Supporting Clinicians in Working with High-Stress Families

Many therapists find it challenging to work with children who have experienced trauma and families facing multiple stressors, high conflict, and systemic issues. These families can be difficult to engage, leading therapists to feel ineffective, and thereby contributing to overarching burnout. Consequently, the children who often need the most support sometimes go without it. 

But what if clinicians working with these vulnerable populations received more robust support, including ongoing group supervision and mentorship? Could this lead to better outcomes for both patients and providers? This is the question our guest, Sarah Cleary, Ph.D. (she/her), has been exploring at Denver Health, developing a variety of supervision experiences for trainees and staff over the past few years. Join us as we discuss how these support systems can make a difference. 

About our Guest:

Sarah Cleary, Ph.D. (she/her) is a Licensed Clinical Psychologist and AF-CBT In-House Trainer with the Child Mental Health Team, Outpatient Behavioral Health Services at Denver Health. She is also an Assistant Professor in the Department of Psychiatry at the University of Colorado School of Medicine.

Transcript

00:00:07:5 - 00:00:34:6
Unknown
Welcome and welcome back. This is Radio Kempe. I'm Kendall with the Kempe Center for the Prevention and Treatment of Child Abuse and Neglect. Thanks for being here. With all that's going on in our world, the work of serving kids and their families continues. Whatever your role in that work, you're pressing on. For many of us. That means treating and healing in the face of childhood trauma.

00:00:34:7 - 00:01:06:6
Unknown
Today, we're acknowledging that trauma may come from abuse or neglect, but it may also come from conflict and stress within a family. Are we prepared for that? Do we avoid that calamity at all cost? Or are we ready to help children, youth and families even when the family conflict threatens our sense of compassion and competence? We're lucky today to be with Sara Cleary of Denver Health.

00:01:06:7 - 00:01:40:0
Unknown
Sara, thanks for doing this. Have been with us all today. Hi. Thank you for having me. Our pleasure. Sara Cleary. You're a psychologist. Is that the right term? Yes, I'm a child psychologist. On the outpatient behavioral health team at Denver Health. Which is the safety net hospital for Denver, Colorado. And recently, I'm also an assistant professor in the department of psychiatry at the University of Colorado School of Medicine.

00:01:40:1 - 00:02:08:3
Unknown
How cool is that? So you've got a PhD. You've done all of that, that you've just described. You've got to be proud of your professional journey. But where did this start for you? Where were you and what happened to start Sara, on this path? Well, I feel like it probably started a lot earlier. Back then, I would have imagined that it did.

00:02:08:8 - 00:02:39:6
Unknown
Because this is actually a career change for me. But when I was four, my parents divorced, and I wouldn't say that it was an amicable divorce. I would say that there was a bit of contention there. To put it lightly. And that was a hard time in my family. And there was a lot of change for me being a young child.

00:02:40:2 - 00:03:23:1
Unknown
And kind of seeing how that impacted myself as well as my parents. I think was impactful. And that was something that I took with me. At the same time, I was also, as a child, very observant and kind of looking at how different members within the family had coped with different tragedies that had happened over time, and kind of recognizing that even though people could be in the same situation based upon their own personality and their own problem solving skills, they could be coping with the situation and really differently.

00:03:23:6 - 00:03:57:0
Unknown
And so that's when I kind of got interested in something called resilience, which is our ability to recover following the experience of adverse events. And so kind of like through this lens, I got really interested in the human experience, and I wanted to convey the human experience and how we portray it and why people do the things that they do and why they react the way that they react.

00:03:58:2 - 00:04:33:2
Unknown
Through the art of theater. So I was actually at theater major initially. I went to college for a theater at Northwestern University in Illinois. And I really love that space. But by the end of it, I kind of realized that it also wasn't a good fit for my personality in the long run. And I wanted to see if I can make more of a direct, positive impact on people's lives.

00:04:33:3 - 00:04:56:4
Unknown
That's a lot. That's a lot to have going on in your head when you're a little kid. Oh, that's that's that's an exceptional little kid. So you were seeing different family members react differently. And taking all that in. What was that like? Just talk a little bit about what that was like in your own head when you were little.

