RURAL CLINICAL SOCIAL WORK PRACTICE:
SELF-CARE AND COMPASSION FATIGUE PREVENTION
by
Hanhy Park
B.S.W., Dalhousie University, 2015

PRACTICUM REPORT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENT FOR THE DEGREE OF
MASTER OF SOCIAL WORK

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
July 2018
© Hanhy Park, 2018

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ABSTRACT
The purpose of this report is to summarize my practicum experience at the Central
Miramichi Community Health Centre in Doaktown, New Brunswick. The Central Miramichi
Community Health Centre is the main healthcare facility in the area servicing the population of
Doaktown, Boiestown, and other surrounding rural areas. The rural location of the health centre
allowed me to experience rural social work practice as well as work within an interdisciplinary
team. This report outlines my expectations and goals within my practicum and how my learning
objectives were met through observation, discussion, and practice. In addition to creating an
environment to strengthen my social work skills, my practicum allowed me to understand the
difficulties and challenges that rural social workers face, such as compassion fatigue. This
experience allowed me to further examine and reflect upon issues of self-care and compassion
fatigue in social work and its implications for my future practice as a social worker.

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Abstract

TABLE OF CONTENTS

ii

Table of Contents

iii

Acknowledgments

v

Chapter One

Introduction
Central Miramichi Community Health Centre (CMCHC)
Client Population and Services Provided
Agency Structure and Mandate of Horizon Health Network
Central New Brunswick Academy (CNBA)

1
1
1
2
3

Chapter Two

Personal and Professional Location
Personal and Cultural Background
Educational Background
Theoretical Framework

5
5
7
8

Chapter Three

Literature Review
Mental Health
Clinical Social Work
Compassion Fatigue and Self-care
Post-Traumatic Stress Disorder (PTSD)
Symptoms of PTSD
Psychotherapy
Prescription Medications
Alternative Methods
Substance Use Disorder and Alcohol in the Context of PTSD
Rural Social Work
Definition
Culture Shock
Dual-Relationships

10
10
12
13
15
15
18
20
22
23
24
25
26
27

Chapter Four

Practicum Experience and Learnings
Learning Objectives
How Practicum Objectives Were Achieved
Observation
Discussion
Interdisciplinary Consultation
Case Examples
Jane
John
Reflection
Recordings
Self-Care and Compassion Fatigue
Rural Social Work Practice

30
30
32
32
35
37
38
39
41
44
44
46
48

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Chapter Five

References

Implication and Recommendation for Social Work Practice
51
Implication for Practice
52
Recommendations: Self-Care Policy on an Organizational Level 54
Conclusion
56
59

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ACKNOWLEDGEMENTS
I would like to acknowledge and thank the team at Central Miramichi Community Health
Centre, Boisetown Health Centre, and the Central New Brunswick Academy for their warmth
and kindness during my practicum. They all contributed to creating a great environment for
learning. I am incredibly grateful for my agency supervisor, Lynsey Norrad Wilson, who showed
me openness, understanding, dedication, kindness, and incredible knowledge which I will carry
forward in my future practice. I thank Audrey Cochrane for being an amazing source of
knowledge and for always willing to contribute to my learning throughout my academic career. I
would like to thank Joanna Pierce for being an incredible academic supervisor, being there for
me during every obstacle and accomplishment throughout my degree. Thank you Glen Schmidt
for being on my committee and being an amazing resource for me. Thank you to my friends and
colleagues who have been with me throughout this journey. Lastly, I would like to thank my
parents, Jaedong and Hyunkyung Park, for completely supporting me through every single life
decision and being my source of strength and resilience. Without your encouragement and love I
would not be where I am today, I dedicate this project to you both.

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Chapter 1: Introduction
The following report captures my experience of my practicum with Horizon Health
Network, which is one of two health authorities in New Brunswick that operates twelve hospitals
and over 100 medical clinics and facilities (Horizon Health Network, 2017a). I completed my
practicum at the Central Miramichi Community Health Centre while also working in other
collaborative agencies and locations. The following chapter will provide an overview of the
structure, mandate, and core mission of the Horizon Health Network while providing an
introduction of my main agency and its community.
Central Miramichi Community Health Centre
The Central Miramichi Community Health Centre (CMCHC) is a clinic located in
Doaktown, New Brunswick, that provides a wide variety of health services including: primary
health care, illness and injury prevention, community development services, and chronic disease
management (Horizon Health Network, 2017b). The clinic is staffed by one manager, one
doctor, one social worker, three nurse practitioners, seven nurses, one respiratory therapist, one
dietitian, four clerks, and other allied professionals who provide services from the clinic on a
regular basis. The nearest neighbouring health care providers are located a one-hour drive north
(Miramichi Regional Hospital) and a one-hour drive south (Dr. Everett Chalmers Regional
Hospital in Fredericton).
Client Population and Services Provided
There is a wide variety of services provided at CMCHC thanks to the diverse health care
team. The client issues are very widespread in this health centre and the social worker generally
works with clients who require support for anxiety, depression, general stress, grief, and
addiction issues. The centre has multiple programs and groups which are organized in

