​I am inspired to write about a group that I facilitated this week which combined elements of MIECAT arts therapy procedures with Narrative Therapy outsider witness practice. 
Outsider witness practice is well documented in Narrative Therapy literature if you are interested to read more but I give a basic description of it at the end of this post.
In recent years I have been adapting this practice using arts based activities to enrich  the already transformative experience.
Yesterday I was asked to run a group therapy session on identity using an art based approach. The clients were a group of people coming to our trauma treatment program and I had not worked with them before. I was told that the group were a bit flat and struggling in the morning and later that day I discovered that the group had previously been having difficulty feeling connected.

Here is a brief outline of the group process I used.

Selecting images
I asked participants to select postcard images (free ones collected from cafes over the years) to describe aspects of themselves which were nothing to do with the experiences or struggles that brought them to our program. Naturally that was difficult as they were feeling overwhelmed by the problems they face, I let them know that even one card that did not relate to problems would be a good job done.
Then I asked them to cluster the cards into groups that seemed to fit together and give each group a name. (This clustering and naming process is a standard MIECAT arts therapy process it helps people make sense of the images and reduce the information held in the cards down to its core message)

The interview process
Group members were instructed to listen to the interview and take down any words or statements that they heard coming out of the interviewees mouth, which stood out to them for any reason. (this is another wonderful MIECAT technique called Key Words. It can be utilised in numerous ways; in this instance, it is serving the purpose of helping the listeners stay focused and engaged and the words collected are essential in our witnessing process)

Facilitator I interviewed each person about the cards they had chosen for about ten minutes.  I invited participants to speak of the cards that were not dominated by problems and listened intently for the slightest opportunity to enquire into storylines which would lead the conversation to areas of the participant’s values, skills, knowledge, meaning full relationships etcetera. (In Narrative Therapy these are sometimes called windows of opportunity)
Participants After each interview participants took note of any key words or statements that had strongly resonated with their own experience and then gave all the words they had recorded to the speaker. Participants received these key words with delight.

Key word poetic statements Once everyone had been interviewed I invited participants to pluck out the words and statements that held the most meaning to them from the key words they had been given. (picking out the key words from the key words) they then created poetic statements with the words which they shared with the group. (this is another tried and true MIECAT procedure which again brings the many words down to the essence of what is most important to the individual)

​Double listening
Not surprisingly speaking about stories not dominated by problems was very difficult for all the group members on this occasion so I needed to listen intently employing what is sometimes called double listening. Double listening is when you are with one ear hearing the problem dominated story and with the other ear listening for implicit or explicit fragments of preferred identity stories for example values held, skills and knowledge acquired, capabilities developed, relationships of meaning etcetera. By remaining curious, paying close attention and asking skilful questions informed by my narrative therapy training to draw out these alternate stories our conversations took surprising and delightful paths.
Some of the noteworthy things we learned about the group members were: of a powerful and protective sense of wit, a capacity to make life enhancing choices at life’s important junctures, ability to step out of the critical mind whilst play music which might translate into other parts of life, a passion for art and activism, values of living life to its fullest and an emerging capacity for self-compassion.

The power of being witnessed.
Through these conversations the group learned a great deal about each other’s lives which had not previously been explored and participants expressed a new-found appreciation for their group members. The stories we heard in this group stand in stark contrast to the stories of childhood abuse, workplace bullying and injury, emotional suffering, and decreased functioning through which the group had previously known one another. Having your courage, humour, passion, values and capability witnessed by an audience and reflected to you in your own words or through visual image is a powerful tool in reclaiming your sense of self from the effects of traumatic experience or illness.
When the team leader met with the group at the end of the day he described participants as buzzing with excitement when he entered the room and the group reported feeling much more connected with one another than they previously had.

Possibilities to include further art making
There are numerous ways to include more art making into this exercise here are some I have included in the past.
Initial representation can be made in any arts modality.
Visual representation of the essence of the key words can made by interviewee.
Each audience member makes a response in arts modality inspired by the key words they have collected to give to the interviewee.
Audience members make a representation of how the interview might inspire them in their own lives.

A rough outline of Outsider witness process
One person is interviewed by a narrative therapist in front of an audience of one or more.
The audience is then interviewed and asked to reflect on the following.
Some aspect of the interviewees story that caught their attention.
What that aspect of the evoked for them in terms of the interviewees hopes, values ambitions and identity.
How this relates to their own experience.
Where they might have been moved to or how they might be inspired by the experience of listening to the interview.
The original interviewee then speaks about their experience of listening to the audience (the retelling)

If you would like to read more about the use of outsider witness practice in Narrative Therapy I recommend the following article it is readily available on the internet.
Outsider-witness practices: some answers to commonly asked questions”  
​Maggie Carey & Shona Russell

I guess compassion fatigue will be experienced differently by everyone who works in the helping professions but I thought it might be helpful to describe my experience as a way of helping other clinicians pay attention to their well being.

My heart feels like a railway station at peak hour.
Long before I had heard of the term compassion fatigue when the only name I had heard to describe what happened to exhausted therapists was burn out, I experienced what I called burnt open.
When I am at the end of my helping tether my heart begins to feel like a railway station at peak hour through which too many people have passed. It is as though my skin has become porous, I feel pain and joy and love more deeply and I will cry easily at anything. It is an ecstatic compassionate experience but if I don’t take heed and rest shortly afterward I will become completely exhausted or fall ill. At these strange burnt open times I can also begin to feel like i am  exhibiting behavioral traits of the clients I have been working with. For example on occasion when my exhaustion has come whilst working with clients vulnerable to suicide, I have begun to  randomly experience the thought “I want to kill myself”. At these times I know that I must stop, rest and regenerate.

