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Staying Grounded When Your Clients’ Pain Takes You to an Unwelcome Place
By Scott Janssen, MSW, LCSW

Phoebe has been talking about the time an ex-boyfriend “flipped out” and spent two days beating, torturing, and raping her before tossing her out of a moving car in an unfamiliar city. Overcome by sobs, eyes closed, she buries her head in her hands and pulls her knees up onto the chair, pressing them against her chest as though trying to make herself as small and impenetrable as possible.

I unclench tightened fists and take a deep breath, trying to settle the storm roiling within. My heart is racing. My breathing is rapid and shallow. The muscles in my shoulders are tight and I’m clenching my jaw. There’s an agitated energy around my solar plexus ready to explode.

Rage squeezes out all feelings save for a peripheral sense of compassion for Phoebe. I tell myself to relax, focus. She doesn’t need anger. She needs kindness.

I imagine my heart opening and instantly feel warmth in my chest. I envision Phoebe surrounded by a warm and healing light. Infusing my voice with as much gentleness as I can muster, speaking slowly and softly, I ask her to notice the way her hands are rubbing her face. When she opens her eyes, I’m filled with deep sadness and, as if automatically, my jaw and fists tighten again.

As inner tension builds, I begin to feel numb inside and things start getting mentally foggy. I realize I’m dissociating. I press my feet into the floor and remind myself that the events we are exploring are in the past. She survived. She’s safe.

Somehow I make it through what was supposed to have been a harmless practice session with other social workers and psychologists who’ve been taking turns as clients and practitioners as we train to work with posttraumatic stress. For the rest of the day I’m agitated and uneasy.

Hard Questions, Hard Answers
I’d been working with patients who are dying and their loved ones for years. I was good at walking into crisis situations and staying cool. I knew how to ask hard questions and thought I knew how to listen to hard answers without getting thrown. I’d decided to learn about trauma after working with combat veterans who’d told me harrowing details about the brutal, blood-splattered savagery of war and seeing how it had haunted them. Nothing had knocked me off balance like this. How do you train yourself to hear things such as this without running for the exits?

I was aware of the dangers that repeated exposure to this kind of horrific material can bring. Vicarious trauma, compassion fatigue, cynicism, and moral distress are real dangers in the social work profession. To maintain perspective and prevent burnout, I’d developed skills for staying grounded and monitoring myself for defensive patterns and triggering responses; I needed to ensure equilibrium and proper boundaries as I invited patients to share and process.

Like most social workers, I engaged in good self-care, including opportunities for reflection and psychological support, so that any personal struggles or hot buttons wouldn’t get in the way when helping others. These skills and practices had helped keep my heart open while listening to histories that were heartbreaking. They had been essential for staying present and centered whenever patients with whom I’d formed bonds of care and trust had spoken of surviving or inflicting acts of cruelty and violence.

By the time I met Phoebe I’d cobbled together a pretty good repertoire of grounding and self-awareness strategies. It was clear that day, however, that if my practice were to become trauma informed, it would have to expand … a lot.

Though I often use practices (e.g., visualization, anchoring metaphors, affirmations, and what I refer to as invocations of transpersonal assistance), the core skills I use for staying grounded, empathetic, and self-aware involve a combination of mindfulness, somatic awareness, and narrative strategies.

Mindfulness
Mindfulness is a learned skill that allows one to observe outer and inner events—thoughts, emotions, sensations—without judging, reacting, or getting hooked by them. Jon Kabat-Zinn, PhD, (2005) describes it as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” This kind of attention, simply watching and taking in details without attaching a story or judgment to them, allows social workers to be with a client’s intense emotions and to hear painful histories without losing balance or getting overwhelmed.

If, during an intense session, social workers practicing mindfulness found themselves having reactive thoughts or feelings, they would simply notice them without allowing distraction, allowing them to come and go without resistance or judgment. In this regard, I recommend an approach suggested by Tara Brach (2012), who uses the acronym RAIN, as follows:

• Recognize what is happening in the moment.

• Allow things to be just as they are.

• Investigate your inner experience with kindness.

• Nonidentification, in which who you are “is not fused with or defined by any limited set off emotions, sensations, or stories.”