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consultation with the social worker, such as the methadone program, healthy baby clinics where
clients are offered post-partum depression screenings, and a breast cancer survivors group. The
social worker also engages with the Alzheimer society and often presents to the Memory Café
Group, which is a group for caregivers and Alzheimer patients where she administers the MiniMental State Examination (MMSE). In addition, the social worker provides services and delivers
presentations at other local schools, and in the community, on subjects such as illicit drugs,
assertive communication, conflict resolution, and healthy relationships. Other than social work
services, the clinic provides many other programs such as a weekly high-risk foot care clinic
(many service users being diabetic patients) and a monthly urology clinic.
Agency Structure and Mandate of Horizon Health Network
The Central Miramichi Community Health Centre is a community health care clinic that
works under the Horizon Health Network umbrella. The clinics and hospitals in New Brunswick
that work under this network all follow the same guidelines, mandate, policies, and procedures.
The importance of learning these guidelines was a crucial aspect of working within the clinic’s
scope.
The Horizon Health Network operates many hospitals and health centers all over New
Brunswick, Canada. Horizon Health Network’s mission statement is “helping people be healthy”
(Horizon Health Network, 2017b) and they achieve this result by providing a healthcare delivery
system that puts patients and clients at the center of care. Being a bilingual province, Horizon
Health Network ensures patients and clients can have access to healthcare in the language of
their choice, and multiple committees ensure that cross-cultural needs are met, including a
Francophone Liaison Committee and a First Nations Liaison Committee (Horizon Health
Network, 2017a). Their vision is to provide “Exceptional Care. Every Person. Every Day”

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(Horizon Health Network, 2017a) and the Horizon Health Network’s values are listed on their
website as follows:
We show empathy, compassion and respect.
We strive for excellence
We are all leaders, yet work as a team.
We act with integrity and are accountable
(Horizon Health Network, 2017a)
The mission, vision, and values, guide how all Horizon Health Network providers work
to serve patients and clients in a cohesive and team-oriented manner. They work cohesively to
provide patient and client care and work as an interdisciplinary, collaborative team (Horizon
Health Network 2017a).
Central New Brunswick Academy (CNBA)
One of my favourite parts of my practicum was my work at a local school. At the
beginning of my practicum, my supervisor invited me to join her for a day at the Central New
Brunswick Academy (CNBA), a school at which my supervisor had been consistently offering
on-site counselling for seven years. After one day of sitting in with her and the students, I
immediately knew I wanted to expand my practicum experience to include the school. CNBA
was established in 2010 by consolidating two high schools to create one large facility. Consisting
of 223 students in grades 6-12, CNBA is located at approximately the halfway point between
Boiestown and Doaktown (Central New Brunswick Academy, 2016). Anyone at the school can
refer a student to counselling services, and students often seek services on their own as the social
worker is at the school every Tuesday morning. Some of the common issues that students bring
forward are: depression, anxiety, bullying, and stress. It was instantly apparent that the access to

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the same social worker at the school on a regular basis for a long period of time is beneficial and
that this is an essential resource to the school. My supervisor had been a consistent resource for
the school since its opening, and there were other mental health services available to the
students. Due to the rurality of the school, many outside resources did not seem to be consistent
and this was the main challenge of integrating new services. The beginning of my practicum
lined up with the start of the Integrated Service Delivery (ISD) team and I was able to experience
and witness the integration of this new service. The ISD approach is a new collaborative method
bringing together multiple departments such as Education, Early Childhood Development, Social
Development, Health, Public Safety, school districts, and regional health authorities (New
Brunswick Canada, 2018a). Some services they provide include: direct assessment, intervention
and support services, case co-ordination, consultation, and training (New Brunswick Canada,
2018b).