How might my fatigue impact clients?
Real or imagined I have a sense that without my emotional robustness to hold the safety and set the boundary of the therapeutic space my clients too can become more porous.  They may feel their emotions more intensely and allow more deep or personal content to arise in the therapy session.  Of course moving more deeply into trust and allowing meaningful content to emerge in session is good therapy, but it is essential that it arises in a safe way at the right time for the individual, with a therapist who has all their emotional and cognitive faculties about them.
  
At these times of fatigue I am very cautious.
 I choose my group topics mindfully and I deliberately plan therapy groups which will engage participants intellectually rather than emotionally. In individual work I check more regularly on the safety and emotional status of my clients during the sessions. In both cases I pay more attention to thorough  risk assessment and double check my decisions with my peers where ever possible.
I let my manager and supervisor and loved ones know where I am at so that they can support me and I plan a sick day and a holiday, I make a lot of art and try to increase exercise and meditation, get into nature and schedule in some gentle fun with friends.

But what causes it?
There are many contributing factors, the multiple of variable which can increase in the intensity of my client work, lack of supervision and consultation, beloved workmates resigning, interpersonal difficulties with other staff, time pressure and deadlines organisational instability, difficulties in ones personal life.
But it is never the clients i work with that cause my fatigue, quite the opposite in fact they are the source of inspiration, energy and constant learning.
What I notice brings me undone is feeling isolated or alone, not having a team, and the experience of being responsible for the therapeutic outcomes of too many people without the people power and support to deliver.

How to prevent compassion fatigue.
Make sure you know what it is to feel comfortable, content and relaxed within yourself before you begin practicing. Many training courses, particularly in clinical psychology are so demanding that clinicians begin their careers in a state of exhaustion and anxiety.
Get in touch with who you are and what really matters to you.
Bring awareness to what gives you joy and restores you to a sense of well-being.
Keep up regular exercise and mindfulness practice and find a creative outlet.
Seek out a really skilled, experienced, supportive supervisor and develop a peer support network for yourself.
Be gentle, there is too much pressure to work full time, don’t be afraid to decide for yourself how many days it is healthy for you to work as a therapist at any given time. 

Please leave a comment about your experience of compassion fatigue.
 
 

Personal encounters with Mindfulness Meditation.
I have been attracted to the idea of meditation ever since I first heard of it at fourteen years of age, but it was twelve years later in 1996 that I finally had the opportunity to attend my first meditation retreat. 
Of course it was life changing. I distinctly remember walking to work on return to the city, down the same dirty street I had walked every day prior to the retreat, suddenly I was shockingly aware of the vibrant green leaves contrasting the dull grey streets, as though I had never seen the trees before. Where prior to the retreat I had felt alone and dissatisfied with my friendships, post retreat I was deeply grateful for the friends I did have. Instead of lying in bed in the morning ruminating for an hour or two before I got up I was able to simply get out of bed and get into my day.

Keeping sane in my first year of practice as a therapist.
Coincidentally it was on return from this first retreat that I learned I was being given the very exciting opportunity to join the outpatient therapy team at the addictions treatment centre where I worked as a nurse.
The new role came with a steep and fulfilling learning curve and without my new found meditation practice I would have really struggled with the responsibility. Holding onto my sanity was a strong motivator to keep me committed to that first year of mindfulness practice.

Patiently waiting
For years I wanted to incorporate mindfulness meditation into my therapy practice but I felt hampered by the dominant therapeutic paradigm. Working within the mental health system, I was fearful that teaching my clients to use mindfulness would be viewed as unprofessional or religious. I had not yet seen any empirical evidence demonstrating the efficacy of mindfulness so I kept my mindfulness practice to myself. 
In recent years however it feels like the therapeutic world is abuzz with the miracle of mindfulness meditation. Every year more and more scientific evidence is emerging in support of the capacity for mindfulness to change people’s brains and therefore their lives. 

Practical benefits of incorporating Mindfulness into my therapeutic practice. 
Nowadays I rarely  start a therapy session without a brief mindfulness practice. 
Facilitating a few minutes of mindfulness at the beginning of each session helps me to become highly focused and present to the people who consult with me. Importantly it also helps me to be present to and make therapeutic use of my subtle internal responses to the events which unfold within the therapeutic relationship.
Initial research has shown that clients of clinicians who practice mindfulness meditation have better therapeutic outcomes than the clients of clinicians who do not, Grepmair, Mitterlehner, Bacheler, Rother and Nickell, (2007).

A few minutes of mindfulness helps my clients to arrive into a place of presence to themselves at the start of a session. It increases their capacity to be aware of their thoughts, feelings and reactions during the session and it provides an essential experiential learning opportunity which will translate to their lives outside the therapy room.  When a client's emotions or memories become overwhelming in a session, facilitating some moments of mindfulness helps them get grounded into the present and into their bodies, and teaches them how to keep emotionally safe when feeling overwhelmed. 
When working in a group therapy context I use mindfulness in a similar manner whenever the group energy becomes ungrounded or highly emotional.
And my favourite mindfulness of the senses exercise has never failed to calm the distressed, anxious or tearful clients who frequently call our team at the busy outpatient therapy clinic at which I am employed. 

Increase your knowledge and confidence in using practical Mindfulness techniques with your clients 
If you would like to increase your knowledge and confidence in using practical Mindfulness techniques with your clients please check out my July 4th Learn to Teach Mindfulness Workshop on the booking page of this website or go to the secure page at trybooking  http://www.trybooking.com/HOVW OR http://www.trybooking.com/133064  

Grepmair, Mitterlehner, Bacheler, Rother and Nickell, (2007). 
Promoting mindfulness in psychotherapists training influences the treatment results of their patients: A randomised double-blind control study. Psychotherapy and Psychosomatics, 76, 332-338.doi:10.1159/000107560