Somatic Awareness
Somatic awareness involves tracking subtle and not-so-subtle sensations and physiological changes in one’s body. Listening to intense trauma narratives and witnessing the vortex of pain left in the wake of traumatic events can cause social workers to have physiological reactions such as muscle tension, postural changes, impulses to move, or alterations in breathing. Mindfully noticing these sensations allows clinicians to use their bodies as a source of information and to stay centered. Peter Levine, PhD, (2010) calls this the “embodied self,” in which practitioners “bring conscious awareness to the multitude of internal bodily sensations happening moment by moment.” It allows them to respond with intention while staying focused and attuned to clients. If social workers notice their breathing is shallow and rapid, they may take a few deep inhalations and extend the exhale as they breathe out.

Internal sensory experience is a good gauge of what the nervous system is doing. It can alert social workers when they are moving into a state of fight-flight-freeze or shutting down into collapse. When we learn to track the energy of the nervous system and become aware of when it is revving up or shutting down, we can respond in ways that settle and maintain balance.

Research in the field of interpersonal neurobiology suggests that when people attune to one another, their nervous systems may even synchronize or entrain (van der Kolk, 2014).

As a profession, social workers prioritize empathy and the ability to tune into a client’s experience. But here’s the rub: When those clients are recalling traumatic experiences and struggling to manage intense feelings, their autonomic nervous systems tend to be highly activated. There’s a chance that the process of tuning in may elevate a social worker’s nervous system as well.

Knowing how to track one’s inward sensations and read the language of the nervous system can prevent such entanglements and keep social workers open and grounded, however physiologically activated a client might be (Dana, 2018).

Narrative Strategies
Staying grounded and self-aware is also rooted in the beliefs and stories social workers carry into the session room. What is my role? What am I responsible for? What am I not responsible for? If clinicians enter a session believing it’s their job to take away someone’s pain or to impress them with their competence, they will likely create a state of inner stress and be pulled out of the present moment.

On the other hand, if they enter trusting that a client, even one immobilized by depression or feelings of worthlessness, has reserves of strength and creativity with which to navigate adversity and move toward healing, they free themselves from such pressures and distractions and can focus on helping that client connect with those strengths. 

Each of us creates such a story, whether or not we’re conscious of it. The values, beliefs, and assumptions upon which these stories rest can help or hinder our ability to stay open, centered, and aware as we encounter clients such as Phoebe. By making the story conscious, we can ensure that it supports our ability to stay grounded and has the power to facilitate another’s healing.

Being with clients in deep pain who may be exhibiting troubling behaviors can also reveal other unconscious inner narratives that can undermine our inner equilibrium.

After my session with Phoebe, for example, I was shocked at the violent thoughts I’d had toward her perpetrator.

This awareness has proven invaluable to me with subsequent clients, especially when they’ve shared experiences that have evoked sadness or that violated deeply held values about how we should treat each other.

The more we can bring these stories, with all their unconscious patterns and assumptions, into our awareness, map them out, and defuse them, the more we will be able to stay grounded, avoid anxiety, and be focused with clients.

Being Open to Change
Every social worker will develop a personal set of resources that can be deployed when experiences with clients become intense. Continuing to thrive over the long haul, though, requires more than clinical skills and practices for grounding and self-care. We must be prepared for the work to change us in ways that we cannot predict.

By stepping toward, rather than away from, another’s pain, social workers’ perspectives will be jarred and their assumptions challenged.

Working with combat veterans, for example, may shatter a social worker’s beliefs about human goodness or the limits of what decent people will do in survival situations. Working with children victimized by sexual violence may challenge one’s ideas about fairness or alter long-held spiritual beliefs.

On the other hand, cultivating the ability to witness and intervene with the kind of fierce pain Phoebe was experiencing, whatever the personal risks and challenges, will also bring unexpected gifts. For me, one of the most precious of these gifts is confidence that beneath the surface of trauma, grief, and conflict, there is a life force within each client—a life force that remains vibrant and undiminished regardless of what horrors they have survived. If I can stay grounded and keep my heart open with empathy and compassion, that life force will emerge.

— Scott Janssen, MSW, LCSW, is a hospice social worker in Durham, NC, and member of the National Hospice and Palliative Care Organization’s trauma informed care work group.

References
Brach, T. (2012). True refuge: Finding peace and freedom in your own awakened heart. New York, NY: Bantam Books.

Dana, D. (2018). The polyvagal theory in therapy: Engaging the rhythm of regulation. New York, NY: W, W, Norton & Co.

Kabat-Zinn, J. (2005). Wherever you go, there you are. New York, NY: Hachette Books.

Levine, P. (2010). In an unspoken voice: How the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books.

Van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY: Viking.