00:04:57:9 - 00:05:39:4
Unknown
Yeah. I would say, you know I've always been an observer. I've always had an instinct for watching people and kind of trying to understand their motives and like why things happen the way that they happen. Yeah. Even from an early age, which is interesting. So then, how did that play out once you started to realize that that was this was a career path for you, a kind of a sense of mission, it sounds like.

00:05:39:4 - 00:06:15:3
Unknown
Where did that lead you to do? Yeah, I think like, it was kind of a mission. I feel like I just kind of took life by the reins. I had been working in, university development at northwestern just to kind of, like, have a job and figure out what I wanted to do with my life. And I started taking night classes that I was able to take through the School of Continuing Studies at Northwestern, or really, favorably because I was working at the school.

00:06:15:9 - 00:06:45:8
Unknown
And so I took my first psychology class because that was something that I hadn't even done in college at all. And I'm actually still in touch with the person who was my professor from that class. And we have become, like, friends and acquaintances over the years. Because that class was so impactful for me. And I just like, take the ball running.

00:06:46:5 - 00:07:18:8
Unknown
And since then, I really been able to focus on working with children and families who've experienced trauma and also working with families that are experiencing a high level of stress and conflict. And those are the families, as you mentioned, that a lot of clinicians shy away from working with because it is so difficult and there's so much emotion that holds in those cases.

00:07:19:8 - 00:07:46:7
Unknown
That I think it does create a high level of burnout for clinicians, and that's why it's hard to want to approach that work. But it's also such an important part of creating change for children and families. So take us inside some of those families, some of those scenarios. So this is not necessarily what we traditionally think of abuse or neglect.

00:07:46:8 - 00:08:17:9
Unknown
I mean, but all families have conflict all day, at least in some level. There's stress in a lot of lives. What kind of situations are you talking about here? Right. I mean, in some of the cases that I'm thinking about, it's just a situation where the child and parent are in completely different planet. And they could be talking about the same thing, but they're like shouting from different sides of the universe, and the message just isn't getting through.

00:08:18:1 - 00:08:54:1
Unknown
And so even though both people could be upset about the same thing, like they're not able to talk about it properly and what's going on with the with the parents in all of this or these all divorce cases or what's going on here. Now, that's a fairly I mean, a lot of the families that we work with that are in this situation, our divorce or our blended families, because that does lead itself to some level of contention, and disagreement.

00:08:54:1 - 00:09:31:1
Unknown
And oftentimes children being put in the middle. But sometimes we're working with families that have adopted children who may have been in a traumatic situation prior to coming into the family. And even though that was a long time ago, it's still impacting them. Sometimes we're working with families where there is a history of intimate partner violence. Sometimes we're working with families where there is a history of caregiver substance use, which we actually have a grant that we're working on right now to study looking at different evidence based treatments.

00:09:32:4 - 00:09:59:7
Unknown
With caregivers who've experienced substance use. So, yeah, there's a lot of different scenarios that could be at play. But I think being able to help families communicate better and to repair some sort of rift that occurred in the child parent relationship is really important to being able to impact lasting change. And the kids are in the middle of all that.

00:09:59:7 - 00:10:28:5
Unknown
Am I hearing that right? Yeah. Oftentimes, I mean, usually it's kind of like either they're they're they've witnessed the situation. They've been put intentionally in the middle of a situation or the events red themselves, sometimes in the middle of a situation because they feel like it's their job to kind of like keep the peace. And all of that can be really traumatic for kids.

00:10:28:5 - 00:10:55:6
Unknown
And if I could share some of my own experience. Sarah, I'm a card carrying member of the Red fight oldest children club. And, in my own family's life, to the extent that there was, there was a divorce and that kind of conflict that you're talking about. I was struck I'm still struck by how me and my sibs experienced it differently.

00:10:55:9 - 00:11:31:9
Unknown
Part of that was a huge part of that was personality. Maybe our our position in the family system and whatnot is that is is was it just my family or does that happen? Well, I think that's pretty common. And I think that kind of goes back to what I was talking about. Like, you know, depending on who you are as a person, the situation can impact you differently, even though you were all in the same situation, because everybody's different and everyone types of things differently.

00:11:32:7 - 00:12:02:2
Unknown
And so that's why, you know, oftentimes we're working with multiple kids within the same family. And each kid needs their own treatment, and the parents may receive treatment that's tailored to both kids because each kid is their own person. So you're working with kids and families and you're working with other clinicians who are attending to all of this.

