Applications 4.1 Uncovering Values Exercise If you were going to adopt a child, rank order from first to last, which you would adopt? _____ A child with cerebral palsy _____ A child with AIDS _____ A child from a mixed racial background _____ A child with a physical handicap _____ A child with Down syndrome _____ A child with an alcoholic mother _____ A child that had been abused for the first 2 years of life _____ A child that is deaf _____ A child that is blind _____ A child that was born with a horrible, permanent disfiguring birthmark _____ A child born addicted to cocaine _____ A child born to a schizophrenic mother (she got pregnant while hospitalized) _____ A child born in a rural area of country racially or culturally very different from your own, raised for 2 years in an orphanage there Applications 4.2 Facing Our Values Exercise Name the disability you most fear for yourself. Name the “difference” in others that you find most frightening, upsetting, and/or disconcerting. Name the “difference” within you or about you that you would be most ashamed to admit. Name the “difference” within or about you that you feel most proud of. Under what circumstances would you wish for death? What class/group/cultural set of people do you believe to be the loneliest people in the world? What actions in the world, done by yourself or other people, would you be comfortable labeling as sin? As evil? As wrong? Are there any types of people or belief systems you would label as just plain wrong or even evil? When Values Contrast in Interesting Ways Shortly after Sam's seventeenth birthday, his 19year- old girlfriend, Bindi, told him she was pregnant. Sam decided to quit school and work full- time at Oil Can Henry's, where he could make $8.00 an hour with decent health benefits. He wanted to marry Bindi, and wanted her to have the baby. Bindi's parents were wealthy African- American business people. Sam lived with his mother, who described herself as a starving artist. Sam described her as a flaky Catholic. Sam's father lived in another state and was not often in touch with Sam. Bindi no longer lived at home, but was very close to her parents, who very overtly begged her to get an abortion and take her time thinking about her relationship with Sam. Sam was extremely distraught, and his mother worried that he might be suicidal. Sam's mother got him to agree to meet with a counselor. As luck would have it, Sam ended up with Ms. Benson, an openly feminist clinical social worker in a community practice. Ms. Benson found herself quite taken with Sam's devotion to Bindi, and his desire to marry and have Bindi have the baby. Ms. Benson believed quite strongly that the decision about whether or not to bring the pregnancy to term was primarily Bindi's. However, she found herself in sympathy with Sam, admiring his willingness to make sacrifices, and touched by his wish to have this pregnancy continue, and to be a father. When Values Clash Connie, a seasoned school counselor, thought she had talked with children about every subject known to humankind, but she was wrong. And though she was a vegetarian, an active member of the Humane Society, and the owner of two dogs, three cats, and a gerbil, she also believed she was very balanced and understanding when children told her about going hunting, skinning the wild game to tan the hides, and so on. After all, she lived in a small town in Wyoming. But when Duane, the new boy, came to see her based on his teacher's urging to talk about his misbehaviors in sixth grade, Connie was handed quite a set of challenges. Duane explained that his family was very poor, and that his mother often put out cat food in the alley to catch stray cats. “She sneaks up on ‘em and grabs their tails, and snaps their necks. Like this,” Duane said, making a breaking motion with his two hands. “Then we skin ‘em. Make stew. I don't like it much, but it's what we eat sometimes.” Connie could barely keep her mind in the room and her focus on Duane. The images were strong and horrifying. She knew if her face showed her horror, she would be of very little help to Duane. When Shared Values Present Challenges Diasku was a first generation Japanese- American. He was the first- born son, and took very seriously his duties to his aging Japanese parents. He saved every dime he possibly could so that he could cover his parent's needs. He worked as a rehabilitation counselor in an urban area, and was often asked to work with clients whose first language was Japanese. One day, a young man named Abe came in for an evaluation. He had been badly burned in a cooking accident at a local restaurant. He very much hoped his disability payments would continue, allowing him to provide care for his aging father. Diasku found himself drawn to the young man, because often, the JapaneseAmerican youth he interviewed wanted to be free of the familial obligations of “the old ways.” Abe's injuries were significant, but Diasku knew he would be making a judgment call in terms of the overall length of recovery and other factors that had financial implications for Abe. He could feel himself pulled to maximize the situation to Abe's advantage. MORAL SENSITIVITY AND CLINICAL CONCERNS As you may remember from the last chapter, ethical decision- making models either specify or assume moral sensitivity as a starting point for ethical behavior and decisions (Welfel, 2001). One could reasonably ask, “How does someone become morally sensitized?” We hope that taking ethics courses and reading ethics texts such as this one contribute to adult, professional moral sensitivity. Many who study cultural practices and child development have offered theories of moral development based on reason, instruction, and cognitive maturation (Krebs & Denton, 2005). Diverse thinkers have hypothesized that our values and morality are products of our capacity for and engagement in meaningful relationships, or our spiritual commitment, or our ability to reason. Still others believe that our values have evolved due to natural selection. Matt Ridley (1996) quotes Charles Darwin, who wrote in his 1871 book, The Descent of Man: A tribe including many members who, from possessing in high degree the spirit of patriotism, fidelity, obedience, courage and sympathy, were always ready to aid one another, and to sacrifice themselves for the common good, would be victorious over most other tribes; and this would be natural selection. (p.172) Regardless of the origins of our values and the direction our development takes, it is clear that values vary widely across cultures, change over time, and are influenced by life experiences and relationships. In fact, we are willing to wager that simply reading a quote by Charles Darwin raised value issues for some of you. There is absolutely no doubt that your values will influence the ways you work with people professionally. The question is not if, but how. The essence of professional ethical behavior centers on the welfare and betterment of the client from the client's point of view. Therefore, the imposition of your values directly onto your client is questionable, and needs to be closely examined before you allow yourself to engage in something that direct. In fact, coercive attempts to influence have long been shown to negatively affect perceptions of the influencer (Raven, 1983). Therefore, even if your values correspond with what would be objectively “good” for your client, such as weight loss, more careful sexual activity, or curbing of an addiction, you could harm your therapeutic alliance by allowing your values to seem coercive to your client. On the other hand, you cannot hide your values nor keep them from being part of your work. Your values are part of who you are and what you have to offer to clients in your professional work. Many believe that psychotherapy's attempts to be value- free have failed and been damaging in the process (Doherty, 1995; Tjeltveit, 1999). In the next chapter, we cover the rich concept of informed consent and informed refusal in the counseling relationship. The interactive process of informed consent provides an important starting point for the counselor and the client in examining values pertinent to their work together. However, except in settings explicitly defined by a particular set of values, such as a pastoral counseling center, the direct promotion of your values will likely be ineffective as well as unethical. CHOICES ABOUT DISPLAYING VALUES In the United States, we live in a secular democracy. We deliberately separate church and state, and we have worked over time toward a pluralistic society based on justice and equal access