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Chapter 2: Personal and Professional Location
The purpose of dedicating an entire chapter to define and describe my personal and
professional position is to explore my context of practice. It is important to identify and reflect
on our own positionality because it raises deep-rooted concerns and biases that may
unconsciously affect our practice. During my practicum, I found certain biases and assumptions
that I was not fully aware of until my reflection activities. I stayed in a position of not-knowing
and did my best to not let my biases and assumptions create any barriers between my clients and
myself. However, I realized through my practicum that without continuous reflection it is easy to
return to previous ways of thinking and let it affect my practice.
Personal and Cultural Background
I am an able-bodied woman and I recently joined the Canadian Armed Forces (CAF) as a
Social Work Officer (SWO). I immigrated to Canada at six years old and returned to South
Korea for a year in grade six but have lived in Canada for the majority of my life. I moved within
Canada many times, and I will likely continue moving frequently as a result of joining the CAF.
Upon reflection, I realized that I struggled with my cultural identity and became very
accustomed to moving frequently at a young age. Consequently, I believe I developed the
tendency to easily disconnect from others, which is both helpful and hindering in my
professional and personal identity.
I am a feminist, structural, and clinical social worker, with a passion for advocating for
those with mental health issues. Because of my cultural and professional identity, I have
assumptions surrounding every aspect of life which I work on reshaping on a daily basis. Being a
former military spouse, I thought that I would naturally be more empathetic towards other
spouses who are going through difficulties and feel more connected with them. However, in my

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practicum during my Bachelor of Social Work, I found that when military spouses confided in
me about their issues I would often have thoughts like “well I’ve been through that too and I was
fine”. When I became conscious of these thoughts, I was alarmed by my lack of empathy and
reflected on where my thoughts were coming from. The thoughts weren’t extremely prominent
but they were enough for me to doubt the hardships that the women were feeling, and I realized
this may influence my practice. It is important to stay self-aware and unpack the different biases
I might hold unconsciously throughout my entire practicum and future practice.
Due to my mix of backgrounds, I identify my culture as an eclectic collection of all my
experiences. Chang (2008) states, “the concept of culture is inherently group-oriented, because
culture results from human interactions with each other” (p. 16-17). When looking at this
definition of culture, it is evident that I have had a very wide variety of human interactions. I
have had close friends that grew up not knowing when their next meal was going to be, and I
have shared a dorm with individuals who grew up extremely wealthy. I grew up speaking Korean
to my parents while at the same time shedding myself from certain aspects of Korean culture. In
my teenage years, I shared a boarding house with fifty other girls, the majority of whom were
white, and I adapted in order to fit in. As a young adult, I moved to the other side of the country
and adapted to the military lifestyle. These diverse and collective experiences have shaped and
shifted my values and ways of thinking so much that it is hard to identify exactly ‘where I come
from’. Throughout my social work path, I found that I needed to consciously make the effort to
remind myself that a diverse background does not mean disarray, but it means I have multiple
experiences to draw from.
Acknowledging my own assumptions is a crucial and difficult part of social work, and
assumptions and values are complicated to unpack. I grew up in a smaller town, around friends

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with parents who struggled financially, then attended a boarding school surrounded by students
with extremely wealthy parents. Reflecting on these two contrasting experiences, I believe that if
I had never attended boarding school, I would assume that wealthy individuals are spoiled,
unappreciative, and entitled. On the other hand, if I had never gone to my first school in a small
town I may have grown up assuming that everyone has the same opportunities and experiences
during high school. I must continue to explore and unpack my assumptions and remember that
all experiences are different.
Educational Background
I decided to major in sociology in my second year at Queen’s University in Kingston,
Ontario, before taking a year off to work and volunteer while contemplating my future plans.
During my year off from full-time studies I enrolled in the online introductory social work
course through Thompson Rivers University (TRU) for an opportunity to gain an introduction to
social work. After realizing that social work was the field I wanted to pursue, I transferred to
Dalhousie University in Halifax, Nova Scotia and completed the remainder of my undergraduate
degree via online distance education while residing in New Brunswick. My sociology education
was brief, as the first year was spent taking multiple courses, but the one year of intensive
sociology knowledge helped aid my decision to redirect my time towards social work. Reading
Anne Bishop’s (2002) Becoming an Ally in my TRU course had an enormous impact on my
decision, as the notions of intersectionality, oppression, and power, resonated deeply.
For my undergraduate practicum, I completed an eight-month, 760-hour practicum at a
private counselling agency which began the development of my professional social work
practice. During my practicum, I had the opportunity to provide individual counselling to
children, adults, couples, and youth for a variety of personal issues. I took two additional