00:12:02:3 - 00:12:43:0
Unknown
Can I, as a clinician, walk in with my standard skill set? The the approaches, you know, the intervention, so to speak, that I've been trained to to deliver. Can I walk in the door and handle this like I'd handle any other case and I'll be fine? Or is it different? And how? Well, I mean, there's kind of like treatment as usual, which would just be kind of like coming in with your standard skill set, and then there are evidence based treatments that specialize in particular areas, of treatment.

00:12:43:1 - 00:13:34:9
Unknown
So for example, I'm, I am a certified therapist in trauma focused magnet behavioral therapy or CBT, which is kind of like the gold standard for evidence based treatment for children and families who've experienced trauma. However, in that model, we're typically working with the non offending parent. The parent is like not a perpetrator of violence, where the child and parent have a fairly supportive relationship, but it may need some reparation for, a trauma that has occurred and when I was newly licensed, I found that I loved CBT.

00:13:34:9 - 00:14:00:0
Unknown
It's my first love of evidence based models. And I'm really passionate about it, but it's not always a good fit for a lot of the families that I'm working with, especially working in a safety net hospital where we see people with various systemic difficulties that are going on that are impacting them, and creating what I realized that when did you realize that?

00:14:00:0 - 00:14:36:0
Unknown
What was the moment where you realized this is different? I think there is one case that I had in particular that I had been working on where I was trying to do it with a girl, who had experienced familial sexual abuse. And, her mom as her supportive caregiver. And what I realized was there is so much contention in the relationship between the mom and the girl, in part because of things that had happened prior to that.

00:14:36:0 - 00:15:16:0
Unknown
And as a result of that and because of that, and I felt like this this model is just not the best fit for what this family needs at this point in time. And I had heard of this other model called alternatives for families attacking the behavioral therapy or at CBT. And I decided to go train in that, because that model was originally developed for working with parents with a history of physical abuse or harsh discipline, or childhood aggression.

00:15:16:1 - 00:16:05:6
Unknown
But it's also been applied in different contexts, such as families where there's a high level of conflict, the intense in, where there's a lot of arguing and hard feelings. It's also been applied working with families in the foster care system with intimate partner violence, and also, with caregiver substance use. So I was thinking, even though this is a population, that in some ways I feel like I was afraid to work with, and I was kind of saying even just yesterday after we attacked, I was saying to my resident that I'm supervising, at Denver Health that when there's something that we feel like we're not competent in, that's the thing that we

00:16:05:6 - 00:16:31:8
Unknown
need to approach because we don't want anything to hold us back, you know? So you're one of those run into the fire people embrace the uncertainty, embrace the challenge. I think that's just part of working in public health. Yeah. Cause you just never know what's going to come your way, and you have to be ready to approach anything.

00:16:31:8 - 00:17:01:0
Unknown
And so if there is an area that you feel uncomfortable working with, for example, on my internship, it was working with angry, disruptive behavior. A little boys. And so I was presented with the epitome of that presentation. And yeah, and that was an experience. But now I'm not afraid of it because I know that I can do it.

00:17:01:1 - 00:17:30:5
Unknown
And that's part of being a good therapist is being ready for whatever's thrown at you. So what about that? Talk to us about the experience of the clinicians there that you're referencing that fear. I mean, we're helpers, right? We're in the helping sessions. We want to help, and we work hard to feel like we're competent. And even if we're smart enough to realize we don't have all the answers, our job is more to help the client find their.

00:17:30:5 - 00:17:57:8
Unknown
It's there's even if we understand that, can it be a little unsettling when you're not sure you're helping, right. Yeah. And I think evidence based practice is helpful or at least I feel like it's helpful because it provides a roadmap for what we should be doing with people at any point in time. And so any time that we feel lost, we can be like, okay, well, this is what am I allowed to do?

00:17:57:9 - 00:18:23:7
Unknown
And so if I just try to get back on track, maybe that's what's going to help. And a lot of times it is what's helpful. But I think it's also helpful to have consultation when you're doing a model, not just when you're training in it, which I think that's the part where like the models provide training during like the first year that you're using the model.

00:18:23:8 - 00:18:58:5
Unknown
But I think that staff working with chronically high stress families really need ongoing support. And support, like professionally, but other support, like as a whole person to be able to continue doing this work. And that's something that not a lot of agencies provide for it. I think that self-care is kind of something that put on to the individual, like, you know, you're going to get burnt out.