for all. Large segments of our population hold deep religious and/or philosophical beliefs that define much of the meaning in their members' lives. The first amendment of the Constitution of the United States guarantees that faith systems and various ways of believing and living are not penalized or discriminated against (S. Welch, Gruhl, Comer, & Rigdon, 2004, p. 645). As a society, we try to uphold this value—with varying degrees of success. Most likely, many of you reading this text hold some emotionally charged and central values, springing from your faith, political affiliations, or philosophy. How do you negotiate the ethical challenges of having strong beliefs and a mandate to offer a safe, nonjudgmental counseling environment for young and old, rich and poor, gay and straight, feminist and fundamentalist, disabled and temporarily able- bodied? Do you owe it to your clients to reveal who you are? Just exactly how authentic did Carl Rogers (1957) intend for professional helpers to be? Is it okay to post the Ten Commandments from the Hebrew Bible in your office? Or to have the Qur'an prominently displayed on your office coffee table? Do you wear crucifixes, head scarves, or yarmulkes to signify certain religious affiliations? These are complicated decisions because these overt symbols carry great meaning for both your clients and for you. The symbols might carry similar meanings for you both, or they may be surprisingly dissimilar. You may be a mystically oriented, liberal Catholic with a beautiful rosary that you keep on your desk. You may be comfortable with birth control, gay marriage, and abortion rights, but your client has no way of knowing this. Your client could easily see the rosary and assume you were not the person to talk with about an unwanted pregnancy. We will discuss these important dimensions of your practice in the next chapter, as we explore the particulars of informed consent. Besides overt symbols of religious, political, or philosophical orientations, your office and work setting send many other messages. We have a personal preference we overtly try to convince our students to adopt regarding photos and other personal materials in offices. Our preference is to not display any family photos in counseling offices; the following are some of our concerns. Displaying family members in photographs in your office reveals the family members' identities. Your clients know who your children, spouse, or friends are, but of course, your loved ones cannot be told who you work with. Therefore, you expose your family to being known and identified in ways they cannot know about or respond to. Displaying your personal life too fully gives clients the message that you have created a personal space for them to enter. They are likely to feel free to ask who is pictured in the photo, and to follow up with questions about your familial relationships. Perhaps not many clients will ask, but they nonetheless register this familiarity and it therefore weakens an important professional boundary. You may or may not agree with us on this preference, but it is worth considering that the most basic communication principle is that you cannot not communicate (Wilmot & Hocker, 2000). Your values are revealed every step of the way, from first contact with clients, to the final good- bye. And sometimes they are revealed inadvertently and interpreted incorrectly. The more conscious and deliberate you are in the ways you reveal or choose not to reveal your values, the better. Pause for Reflection Think of the most central symbols of your identity. It might be a flag, a Star of David, a mountain bike, your membership in Alcoholics Anonymous, a gift from a departed loved one, or a memento from your best vacation ever. With whom do you share the meaning of these symbols? Have you ever had someone make fun of or desecrate a symbol of great meaning to you? Can you see ways in which the personal must be kept separate from the professional? CARE FOR THE CARING Here is an unabashedly judgmental value statement for you: We believe that all developing mental health professionals and anyone seeking to help others professionally should take good care of their minds, bodies, and psyches. They should, to use an old idiom, practice what they preach. We are not alone in this belief. Gilroy, Carroll, and Murra (2002) write, “We believe that the key to [burnout] prevention lies in establishing a professional ethos in which self- care is viewed as a moral imperative” (p.406). There are four very important reasons for our stance. First, we believe all humans will live more fulfilled lives if they take care of themselves in mind, body, and spirit (Hattie, Myers, & Sweeney, 2004; Jane E. Myers, Sweeney, & Witmer, 2000). Second, the most valuable tool most professionals have to work with is themselves (Rogers, 1961; Hubble, Duncan, & Miller, 1999; Kottler & Brown, 1996). Keeping the self well- tuned, rested, psychologically balanced, and educated is as important as any theory or technique a counselor might use. Third, good counseling involves empathic exposure to more human misery than would naturally come into the lives of most people. It is the profession of listening to or intervening in the fallout of natural and human- caused pain, disappointment, outrage, angst, and despair. Without good self- care, professional helpers run the risk of vicarious (secondary) Posttraumatic Stress Disorder (PTSD), overload, burnout, and cynicism (Pearlman & MacIan, 1995). Related to the third point, even the most admirable helpers are necessarily imperfect, with our share of pain, traumas, disappointments, and unfinished business. If we leave our own psychological wounds unattended to, they are quite likely to intersect with our work in conscious and unconscious ways that can be damaging to all involved (Goleman, 2003; Luhrmann, 2000). Most graduate mental health programs encourage graduate students to get counseling as part of their professional development. Often, they highly suggest both group and individual counseling. No one enters any professional field with absolutely pure, altruistic motives. Humans are a mixture of prosocial and selfish motives. The safest way to handle your selfserving motives is to understand them and keep in touch with them. If you weren't, at least sometimes, more preoccupied with understanding and/or solving your own problems, you wouldn't be human. If you didn't anticipate, at least to some extent, enjoying the authority that comes with professional title and credentials, you wouldn't be pursuing your degree. But it is never ethical, in the helping relationship, to let your own needs take precedent over the welfare of your clients. Of course, managing self- serving motives isn't the only reason to seek counseling. While studying diagnosis, multicultural materials, and other related topics, students often discover that they have unresolved psychological conflicts, underdeveloped areas of personality, old family issues, and many other good reasons to do some personal work in counseling. Perhaps the most basic reason of all is to insure deeper empathy for your clients by taking time to experience counseling yourself. Research indicates that for graduate students, finances, time, and worries about confidentiality are all common obstacles (Dearing & Maddux, 2005). In urging that all professional helpers take care of themselves, we stop short of insisting that this self- care take the form of personal counseling—at least at any given time in one's life. Of course, being in the business, and considering the consistent research findings regarding how much counseling helps (Seligman, 1995; M.L. Smith & Glass, 1977), we wonder why anyone would choose to become a counselor while at the same time, never sitting on the other side of the desk. If you are training to offer a service you never seek yourself, you may want to explore your deeper attitudes toward those who do seek counseling. On the other hand, sometimes it is not realistic or practical to obtain personal counseling. Other forms of self- care and growth are available and offer meaningful healing and insight. This is a great topic for a group discussion. Think about and share all of the ways you or close friends and family have found for self- care, growth, and healing. You will find a list reflecting a recent group of graduate students' thoughts on this matter in Digressions for Deliberation 4.2. ANXIETIES THAT ARE (OR SHOULD BE) COMMON TOGRADUATE STUDENTS Just as stress is not all bad, a certain amount of anxiety can serve useful functions in our professional development. As mentioned in Chapter 