or the organisation.

Daniel Cleary (MIACP, MACI, SAI) Supervisor & Psychotherapist. BSc Hons Counselling & Psychotherapy, MA Cross Professional Supervision, MA Addictions Studies, MSc Healthcare Ethics and Law. Psychotherapist in North Dublin with a Child & Family Service as a Domestic Abuse Practitioner. Private practice in Co Kildare. Contact daniel.r.cleary@hotmail.com (087) 991 6789.

References

Al-Alosi, H. (2017). “Technology-facilitated abuse: The new breed of domestic violence.” Retrieved on 28^th January 2021 from: http://theconversation.com/technology-facilitated-abuse-the-newbreed-of-domestic-violence-74683.

Alejo, K. (2014). “Long-Term Physical and Mental Health Effects of Domestic Violence”. Research Journal of Justice Studies and Forensic Science, Volume 2, Article 5.

Alkema, K., Linton, J.M. & Davies, R. (2008). “A study of the relationship between self-care, compassion satisfaction, compassion fatigue, and burnout among hospice professionals”. Journal of Social Work in End-of-Life & Palliative Care, 4(2), pp.101-119

Ansari, S. & Boyle, A. (2017). “Emergency department-based interventions for women suffering domestic abuse: a critical literature review”. European Journal of Emergency Medicine, 24(1), pp.13-18.

Austin, W. (2012, March). “Moral distress and the contemporary plight of health professionals”. In HEC forum (Vol. 24, No. 1, pp. 27-38). doi: 10.1007/s10730-012-9179-8. PMID: 22441996.

Berclaz, M. (2009). Psychosocial and Spiritual Support During and After Critical Incidents. Retrieved on 5^th January 2021 from http://www.psyurgence.ch/documents/psychosocial_and_spiritual_ support_2009.pdf

Berger, R. & Quiros, L. (2014). “Supervision for trauma-informed practice”. Traumatology, 20(4), p.296.

Bissett, M.F. (2014). The role of values and value congruence for job satisfaction, person organisation fit, work engagement and resilience. Retrieved on 7^th January 2021 from https://ir.canterbury.ac.nz/ bitstream/handle/10092/9171/thesis_fulltext.pdf?sequence=1.

Bloomquist, K.R., Wood, L., Friedmeyer-Trainor, K. & Kim, H.W. (2015). “Self-care and professional quality of life: Predictive factors among MSW practitioners”. Advances in Social Work, 16(2), pp.292-311.

Bober, T., & Regehr, C. (2006). “Strategies for reducing secondary or vicarious trauma: Do they work?” Brief Treatment and Crisis Intervention, 6, 1-9.

Bowen, E. (2011). The rehabilitation of partner-violent men. Chichester: Wiley-Blackwell.

Bressi, S.K. & Vaden, E.R. (2017). “Reconsidering self-care”. Clinical Social Work Journal, 45(1), pp.33-38.

British Psychological Society (2007). Division of counselling psychology: Guidelines for supervision. Leicester: British Psychological Society

Camp, M & Sadler, J. (2019). “Moral distress in medical student reflective writing”, AJOB Empirical Bioethics, 10:1, 70-78.

Carpenter, G. L., & Stacks, A. M. (2009). “Developmental effects of exposure to intimate partner violence in early childhood: A review of the literature”. Children and Youth Services Review, 31(8), 831−839.

Chang, E.C., Kahle, E.R., Yu, E.A. & Hirsch, J.K. (2014). “Understanding the relationship between domestic abuse and suicide behaviour in adults receiving primary care: Does forgiveness matter?” Social work, 59(4), pp.315-320.

Cherny, N.I., Werman, B. & Kearney, M. (2015). “Burnout, compassion fatigue, and moral distress in palliative care”. Oxford textbook of palliative medicine, 9(2), p.246.

Cohen, K. & Collens, P. (2013). “The impact of trauma work on trauma workers: A metasynthesis on vicarious trauma and vicarious posttraumatic growth”. Psychological Trauma: Theory, Research, Practice, and Policy, 5(6), p.570.

Cort, L. & Cline, T. (2017). “Exploring the impact of domestic abuse on the mother role: how can educational psychologists contribute to this area?” Educational Psychology in Practice, 33(2), pp.167-179.

Devaney, J. (2015). “Research review: The impact of domestic violence in children”. Irish Probation Journal, 12, pp. 79-94.

Gadomski, A.M., Wolff, D., Tripp, M., Lewis, C. & Short, L.M. (2001). “Changes in health care providers’ knowledge, attitudes, beliefs, and behaviours regarding domestic violence, following a multifaceted intervention”. Academic Medicine, 76(10), pp.1045-1052.

Gill, A., Radford, L., Barter, C., Gilchrist, E., Hester, M., Phipps, A., Whiting, N., McCarry, M., Scott, M., Stark, E. & Rummery, K. (2012). Violence against women: Current theory and practice in domestic abuse, sexual violence and exploitation. Jessica Kingsley Publishers.

Hamlin, E.R. (1991). “Community-based spouse abuse protection and family preservation team”. Social work, 36(5), pp.402-406.