00:18:58:5 - 00:19:26:1
Unknown
So you said, take care of yourselves and make sure you're going to bed on time and you're eating good, and you're going to a gym and you're doing yoga, you're doing deep breathing, and like, you should be doing all of that stuff or whatever it is that works for you, that you found is helpful. But I also think that it's helpful when organizations are willing to provide some of that support for their staff to.

00:19:26:2 - 00:19:52:5
Unknown
Because what we traditionally find is that in most community mental health settings, there's a high level of turnover, because staff are working with these chronically high stress families and no matter how much you're going to bed on time and how much you're going to the gym, at a certain point you feel overwhelmed.

00:19:52:6 - 00:20:17:4
Unknown
That's tough. It's I'm struck, too, by what you just said about it's that whole self-care thing is different for different people. I mean, we hear that all the time. I don't think you can go to a conference session in our field and, and, you know, fail to have anybody mention that. But what does that look like? And what if you don't like yoga or you're not big on it?

00:20:17:4 - 00:20:43:1
Unknown
My favorite is always scented candles. Sit down in your, you know, like the what if you know what if you made scented candles? How do I know that what I'm doing as a clinician is really self-care? Or where might it be counterproductive? Whatever it is that I do, how do I know? I guess maybe you're saying that's where the organization comes in.

00:20:43:1 - 00:21:16:4
Unknown
How do I know that my own self-care is actually helping me? Right. Well, I guess, you know, it's kind of like figuring out what things you enjoy. Like some people love skiing here in Colorado. I personally don't ski and I don't like the winter. But, you know, like, for me, like playing with my dogs or taking my dogs for, like, going for a drive and seeing nature, does things feel like they fill my tub?

00:21:16:5 - 00:21:46:3
Unknown
And so then when I get back to work, I'm a little bit more ready to face the challenges. But I also think that having support in the workplace is an essential part of, preventing burnout or clinicians. So part of what I'm doing, so I actually ended up getting certified in CBT because I felt so strongly about working with families.

00:21:46:3 - 00:22:21:7
Unknown
And then I also was able to become an in-house trainer in that model as well. So I'm able to provide training to the staff at Denver Health on that model, so that we can always have ongoing support. And I think that's really important. Part of what I've been doing is leading a team of therapists that are all trained in AC, DC, who are working to provide that model to families who have experienced, caregiver substance.

00:22:21:8 - 00:22:55:8
Unknown
AC is there a grant that we have through the foundation for our opioid response efforts? And we have a biweekly meeting where we talk about our cases, we can support each other on our cases. And it's not just me. I mean, I'm the one that has the quote unquote expertise. I guess, or the model, but to make sure that we're providing it to fidelity, but all of our therapists are very experienced and skilled.

00:22:56:9 - 00:23:26:5
Unknown
And we all provide support to each other, which I think is really helpful. And then every year I've also been able to train, our class of psychology residents in the model as well. And every time that we train new people in it, that means that in the future, there will be more people out there in the world who feel more equipped to work with high stress families.

00:23:26:5 - 00:24:00:2
Unknown
And I think that's important, too. So take us back to the model, because some of the folks who are listening to you are familiar with the model. They're probably familiar with multiple models that in some way relate to this, and they're able to instantly say, oh, she's one of those. She's doing that. I remember that, for us ordinary mortals, what's different about give us the name of that model one more time, and then what is different about this model?

00:24:00:3 - 00:24:35:1
Unknown
What's different than other social work or our, psychology related interventions that we might be familiar with? What's different? Okay. And it's called alternatives for families. A cognitive behavioral therapy or a FBT can you love acronyms? And oh, we do we do love those. But I think what's different well, so traditional family therapy kind of like puts everyone from the family in a room and they, interact.

00:24:35:1 - 00:25:04:9
Unknown
And some of them start tagging over each other and dismissing each other. And the therapist sees the dynamic and tries to, like, call it out and mediate the situation. When you're working with kids, I feel like that just contributes to a dynamic of them continuing to be put in the middle and continuing to hear their parents talk negatively about them in front of them, which is not really that helpful for the kid.