1, professionals- in- training are often uncomfortable with the power and prestige that come with the titles associated with professional counseling and helping interventions. There are solid reasons for this discomfort. Rather than deny it or become overly reactive to it, it is best to acknowledge these various anxieties and gain guidance and wisdom that can come from facing and addressing our fears. Digressions for Deliberation 4.2 Ideas on Self- Care Human healing and moral and psychological development occurs in many settings and through many channels. This list includes ideas students and colleagues have generated for psychological self- care and healing. Marianne: I would say that everyone should seek therapy once in a while, but I also have found great challenge and a sort of deepening of my soul by going on a vision quest, and by doing direct work on my sense of calling and meaning in the world. Monica: I have a wonderful spiritual advisor. I was raised Catholic, and while I don't agree with everything in the church, there is a rich tradition of mysticism that intrigues me. Tri: As a first generation Vietnamese- American, I have found that both pursuing some of my family's traditional values, and actually visiting Vietnam, has brought about a kind of balance in my life. I plan to do more of it. And, there's always soccer! Joyce: I need a lot of alone time. I've been an introvert forever, so I like to go on retreats, learn new techniques by experiencing them myself, and sometimes, I actually feel that I am healed directly by my work, if I just take time to let it sink in. Deanne: For me, as an athlete, working out is essential. I played tennis in Jamaica almost daily throughout high school and college. After a series of injuries, I've had to turn the intensity down a bit, but it is still essential for me. Greg: Even though I grew up on the reservation, I never really understood the power of my ancestors' spiritual practices. Now I participate in sweats and in other activities that help me walk in both worlds reasonably sanely. Karin: Growing up, my family didn't have the resources to do much but buy groceries. Now I get an occasional pedicure, a massage, or something like that and I feel like the Queen of the World. Life is precious and short. I think we should give ourselves a treat now and then. Tina: Art. For me, poetry, music, and fine pieces of oil or watercolor all stir something healing and wonderful in me. I dabble in all of those things myself, but it's really other people's work that gives me that sense of something good beyond myself. Rob: In my other life, I'm a carpenter. I think all people need a hobby or two that grabs them—that they feel passionate about. You have to get out of your head occasionally, so that when you get back in your head, you see things more clearly. Nancy: I meditate. Sometimes it's mountain walking meditation, or gardening meditation. I'm a secular Jewish woman with Buddhist leanings, and a lot of Christian friends. I think clearing the mind and meditating is a wonderful practice—it can't replace getting some counseling when you need it, but it sure helps me lead a more balanced, mindful life. Eli: For me, nature is the most healing thing on the planet, except for maybe my pets. I love caring for my dog. I love walking and hiking. I need to find that grounding, that sense of being part of a greater plan, or I get really antsy and unfocused. And I like to travel, too … when I can afford it. You know, James Baldwin (2005) said, “I met a lot of people in Europe. I even encountered myself” (p.48). This is a personal, noncomprehensive list that we hope helps broaden your own ideas about self- care and potentially growth- producing and healing human activities. The Imposter Syndrome Research into the imposter syndrome first began in 1978 by researchers Pauline Clance and Suzanne Imes (1978), who studied successful, high- achieving women. They found that these women suffered from significant self- doubt and had not internalized their successes as their own. The women believed that other people had been deluded into thinking of them as competent, and that their accomplishments were due to good contacts or luck. This was true even though the facts indicated the exact opposite. The women reported fearing that they would be found to be phonies, and were often filled with self- doubt. In our experience, many graduate students, regardless of sex or gender, struggle with imposter syndrome. Seeing your first client, starting work on your first internship, or seeking your first professional position will likely raise fears of inadequacy and incompetence (J. Sommers- Flanagan & Sommers- Flanagan, 1989). Humans tend to cope with this kind of anxiety along a continuum with dysfunctional extremes on either end. The continuum might be described as the following: One extreme: Absolute self- deprecation, coupled with false humility, used to excuse one's lack of participation and knowledge. Middle ground (or Golden Mean): Appropriate humility and willingness to ask for help, seek outside resources, and put in the extra effort to feel confident and responsible. Opposite extreme: Bravado and overconfidence. “Fake it ‘til you make it” sort of attitude. Misuse of authority, unwillingness to admit mistakes or uncertainties, and refusal to seek the extra help or spend the extra time necessary to know what one needs to know. We cover issues in competence in more depth in Chapter 9. For now, we encourage you to embrace your beginner's anxieties, and the feelings of inadequacy that naturally come with being new in the field. Further, we hope you realize that you will never “arrive” and be a totally actualized, completely educated, and fully mature professional. Continuing education, collegial supervision groups (e.g., Thomas, 2005), and a determination to be a lifelong learner are all essential to a healthy, ethical counseling practice. The Invisible Knapsack There is another problem sometimes present in developing mental health professionals, but less commonly known to be associated with sleepless nights—although it should be. The phenomenon, in one form or the other, has most likely been around as long as humans have graced the earth. Peggy McIntosh (1998) was the first to name this problem the invisible knapsack. Members of any dominant culture have one, but most of us are unwilling to admit it, and even less willing to open it, dig into the contents, and decide what to do about it. In our knapsack, we have all the little benefits and commonalities that make being a member of the dominant culture enviable and secure. Some of these include: I can, if I wish, arrange to be in the company of people of my race most of the time. I can turn on the television or open to the front page of the paper and see people of my race widely represented. I can arrange to protect my children most of the time from people who might not like them. I can swear or dress in second- hand clothes or not answer letters without having people attribute these choices to the bad morals, the poverty, or the illiteracy of my race (p.148). As a class, or on your own, make your own personal list. If you are a member of the white dominant culture, make your list from that perspective. If you are a member of a nonwhite race or culture, make a list of advantages you believe are operational for your white counterparts. Whites have the luxury of being the normative group. Social psychologist, Susan Fiske, reports that when asked who they are, her white students rarely, if ever, begin with a statement of their race or ethnicity. However, almost to a person, her students of color spontaneously include their racial or cultural identity (Hackney, 2005). Most of us would like to believe that we have overcome the learned biases and prejudices of our families and culture, but such unlearning is a lifelong process, and often we suppress our prejudices long before we overcome them (Rutland, Cameron, Milne, & McGeorge, 2005; Smedley & Smedley, 2005). In the Rodgers and Hammerstein's (1949) musical, South Pacific, they sing a snappy little number that insists that children must be taught to fear and hate—such emotions directed at others do not come about naturally. In Chapter 9, we provide you with a guide for multicultural competencies. Such competence is closely related to personal and professional identity development (Chris topher, 1999; Munely et al., 2004). Most accredited graduate mental health professional programs have significant course work devoted to multicultural counseling and a concern for multiculturalism is infused in the new ACA ethics code, as well as a frequent