Hamric, A.B., Borchers, C.T. & Epstein, E.G. (2012). “Development and testing of an instrument to measure moral distress in healthcare professionals”. AJOB Primary Research, 3:2, 1-9. Retrieved on 6^th January 2021 from https://www.tandfonline.com/doi/abs/10.1080/21507716.2011.652337 Hanna, D.R. (2004). “Moral distress: the state of the science”. Research and Theory for Nursing Practice, 18(1), pp.73-93.

Hanson, R.F., Sawyer, G.K., Begle, A.M. & Hubel, G.S. (2010). “The impact of crime victimisation on quality of life”. Journal of Traumatic Stress: Official Publication of the International Society for Traumatic Stress Studies, 23(2), pp.189-197.

Herman, J. L. (1992). Trauma and Recovery New York: Basic Books. Retrieved on 6^th January 2021 from https://whatnow727.files.wordpress.com/2018/04/herman_trauma-and-recovery.pdf Herman, J. (2001). Trauma and recovery: From domestic abuse to political terror. Pandora.

Holt, S. (2011). “Domestic abuse and child contact: Positioning children in the decision-making process”. Child Care in Practice, 17(4), pp.327-346.

Iliffe, G. & Steed, L.G. (2000). “Exploring the counsellor’s experience of working with perpetrators and survivors of domestic violence”. Journal of interpersonal violence, 15(4), pp.393-412.

Jameton, A. (2013). “A reflection on moral distress in nursing together with a current application of the concept”. Journal of Bioethical Inquiry, 10(3), pp. 297-308.

Karakurt, G., Patel, V., Whiting, K. & Koyutürk, M. (2017). “Mining electronic health records data: Domestic violence and adverse health effects”. Journal of family violence, 32(1), pp.79-87

Macy, R., Ferron, J & Crosby, C. (2009), “Partner violence and survivors’ chronic health problems: Informing social work practice”. Social Work, 54(1), pp. 29–43

Mann, R.M. (2000). Who owns domestic abuse? The local politics of a social problem. University of Toronto Press.

McEwan, T. (2001). Managing values and beliefs in organisations. Pearson Education. Prentice Hall Limited.

Meyer, C. (2017). “The physical and emotional effects of domestic violence”. Retrieved on 16^th December 2020 from https://www.liveabout.com/the-physical-and-emotional-effects-ofdomestic-violence-1102426.

Mowles, C. (2008). “Values in international development organisations: negotiating non-negotiables”. Development in Practice, 18(1), pp.5-16.

Nijenhuis, E.R. & van der Hart, O. (2011). “Dissociation in trauma: A new definition and comparison with previous formulations”. Journal of Trauma & Dissociation, 12(4), pp.416-445.

Russell, A.C. (2012). “Moral distress in neuroscience nursing: An evolutionary concept analysis”. Journal of Neuroscience Nursing, 44(1), pp.15-24.

SafeIreland (2020). “Impact of domestic violence”. Retrieved on 16^th December 2020 from https:// www.safeireland.ie/get-help/understanding-domestic-abuse/impact-of-domestic-violence

Sansbury, B.S., Graves, K. & Scott, W. (2015). “Managing traumatic stress responses among clinicians: Individual and organisational tools for self-care”. Trauma, 17(2), pp.114-122.

Skyner, D.R. & Waters, J. (1999). “Working with perpetrators of domestic violence to protect women and children: A partnership between Cheshire Probation Service and the NSPCC. Child Abuse Review”: Journal of the British Association for the Study and Prevention of Child Abuse and Neglect, 8(1), pp.46-54.

Sokoloff, N.J. & Dupont, I. (2005). “Domestic violence at the intersections of race, class, and gender: Challenges and contributions to understanding violence against marginalised women in diverse communities”. Violence against women, 11(1), pp.38-64.

Sunderland, N., Catalano, T., Kendall, E., McAuliffe, D. & Chenoweth, L. (2010). “Exploring the concept of moral distress with community-based researchers: An Australian study”. Journal of Social Service Research, 37(1), pp.73-85.

Thompson, E.H., Frick, M.H. & Trice-Black, S. (2011). “Counselor-in-training perceptions of supervision practices related to self-care and burnout”.Professional Counselor, 1(3), pp.152-162.

van der Kolk, B.A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books Ltd.

Watson, D. & Parsons, S. (2005). Domestic abuse of women and men in Ireland: Report on the national study of domestic abuse 2003. Dublin: Stationery Office.

Wise, E.H., Hersh, M.A. & Gibson, C.M. (2012). “Ethics, self-care and well-being for psychologists: Reenvisioning the stress-distress continuum”. Professional Psychology: Research and Practice, 43(5), p.487. Women’s Aid (2019). “What is domestic abuse?” Retrieved on 6^th December 2020 from https://www. womensaid.org.uk/information-support/what-is-domestic-abuse

World Health Organisation (2013). Guidelines for the management of conditions specifically related to stress. Geneva: WHO

(C) IAHIP 2021 - INSIDE OUT 94 - SUMMER 2021