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training courses at Dalhousie University which were offered by the continuing education
department on counselling skills which further developed my skill set. This experience initiated
the development of my professional identity and I was able to develop a foundation to further
build my clinical counselling skills.
Theoretical Framework
Currently, I consider myself as working from an anti-oppressive and feminist theoretical
framework, utilizing solution-focused methods. However, I believe that my social work
framework is constantly changing and evolving as I change and learn as an individual.
Payne (2014) defines anti-oppressive practice as combating the oppressive effects of
discrimination by privileged and powerful groups while working toward social equality. I have
experienced and witnessed injustice and social inequity throughout my life in Canada and in
South Korea, and this aspect of my experience is what causes anti-oppressive practice to resonate
on a personal level. Berzoff and Drisko (2015) state that mental health settings have moved away
from using developmental theories and how people develop within oppressive social structures
and moved towards a neurobiological focus. The process of being aware of, and acknowledging
racial and cultural biases, is crucial for anyone to become culturally competent and to practice in
an anti-oppressive manner.
Feminist practice has several different perspectives such as radical, socialist, black, and
postmodern feminism (Payne, 2014). For my practice, feminist practice means working towards
equality between women and men while being conscious of the societal systems and norms that
are in place that create oppression for women. For example, as a woman, I have spent the
majority of my life not understanding the concept of victim-blaming and have been guilty of
victim-blaming in certain situations prior to my social work degree. It is important to be

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cognizant of these biases and assumptions and work towards a framework that includes feminist
values.
The solution-focused and strengths-based aspect of my framework can be defined as a
practice that looks forward while amplifying strengths in clients’ lives (Payne, 2014). I wish to
bring this theoretical framework into my social work practice and utilize the positive approach of
highlighting strengths. However, there are some issues surrounding strengths-based work, as
being positive does not always recognize the reality of the client if they are experiencing
difficulty (Payne, 2014).
My personal and professional experiences have shaped my perspective and influenced
my framework of social work practice. My personal and professional experiences all combine to
create who I am today. Who I am may change over time, but it is important to remember to be
mindful of my biases and assumptions while practicing social work.

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Chapter 3: Literature Review
My clinical practicum provided me with a diverse experience to build my practice on,
and the following literature aided in gaining deeper insight of the experiences of my clients and
will assist in my future practice as a social worker. This literature review creates a solid
foundation of understanding of mental health, Post-Traumatic Stress Disorder (PTSD), and rural
social work.
Mental Health
Mental health issues and mental illness have an overwhelming effect on society and
human existence (Epp, 1988). Definitions and treatment methods are continuously evolving and
it is crucial to keep up with changes and be aware of the history of mental health.
According to Armitage (2005), mental health services include large mental health
hospitals, independent medical practitioners, community-based mental health clinics, psychiatric
wards within acute-care general hospitals, and independent services provided by larger
organizations, such as the Canadian Mental Health Association. In the past and present,
institutionalizing individuals with mental illness causes more stigma towards mental illness. This
stigma prevents society from speaking about mental health issues and perpetuates a cycle of
stigma and silence. Armitage (2005) states in all of Canada’s provinces, that major mental
hospitals have been closed and mental illness treatment is provided within the community. This
change was caused by the demands of parents and support groups for more accessible services,
concern for civil rights of those who are institutionalized, cost considerations, and the
availability of new forms of drugs and treatment (Armitage, 2005). Furthermore, Levine (2015)
states that the transition of mental health care from hospitals to communities began “with the
1961 report of the Joint Commission on Mental Health [… and] the report was the impetus for

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President John F. Kennedy’s address […] for the Community Mental Health Act passed [in
1963]” (p. S22). According to Levine (2015), in the period immediately after World War II in
1946, the Department of Veterans Affairs made great efforts to train more psychologists,
psychiatrists, and social workers, to serve a large number of veterans returning home which
created a large influx of mental health professionals. Due to this overarching objective, many of
the mental health professionals in psychiatry, psychology, and social work, had a very specific
area of expertise in treating mostly veterans who were adult men, and had little experience
working with children, women, or the elderly (Levine, 2015). This piece of history is particularly
interesting to me, as it brings to light the issues professionals face when they are too focused on
one specific area because of the population they serve. Upon reflection, it is even more evident
that I must do my best to branch out from my personal interests and try to gain as much diverse
social work experience as I possibly can during my practicum.
According to Epp (1988), defining mental health and agreeing on a broad
conceptualization of the term is crucial because mental health affects every individual of society.
Epp also explains that mental health has been viewed as the absence of mental disorder and past
definitions of mental health were focused on “the psychological and behavioural characteristics
of individual people rather than on conditions in society as a whole” (1988, p. 332). For the
context of my practicum, I will be utilizing Epp’s definition of mental health as follows:
Mental health is the capacity of the individual, the group and the environment to interact
with one another in ways that promote subjective well-being, the optimal development
and use of mental abilities (cognitive, affective and relational), the achievement of
individual and collective goals consistent with justice and the attainment and preservation
of conditions of fundamental equality. (1988, p. 333)