topic of entire journals in the field (American Psychological Association, 2003). However, the road to the kind of identity development that embraces diversity is a long one. One model for the cultural identity development journey includes six stages (L.J. Myers et al., 1991) beginning with individuation, which is described as identifying rather cluelessly with mainstream culture, displaying little insight into self or others. In the second phase, dissonance, there is the beginning of personal identity as different from the masses—often involving the individual noticing parts of self that are real, but have been ignored or devalued by others. The third phase, immersion, occurs when people begin to identify with those similar to themselves, especially those having similar traits to those devalued by the culture around them. This allows the individual, in the fourth phase (internalization), to have the courage to begin to give a positive valence to those parts of self previously devalued. In phase five, integration, the positive valence continues, with recognition that there are many assumptions we make about the world that are inaccurate and that can be changed for the better. In the last stage, transformation, the shift in worldview is profound. There is a reflective recognition of the interrelatedness of all people, with an appreciation of the unique cultures and histories we share (Munely et al., 2004). Pause for Reflection It is important to look at the invisible knapsack concept from an alternative angle: Imagine you decided to seek counseling for yourself or your family. Imagine a situation where you absolutely cannot hope to see someone from your own race or culture. What race, other than your own, would you prefer? What attributes about your potential counselor might make you uncomfortable? How would you compensate for the differences in background? BURNOUT AWARENESS AND PREVENTION Burnout is a relatively common experience for people in the helping professions (Bakker, Schaufeli, Sixma, Bosveld, & Van Dierendonck, 2000; Skovholt, 2001). Researchers Maslach and Jackson (1981) define burnout symptoms as (a) emotional exhaustion, (b) depersonalization, and (c) reduced personal accomplishment. All three of these symptoms spell trouble for mental health professionals and their clients. Emotionally exhausted therapists cannot center themselves and maintain the balance needed for empathy and containment of the client's emotions. Depersonalized counselors develop negative, cynical attitudes toward clients and cannot offer positive regard, neutrality, or perspective. Helpers suffering from a sense of reduced personal accomplishment are plagued by feelings of ineffectiveness in their professional role. As graduate students, you may not want to grapple with thoughts about burning out in a profession you are just beginning, but it is likely you have already experienced some form of burnout in your life—and may even be experiencing a bit of graduate student burnout right now! Living a balanced, healthy life means taking steps to minimize or prevent burnout throughout your personal and professional life. Factors and Symptoms of Stress and Burnout Burnout results from mishandled and excessive stress. Stress, itself, is a fact of life. Hans Selye (1974) was one of the first to point out that stress has many positive qualities. A certain amount of physical responsiveness to life's demands is necessary to motivate and energize people. Selye referred to this energy source as positive stress, or eustress. As Holmes and Rahe (1967) pointed out many years ago, any change in the routine of our lives—even welcome ones—can be stressful. Digressions for Deliberation 4.3 provides the list that Holmes and Rahe used when they asked nearly 400 respondents to rate the relative stress introduced into someone's life by these events. There are vast individual differences in stress tolerance and coping style among humans. There are differences in mind, body, and cultural beliefs that influence both what we find stressful, and the ways we then cope (Ray, 2004). It is important for you to learn about yourself, your stress tolerance, and your own personal signs of too much stress. The Holmes and Rahe scale (1967) helps identify possible stressors for middle- class members of the dominant culture. There are many other sources of socioeconomic and culturally determined stress that you might add to the list. In addition, Thomas Skov holt (2001), in his excellent book, The Resilient Practitioner, provides a 20- item list he calls “Hazards of Practice” (p.76) and elaborates on each one (see Skovholt, Chapter 6). These hazards include: We work with clients who have unsolvable problems that must be solved. Our clients and students are not necessarily “honors students.” Our clients and students have motivational conflicts. There is often a readiness gap between our desire to help, and see change, and our clients' or students' readiness to change. Sometimes, the people with whom we work project negative feelings onto us. Sometimes, we cannot help because we are not good enough, or we are the wrong person. Our clients have greater needs than we, our social services, and our education and health systems can meet. Mental health practitioners have a difficult time saying “No.” Our profession involves living in an ocean of stressful emotions. We must often face ambiguous professional loss—clients and students who leave abruptly and we never know why, nor have time to process the loss. Our work is confidential and we cannot talk about it openly and readily with whomever we might wish. Our work involves providing constant empathy, interpersonal sensitivity, and one- way caring. We cannot easily measure our success. We can all too easily see our failures or shortcomings. Digressions for Deliberation 4.3 The Holmes and Rahe Stress Scale Death of spouse 100 Divorce 75 Marital separation 65 Jail term 63 Death of a close family member 63 Personal injury or illness 53 Marriage 50 Dismissal from work 47 Marital reconciliation 45 Retirement 45 Change in health of family member 44 Pregnancy 40 Sex difficulties 39 Gain of new family member 39 Business readjustment 39 Change in financial state 38 Death of close friend 37 Change to different line of work 36 Change in no. of arguments with spouse 36 Major mortgage 31 Foreclosure of mortgage or loan 30 Change in responsibilities at work 29 Son or daughter leaving home 29 Trouble with in- laws 29 Outstanding personal achievement 28 Partner begins or stops work 26 Begin or end school 26 Change in living conditions 25 Revision of personal habits 24 Trouble with boss 23 Change in work hours or conditions 20 Change in residence/schools/recreation 19 Change in social activities 18 Small mortgage or loan 17 Change in sleeping/eating habits 16 Change in no. of family get- togethers 15 Vacation 13 Christmas 12 Minor violations of the law 11 Applications 4.1 Uncovering Values Exercise If you were going to adopt a child, rank order from first to last, which you would adopt? _____ A child with cerebral palsy _____ A child with AIDS _____ A child from a mixed racial background _____ A child with a physical handicap _____ A child with Down syndrome _____ A child with an alcoholic mother _____ A child that had been abused for the first 2 years of life _____ A child that is deaf _____ A child that is blind _____ A child that was born with a horrible, permanent disfiguring birthmark _____ A child born addicted to cocaine _____ A child born to a schizophrenic mother (she got pregnant while hospitalized) _____ A child born in a rural area of country racially or culturally very different from your own, raised for 2 years in an orphanage there Applications 4.2 Facing Our Values Exercise Name the disability you most fear for yourself. Name the “difference” in others that you find most frightening, upsetting, and/or disconcerting. Name the “difference” within you or about you that you would be most ashamed to admit. Name the “difference” within or about you that you feel most proud of. Under what circumstances would you wish for death? What class/group/cultural set of people do you believe to be the loneliest people in the world? What actions in the world, done by yourself or other people, would you be comfortable labeling as sin? As evil? As wrong? Are there any types of people or belief systems you would label as just plain wrong or even evil? When Values Contrast in Interesting Ways Shortly after Sam's seventeenth birthday, his 19year- old girlfriend, Bindi, told him she was pregnant. Sam decided to quit school and work full- time at Oil Can Henry's, where he