00:25:05:0 - 00:25:33:6
Unknown
And it may be cathartic for the parents at the time, but it doesn't, in my mind, ultimately lead to the change that we need to see. What's different about Abcde? T is that most of the treatment occurs separately. So in the very beginning, you meet briefly with the child and the caregiver is to kind of like, see what's going on and determine what needs to be worked upon.

00:25:33:6 - 00:26:13:4
Unknown
But from there on out until the very end of treatment, the first few phases of treatment happen with the child individually and let the parents individually. And I think that is somewhat unique in that most of the treatment has happened happening separately in dyads. And yeah, go ahead. The parents are learning all of the same skills with regard to emotion regulation and understanding how our thoughts impact our feelings and behaviors and what to do with, as the child is learning.

00:26:13:4 - 00:26:39:5
Unknown
And so they're able to see it from their own perspective, but also to help support it for the child as the child's trying to implement the skills at home. So I think that helps decrease some of the conflict that I don't want to have that in my therapy room. That's supposed to be a safe place for the patient, which is the child.

00:26:40:7 - 00:27:23:3
Unknown
And I don't feel like that's something I want to promote while I'm there. And so being able to provide the skills separately, I think helps provide a safe space for both parties. And then we eventually work. I'm bringing everyone back together and practicing the skills that we've learned. And it's really powerful that what's striking to me, what you just described, the way that yes, you're dealing with a group at the start, but then you're working individually so that they can express their own voice, their own needs in a safe space, and then come back together.

00:27:23:4 - 00:27:49:6
Unknown
It's striking how that is in some ways similar to how mediation is taught in family conflict cases where, yes, we all have to be together and kind of get it out all under the table, but then the mediator goes and works individually in a safer space just with them and the individual to say, so what do you need?

00:27:49:6 - 00:28:25:7
Unknown
What are you trying to do here? And then bring it back together. Interesting, interesting, interesting. So does it work? I think it works. I guess, again, it's not the best fit model for everybody, and it does take a long time. I would say to get to that point. And so because of that, sometimes there's a high dropout rate because people with motivation somewhere in the middle, but if they're feeling like if they're starting to see some progress in their own emotion regulation, they're starting to see some progress.

00:28:25:7 - 00:28:54:4
Unknown
And the kids regulation ability, but I feel like the parents are an essential part of the process because theoretically, adults should have more control over what's going on for them, and then they can help model that for the kids. So when parents are able to make progress, the kids make more progress. And I would guess that everybody makes more progress is they've God, Sarah Cleary is there, their psychologist.

00:28:54:4 - 00:29:24:6
Unknown
And I'm just saying, oh, you could given your insight into this, your experience with all this, what's your message to all of us? What's your call to action? If I am someone, whatever my role is, whatever the letters are after my name, and I'm working with kids and families who are in these high conflict, high stress kind of situations, what can I do?

00:29:24:6 - 00:29:57:3
Unknown
What is your vision for what I can do as an individual and what we can do as a society? Well, so I would say like find the thing that makes you uncomfortable because that's the thing that you probably need to focus more on. So I think we all as therapists have something that when we walk into a room we just feel like like I don't know if I feel equipped to handle this today.

00:29:58:3 - 00:30:33:9
Unknown
And whatever that is that's coming up the most for you. That's the thing that you probably would want to seek more training and supervision in so that you can feel more successful in that area, because when we feel ineffective, that contributes to burnout. So that would be the first part and then find either a training or a support group, like a supervision or a consultation group that could help approach that need so that you don't feel like you're alone and feeling that way.

00:30:33:9 - 00:31:13:3
Unknown
So for example, I've been surveying the residents that I've been working with over the last couple of years, to try to assess if what we're doing is effective. And so we found that at the beginning of the year, they had some trepidation about starting the model and working with families, in a challenging system. And then as the year goes on, they feel more confident, they feel more supported, and they have a sense of belonging within the group.

00:31:13:3 - 00:31:40:4
Unknown
And I think that contributes to also higher ratings of them feeling like they want to continue doing this work in the future, and hopefully they will. Beautiful as that. Thank you, Sarah Cleary. Thank you. Thank you. What a beautiful message. Both. You know, for us in our individual work, but also how we can support each other. Thank you.

00:31:40:4 - 00:31:53:5
Unknown
Thank you for that. And to our listeners, join us again soon and often. We'll be glad to have you. This has been Radio Kempe.