could make $8.00 an hour with decent health benefits. He wanted to marry Bindi, and wanted her to have the baby. Bindi's parents were wealthy African- American business people. Sam lived with his mother, who described herself as a starving artist. Sam described her as a flaky Catholic. Sam's father lived in another state and was not often in touch with Sam. Bindi no longer lived at home, but was very close to her parents, who very overtly begged her to get an abortion and take her time thinking about her relationship with Sam. Sam was extremely distraught, and his mother worried that he might be suicidal. Sam's mother got him to agree to meet with a counselor. As luck would have it, Sam ended up with Ms. Benson, an openly feminist clinical social worker in a community practice. Ms. Benson found herself quite taken with Sam's devotion to Bindi, and his desire to marry and have Bindi have the baby. Ms. Benson believed quite strongly that the decision about whether or not to bring the pregnancy to term was primarily Bindi's. However, she found herself in sympathy with Sam, admiring his willingness to make sacrifices, and touched by his wish to have this pregnancy continue, and to be a father. When Values Clash Connie, a seasoned school counselor, thought she had talked with children about every subject known to humankind, but she was wrong. And though she was a vegetarian, an active member of the Humane Society, and the owner of two dogs, three cats, and a gerbil, she also believed she was very balanced and understanding when children told her about going hunting, skinning the wild game to tan the hides, and so on. After all, she lived in a small town in Wyoming. But when Duane, the new boy, came to see her based on his teacher's urging to talk about his misbehaviors in sixth grade, Connie was handed quite a set of challenges. Duane explained that his family was very poor, and that his mother often put out cat food in the alley to catch stray cats. “She sneaks up on ‘em and grabs their tails, and snaps their necks. Like this,” Duane said, making a breaking motion with his two hands. “Then we skin ‘em. Make stew. I don't like it much, but it's what we eat sometimes.” Connie could barely keep her mind in the room and her focus on Duane. The images were strong and horrifying. She knew if her face showed her horror, she would be of very little help to Duane. When Shared Values Present Challenges Diasku was a first generation Japanese- American. He was the first- born son, and took very seriously his duties to his aging Japanese parents. He saved every dime he possibly could so that he could cover his parent's needs. He worked as a rehabilitation counselor in an urban area, and was often asked to work with clients whose first language was Japanese. One day, a young man named Abe came in for an evaluation. He had been badly burned in a cooking accident at a local restaurant. He very much hoped his disability payments would continue, allowing him to provide care for his aging father. Diasku found himself drawn to the young man, because often, the JapaneseAmerican youth he interviewed wanted to be free of the familial obligations of “the old ways.” Abe's injuries were significant, but Diasku knew he would be making a judgment call in terms of the overall length of recovery and other factors that had financial implications for Abe. He could feel himself pulled to maximize the situation to Abe's advantage. MORAL SENSITIVITY AND CLINICAL CONCERNS As you may remember from the last chapter, ethical decision- making models either specify or assume moral sensitivity as a starting point for ethical behavior and decisions (Welfel, 2001). One could reasonably ask, “How does someone become morally sensitized?” We hope that taking ethics courses and reading ethics texts such as this one contribute to adult, professional moral sensitivity. Many who study cultural practices and child development have offered theories of moral development based on reason, instruction, and cognitive maturation (Krebs & Denton, 2005). Diverse thinkers have hypothesized that our values and morality are products of our capacity for and engagement in meaningful relationships, or our spiritual commitment, or our ability to reason. Still others believe that our values have evolved due to natural selection. Matt Ridley (1996) quotes Charles Darwin, who wrote in his 1871 book, The Descent of Man: A tribe including many members who, from possessing in high degree the spirit of patriotism, fidelity, obedience, courage and sympathy, were always ready to aid one another, and to sacrifice themselves for the common good, would be victorious over most other tribes; and this would be natural selection. (p.172) Regardless of the origins of our values and the direction our development takes, it is clear that values vary widely across cultures, change over time, and are influenced by life experiences and relationships. In fact, we are willing to wager that simply reading a quote by Charles Darwin raised value issues for some of you. There is absolutely no doubt that your values will influence the ways you work with people professionally. The question is not if, but how. The essence of professional ethical behavior centers on the welfare and betterment of the client from the client's point of view. Therefore, the imposition of your values directly onto your client is questionable, and needs to be closely examined before you allow yourself to engage in something that direct. In fact, coercive attempts to influence have long been shown to negatively affect perceptions of the influencer (Raven, 1983). Therefore, even if your values correspond with what would be objectively “good” for your client, such as weight loss, more careful sexual activity, or curbing of an addiction, you could harm your therapeutic alliance by allowing your values to seem coercive to your client. On the other hand, you cannot hide your values nor keep them from being part of your work. Your values are part of who you are and what you have to offer to clients in your professional work. Many believe that psychotherapy's attempts to be value- free have failed and been damaging in the process (Doherty, 1995; Tjeltveit, 1999). In the next chapter, we cover the rich concept of informed consent and informed refusal in the counseling relationship. The interactive process of informed consent provides an important starting point for the counselor and the client in examining values pertinent to their work together. However, except in settings explicitly defined by a particular set of values, such as a pastoral counseling center, the direct promotion of your values will likely be ineffective as well as unethical. CHOICES ABOUT DISPLAYING VALUES In the United States, we live in a secular democracy. We deliberately separate church and state, and we have worked over time toward a pluralistic society based on justice and equal access for all. Large segments of our population hold deep religious and/or philosophical beliefs that define much of the meaning in their members' lives. The first amendment of the Constitution of the United States guarantees that faith systems and various ways of believing and living are not penalized or discriminated against (S. Welch, Gruhl, Comer, & Rigdon, 2004, p. 645). As a society, we try to uphold this value—with varying degrees of success. Most likely, many of you reading this text hold some emotionally charged and central values, springing from your faith, political affiliations, or philosophy. How do you negotiate the ethical challenges of having strong beliefs and a mandate to offer a safe, nonjudgmental counseling environment for young and old, rich and poor, gay and straight, feminist and fundamentalist, disabled and temporarily able- bodied? Do you owe it to your clients to reveal who you are? Just exactly how authentic did Carl Rogers (1957) intend for professional helpers to be? Is it okay to post the Ten Commandments from the Hebrew Bible in your office? Or to have the Qur'an prominently displayed on your office coffee table? Do you wear crucifixes, head scarves, or yarmulkes to signify certain religious affiliations? These are complicated decisions because these overt symbols carry great meaning for both your clients and for you. The symbols might carry similar meanings for you both, or they may be surprisingly dissimilar. You may be a mystically oriented, liberal Catholic with a beautiful rosary that you keep on your desk. You may be comfortable with birth control, gay marriage, and abortion rights, but your client has no way of knowing this. Your client could easily see the rosary and assume you were not the person to talk with about an unwanted pregnancy. We will discuss these important dimensions of your practice in the next chapter, as we explore the particulars of informed consent. Besides overt symbols of religious, political, or philosophical orientations, your office and work setting send many other messages. We have a personal preference we overtly try to convince our students to adopt regarding photos and other personal materials in offices. Our preference is to not display any family photos in counseling offices; the following are some of our concerns. Displaying family members in photographs in your office reveals the family members' identities. Your clients know who your children, spouse, or friends are, but of course, your loved ones cannot be told who you work with. Therefore, you expose your family to being known and identified in ways they cannot know about or respond to. Displaying your personal life too fully gives clients the message that you have created a personal space for them to enter. They are likely to feel free to ask who is pictured in the photo, and to follow up with questions about your familial relationships. Perhaps not many clients will ask, but they nonetheless register this familiarity and it therefore weakens an important professional boundary. You may or may not agree with us on this preference, but it is worth considering that the most basic communication principle is that you cannot not communicate (Wilmot & Hocker, 2000). Your values are revealed every step of the way, from first contact with clients, to the final good- bye. And sometimes they are revealed inadvertently and interpreted incorrectly. The more conscious and deliberate you are in the ways you reveal or choose not to reveal your values, the better. Pause for Reflection Think of the most central symbols of your identity. It might be a flag, a Star of David, a mountain bike, your membership in Alcoholics Anonymous, a gift from a departed loved one, or a memento from your best vacation ever. With whom do you share the meaning of these symbols? Have you ever had someone make fun of or desecrate a symbol of great meaning to you? Can you see ways in which the personal must be kept separate from the professional? CARE FOR THE CARING Here is an unabashedly judgmental value statement for you: We believe that all developing mental health professionals and anyone seeking to help others professionally should take good care of their minds, bodies, and psyches. They should, to use an old idiom, practice what they preach. We are not alone in this belief. Gilroy, Carroll, and Murra (2002) write, “We believe that the key to [burnout] prevention lies in establishing a professional ethos in which self- care is viewed as a moral imperative” (p.406). There are four very important reasons for our stance. First, we believe all humans will live more fulfilled lives if they take care of themselves in mind, body, and spirit (Hattie, Myers, & Sweeney, 2004; Jane E. Myers, Sweeney, & Witmer, 2000). Second, the most valuable tool most professionals have to work with is themselves (Rogers, 1961; Hubble, Duncan, & Miller, 1999; Kottler & Brown, 1996). Keeping the self well- tuned, rested, psychologically balanced, and educated is as important as any theory or technique a counselor might use. Third, good counseling involves empathic exposure to more human misery than would naturally come into the lives of most people. It is the profession of listening to or intervening in the fallout of natural and human- caused pain, disappointment, outrage, angst, and despair. Without good self- care, professional helpers run the risk of vicarious (secondary) Posttraumatic Stress Disorder (PTSD), overload, burnout, and cynicism (Pearlman & MacIan, 1995). Related to the third point, even the most admirable helpers are necessarily imperfect, with our share of pain, traumas, disappointments, and unfinished business. If we leave our own psychological wounds unattended to, they are quite likely to intersect with our work in conscious and unconscious ways that can be damaging to all involved (Goleman, 2003; Luhrmann, 2000). Most graduate mental health programs encourage graduate students to get counseling as part of their professional development. Often, they highly suggest both group and individual counseling. No one enters any professional field with absolutely pure, altruistic motives. Humans are a mixture of prosocial and selfish motives. The safest way to handle your selfserving motives is to understand them and keep in touch with them. If you weren't, at least sometimes, more preoccupied with understanding and/or solving your own problems, you wouldn't be human. If you didn't anticipate, at least to some extent, enjoying the authority that comes with professional title and credentials, you wouldn't be pursuing your degree. But it is never ethical, in the helping relationship, to let your own needs take precedent over the welfare of your clients. Of course, managing self- serving motives isn't the only reason to seek counseling. While studying diagnosis, multicultural materials, and other related topics, students often discover that they have unresolved psychological conflicts, underdeveloped areas of personality, old family issues, and many other good reasons to do some personal work in counseling. Perhaps the most basic reason of all is to insure deeper empathy for your clients by taking time to experience counseling yourself. Research indicates that for graduate students, finances, time, and worries about confidentiality are all common obstacles (Dearing & Maddux, 2005). In urging that all professional helpers take care of themselves, we stop short of insisting that this self- care take the form of personal counseling—at least at any given time in one's life. Of course, being in the business, and considering the consistent research findings regarding how much counseling helps (Seligman, 1995; M.L. Smith & Glass, 1977), we wonder why anyone would choose to become a counselor while at the same time, never sitting on the other side of the desk. If you are training to offer a service you never seek yourself, you may want to explore your deeper attitudes toward those who do seek counseling. On the other hand, sometimes it is not realistic or practical to obtain personal counseling. Other forms of self- care and growth are available and offer meaningful healing and insight. This is a great topic for a group discussion. Think about and share all of the ways you or close friends and family have found for self- care, growth, and healing. You will find a list reflecting a recent group of graduate students' thoughts on this matter in Digressions for Deliberation 4.2. ANXIETIES THAT ARE (OR SHOULD BE) COMMON TOGRADUATE STUDENTS Just as stress is not all bad, a certain amount of anxiety can serve useful functions in our professional development. As mentioned in Chapter 1, professionals- in- training are often uncomfortable with the power and prestige that come with the titles associated with professional counseling and helping interventions. There are solid reasons for this discomfort. Rather than deny it or become overly reactive to it, it is best to acknowledge these various anxieties and gain guidance and wisdom that can come from facing and addressing our fears. Digressions for Deliberation 4.2 Ideas on Self- Care Human healing and moral and psychological development occurs in many settings and through many channels. This list includes ideas students and colleagues have generated for psychological self- care and healing. Marianne: I would say that everyone should seek therapy once in a while, but I also have found great challenge and a sort of deepening of my soul by going on a vision quest, and by doing direct work on my sense of calling and meaning in the world. Monica: I have a wonderful spiritual advisor. I was raised Catholic, and while I don't agree with everything in the church, there is a rich tradition of mysticism that intrigues me. Tri: As a first generation Vietnamese- American, I have found that both pursuing some of my family's traditional values, and actually visiting Vietnam, has brought about a kind of balance in my life. I plan to do more of it. And, there's always soccer! Joyce: I need a lot of alone time. I've been an introvert forever, so I like to go on retreats, learn new techniques by experiencing them myself, and sometimes, I actually feel that I am healed directly by my work, if I just take time to let it sink in. Deanne: For me, as an athlete, working out is essential. I played tennis in Jamaica almost daily throughout high school and college. After a series of injuries, I've had to turn the intensity down a bit, but it is still essential for me. Greg: Even though I grew up on the reservation, I never really understood the power of my ancestors' spiritual practices. Now I participate in sweats and in other activities that help me walk in both worlds reasonably sanely. Karin: Growing up, my family didn't have the resources to do much but buy groceries. Now I get an occasional pedicure, a massage, or something like that and I feel like the Queen of the World. Life is precious and short. I think we should give ourselves a treat now and then. Tina: Art. For me, poetry, music, and fine pieces of oil or watercolor all stir something healing and wonderful in me. I dabble in all of those things myself, but it's really other people's work that gives me that sense of something good beyond myself. Rob: In my other life, I'm a carpenter. I think all people need a hobby or two that grabs them—that they feel passionate about. You have to get out of your head occasionally, so that when you get back in your head, you see things more clearly. Nancy: I meditate. Sometimes it's mountain walking meditation, or gardening meditation. I'm a secular Jewish woman with Buddhist leanings, and a lot of Christian friends. I think clearing the mind and meditating is a wonderful practice—it can't replace getting some counseling when you need it, but it sure helps me lead a more balanced, mindful life. Eli: For me, nature is the most healing thing on the planet, except for maybe my pets. I love caring for my dog. I love walking and hiking. I need to find that grounding, that sense of being part of a greater plan, or I get really antsy and unfocused. And I like to travel, too … when I can afford it. You know, James Baldwin (2005) said, “I met a lot of people in Europe. I even encountered myself” (p.48). This is a personal, noncomprehensive list that we hope helps broaden your own ideas about self- care and potentially growth- producing and healing human activities. The Imposter Syndrome Research into the imposter syndrome first began in 1978 by researchers Pauline Clance and Suzanne Imes (1978), who studied successful, high- achieving women. They found that these women suffered from significant self- doubt and had not internalized their successes as their own. The women believed that other people had been deluded into thinking of them as competent, and that their accomplishments were due to good contacts or luck. This was true even though the facts indicated the exact opposite. The women reported fearing that they would be found to be phonies, and were often filled with self- doubt. In our experience, many graduate students, regardless of sex or gender, struggle with imposter syndrome. Seeing your first client, starting work on your first internship, or seeking your first professional position will likely raise fears of inadequacy and incompetence (J. Sommers- Flanagan & Sommers- Flanagan, 1989). Humans tend to cope with this kind of anxiety along a continuum with dysfunctional extremes on either end. The continuum might be described as the following: One extreme: Absolute self- deprecation, coupled with false humility, used to excuse one's lack of participation and knowledge. Middle ground (or Golden Mean): Appropriate humility and willingness to ask for help, seek outside resources, and put in the extra effort to feel confident and responsible. Opposite extreme: Bravado and overconfidence. “Fake it ‘til you make it” sort of attitude. Misuse of authority, unwillingness to admit mistakes or uncertainties, and refusal to seek the extra help or spend the extra time necessary to know what one needs to know. We cover issues in competence in more depth in Chapter 9. For now, we encourage you to embrace your beginner's anxieties, and the feelings of inadequacy that naturally come with being new in the field. Further, we hope you realize that you will never “arrive” and be a totally actualized, completely educated, and fully mature professional. Continuing education, collegial supervision groups (e.g., Thomas, 2005), and a determination to be a lifelong learner are all essential to a healthy, ethical counseling practice. The Invisible Knapsack There is another problem sometimes present in developing mental health professionals, but less commonly known to be associated with sleepless nights—although it should be. The phenomenon, in one form or the other, has most likely been around as long as humans have graced the earth. Peggy McIntosh (1998) was the first to name this problem the invisible knapsack. Members of any dominant culture have one, but most of us are unwilling to admit it, and even less willing to open it, dig into the contents, and decide what to do about it. In our knapsack, we have all the little benefits and commonalities that make being a member of the dominant culture enviable and secure. Some of these include: I can, if I wish, arrange to be in the company of people of my race most of the time. I can turn on the television or open to the front page of the paper and see people of my race widely represented. I can arrange to protect my children most of the time from people who might not like them. I can swear or dress in second- hand clothes or not answer letters without having people attribute these choices to the bad morals, the poverty, or the illiteracy of my race (p.148). As a class, or on your own, make your own personal list. If you are a member of the white dominant culture, make your list from that perspective. If you are a member of a nonwhite race or culture, make a list of advantages you believe are operational for your white counterparts. Whites have the luxury of being the normative group. Social psychologist, Susan Fiske, reports that when asked who they are, her white students rarely, if ever, begin with a statement of their race or ethnicity. However, almost to a person, her students of color spontaneously include their racial or cultural identity (Hackney, 2005). Most of us would like to believe that we have overcome the learned biases and prejudices of our families and culture, but such unlearning is a lifelong process, and often we suppress our prejudices long before we overcome them (Rutland, Cameron, Milne, & McGeorge, 2005; Smedley & Smedley, 2005). In the Rodgers and Hammerstein's (1949) musical, South Pacific, they sing a snappy little number that insists that children must be taught to fear and hate—such emotions directed at others do not come about naturally. In Chapter 9, we provide you with a guide for multicultural competencies. Such competence is closely related to personal and professional identity development (Chris topher, 1999; Munely et al., 2004). Most accredited graduate mental health professional programs have significant course work devoted to multicultural counseling and a concern for multiculturalism is infused in the new ACA ethics code, as well as a frequent topic of entire journals in the field (American Psychological Association, 2003). However, the road to the kind of identity development that embraces diversity is a long one. One model for the cultural identity development journey includes six stages (L.J. Myers et al., 1991) beginning with individuation, which is described as identifying rather cluelessly with mainstream culture, displaying little insight into self or others. In the second phase, dissonance, there is the beginning of personal identity as different from the masses—often involving the individual noticing parts of self that are real, but have been ignored or devalued by others. The third phase, immersion, occurs when people begin to identify with those similar to themselves, especially those having similar traits to those devalued by the culture around them. This allows the individual, in the fourth phase (internalization), to have the courage to begin to give a positive valence to those parts of self previously devalued. In phase five, integration, the positive valence continues, with recognition that there are many assumptions we make about the world that are inaccurate and that can be changed for the better. In the last stage, transformation, the shift in worldview is profound. There is a reflective recognition of the interrelatedness of all people, with an appreciation of the unique cultures and histories we share (Munely et al., 2004). Pause for Reflection It is important to look at the invisible knapsack concept from an alternative angle: Imagine you decided to seek counseling for yourself or your family. Imagine a situation where you absolutely cannot hope to see someone from your own race or culture. What race, other than your own, would you prefer? What attributes about your potential counselor might make you uncomfortable? How would you compensate for the differences in background? BURNOUT AWARENESS AND PREVENTION Burnout is a relatively common experience for people in the helping professions (Bakker, Schaufeli, Sixma, Bosveld, & Van Dierendonck, 2000; Skovholt, 2001). Researchers Maslach and Jackson (1981) define burnout symptoms as (a) emotional exhaustion, (b) depersonalization, and (c) reduced personal accomplishment. All three of these symptoms spell trouble for mental health professionals and their clients. Emotionally exhausted therapists cannot center themselves and maintain the balance needed for empathy and containment of the client's emotions. Depersonalized counselors develop negative, cynical attitudes toward clients and cannot offer positive regard, neutrality, or perspective. Helpers suffering from a sense of reduced personal accomplishment are plagued by feelings of ineffectiveness in their professional role. As graduate students, you may not want to grapple with thoughts about burning out in a profession you are just beginning, but it is likely you have already experienced some form of burnout in your life—and may even be experiencing a bit of graduate student burnout right now! Living a balanced, healthy life means taking steps to minimize or prevent burnout throughout your personal and professional life. Factors and Symptoms of Stress and Burnout Burnout results from mishandled and excessive stress. Stress, itself, is a fact of life. Hans Selye (1974) was one of the first to point out that stress has many positive qualities. A certain amount of physical responsiveness to life's demands is necessary to motivate and energize people. Selye referred to this energy source as positive stress, or eustress. As Holmes and Rahe (1967) pointed out many years ago, any change in the routine of our lives—even welcome ones—can be stressful. Digressions for Deliberation 4.3 provides the list that Holmes and Rahe used when they asked nearly 400 respondents to rate the relative stress introduced into someone's life by these events. There are vast individual differences in stress tolerance and coping style among humans. There are differences in mind, body, and cultural beliefs that influence both what we find stressful, and the ways we then cope (Ray, 2004). It is important for you to learn about yourself, your stress tolerance, and your own personal signs of too much stress. The Holmes and Rahe scale (1967) helps identify possible stressors for middle- class members of the dominant culture. There are many other sources of socioeconomic and culturally determined stress that you might add to the list. In addition, Thomas Skov holt (2001), in his excellent book, The Resilient Practitioner, provides a 20- item list he calls “Hazards of Practice” (p.76) and elaborates on each one (see Skovholt, Chapter 6). These hazards include: We work with clients who have unsolvable problems that must be solved. Our clients and students are not necessarily “honors students.” Our clients and students have motivational conflicts. There is often a readiness gap between our desire to help, and see change, and our clients' or students' readiness to change. Sometimes, the people with whom we work project negative feelings onto us. Sometimes, we cannot help because we are not good enough, or we are the wrong person. Our clients have greater needs than we, our social services, and our education and health systems can meet. Mental health practitioners have a difficult time saying “No.” Our profession involves living in an ocean of stressful emotions. We must often face ambiguous professional loss—clients and students who leave abruptly and we never know why, nor have time to process the loss. Our work is confidential and we cannot talk about it openly and readily with whomever we might wish. Our work involves providing constant empathy, interpersonal sensitivity, and one- way caring. We cannot easily measure our success. We can all too easily see our failures or shortcomings. Digressions for Deliberation 4.3 The Holmes and Rahe Stress Scale Death of spouse 100 Divorce 75 Marital separation 65 Jail term 63 Death of a close family member 63 Personal injury or illness 53 Marriage 50 Dismissal from work 47 Marital reconciliation 45 Retirement 45 Change in health of family member 44 Pregnancy 40 Sex difficulties 39 Gain of new family member 39 Business readjustment 39 Change in financial state 38 Death of close friend 37 Change to different line of work 36 Change in no. of arguments with spouse 36 Major mortgage 31 Foreclosure of mortgage or loan 30 Change in responsibilities at work 29 Son or daughter leaving home 29 Trouble with in- laws 29 Outstanding personal achievement 28 Partner begins or stops work 26 Begin or end school 26 Change in living conditions 25 Revision of personal habits 24 Trouble with boss 23 Change in work hours or conditions 20 Change in residence/schools/recreation 19 Change in social activities 18 Small mortgage or loan 17 Change in sleeping/eating habits 16 Change in no. of family get- togethers 15 Vacation 13 Christmas 12 Minor violations of the law 11 We face chronic regulation oversight and control by external, often unknown, others. Our work can become routine, yielding cognitive deprivation and boredom. We must put up with cynical, critical, and negative colleagues and managers. We must face ongoing ethical and legal challenges and fears. In repeatedly witnessing and hearing of the trauma endured by others, we become traumatized ourselves. We live with the awareness of potential physical trauma from angry clients, students, or family members. At the risk of causing you to consider an abrupt career change, we include one last list. Drawing from our own professional experiences and the research of many in our field (Bakker et al., 2000; Holmes & Rahe, 1967; Skovholt, 2001), this list details possible signs of burnout and related indicators of professional imbalances, such as overidentification and/or underidentification with one's work (Emerson & Markos, 1996). Symptoms of Underidentification theorganization (or world)- owes- me- this- job attitude unwilling to seek continuing education, defensive about counseling style socializing with students (Just one of the guys, lack of professional identity) or aloofness from students—puts most of them at a judgmental distance plays the numbers game but is outta there whenever possible secretly scorns people in need of help, compares them to self (oneupmanship) cynicism and callousness Symptoms of Overidentification hero syndrome (needing to save someone/everyone at all costs) taking the work, worries, and stories home failing to keep boundaries between professional identity and core/personal identity willingness to rob friendships and family relationships on behalf of the job repeatedly using personal resources (time, money, books,) to serve “the cause” at work socializing with students inappropriately (secret mentoring) having your job as central or complete identity inability to envision doing something else with your life seeing self as above the rules of the profession, due to your “high calling” ignoring numbers game because personal devotion is obvious, should be enough giving beyond the point of health or wisdom failure to seek unbiased consultation or supervision chronic shame and doubt Symptoms of Burnout dreading going to work feelings of relief if you have no- shows or get “rained out” difficulties concentrating difficulties listening chronic irritability with students and colleagues; cynical derogatory attitude recurrence of physical or emotional symptoms from past reduced immune system functioning failure to bounce back after usual breaks/vacations break- down of observation of rules, guidelines, paperwork (or rigid adherence) inability to accept constructive feedback physical, mental, emotional exhaustion (across life settings) It can be quite overwhelming to consider all the stresses and strains common to the helping professions, and threatening to consider the ways this stress might translate into our work with clients. However, mental health professionals, more than most, should also realize the central importance of how we actually think about and handle these inevitable truths. The mind is its own place, and in itself Can make a Heav'n of Hell, a Hell of Heav'n. —John Milton, Paradise Lost In other words, the ways you choose to think about your work, and your life, can make a radical difference in your overall functioning, health, and professional longevity. We discuss this more specifically in the next section.