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This definition along with the notion that mental disorder is a single factor of an individual’s
overall mental health and not the only determining factor of mental wellness will set the
foundation for my future work in mental health.
Clinical Social Work
Clinical social work utilizes a diverse knowledge base that includes biopsychosocial
development, interpersonal relationships, environmental determinants, clinical methods,
prevention, cultural and racial awareness, socially structured oppression, and strengths-based
work (Berzoff & Drisko, 2015). Clinical social work draws upon different types of empirical
research as well as multiple theories of human research (Berzoff & Drisko, 2015). Furthermore,
clinical social work is commonly known as work involving individuals, families, and groups, and
the term is designed to unite the diversity found within practice (Munson, 1993). The term
clinical social work is constantly evolving. Munson (1993) defined clinical social work as
“organized efforts by graduates of accredited schools of social work to assist people to overcome
physical, financial, social, or psychological disruptions in functioning through individual, group,
or family intervention methods” (p. 10). The key to Munson’s definition is that clinical social
work assists members of society in multiple facets and in many aspects of life’s difficulties.
The National Association of Social Workers (NASW) officially recognized clinical social
work as a specialization in 1976 and determined that clinical work requires a master’s degree in
social work as well as two years of supervised clinical experience (Karpetis, 2014). This official
recognition was granted eight years after clinical social work was introduced in the United States
of America by social workers who felt client problems were more complex than social and
environmental factors (Karpetis, 2014). However, according to Karpetis (2014), the definitions

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of the term clinical social work still have many discrepancies and these multiple definitions
result in a professional divide.
Due to the flexibility of the social work profession, it can be hard to exactly define what
clinical social work means. For example, some authors highly support evidence-based practice
and consider it to be essential for developing and maintaining clinical social work practice
(McNeece & Thyer, 2004). Conversely, other authors such as Werkmeister Rozas and Grady
(2011) believe that evidence-based practice strengthens the social work profession but highlights
potential limitations when exclusively utilizing evidence-based practice and promotes a more
integrative approach. As social workers, we must remember to define our practice and be
transparent about our framework.
Compassion Fatigue and Self-Care
Many authors cite Charles Figley’s work from over two decades ago when writing on
compassion fatigue. According to Figley, compassion fatigue is the feeling of confusion and
helplessness in caregivers and the term can be interchanged with secondary traumatic stress (as
cited by Harms & Pierce, 2011, p. 95). Figley also highlights that compassion fatigue reduces the
caregiver’s capacity to be empathetic (as cited by Adams, Boscarino, Figley, 2006, p. 103).
McCann and Pearlman believe that in order for effective social work practice, social workers
must utilize compassion and empathy to build rapport (as cited by Radey & Figley, 2007, p.
207). Figley suggests that the feeling of disconnection from others and hopelessness stem from
taking on clients’ problems causing mental, emotional, and physical exhaustion (as cited by
Radey & Figley, 2007, p. 207).
Figley (2002), created a model to predict compassion fatigue as well as identify specific
components that can help prevent compassion fatigue. This model includes nine variables

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identified that range between the exposure to client and compassion fatigue which forms a casual
model of compassion fatigue (Figley, 2002). The variables shown in the model are: exposure to
client, empathetic concern, empathetic ability, empathic response, disengagement, satisfaction,
residual compassion stress, prolonged exposure, traumatic memories, degree of life disruptions,
and compassion fatigue (Figley, 2002, p. 1437). Residual compassion stress is a result of
“emotional energy from the empathic response to the client and is the on-going demand for
action to relieve the suffering of a client” (Figley, 2002, p. 1437). According to Figley (2002), a
sense of achievement or satisfaction and disengagement are two ways to lower compassion stress
and prevent compassion fatigue. A common factor of both disengagement and satisfaction is the
requirement of a conscious and rational effort (Figley, 2002). A sense of achievement and
satisfaction of service delivery requires a conscious effort by the service provider to recognize
where their responsibilities end and the client’s responsibility starts (Figley, 2002). Similarly,
disengagement occurs when the service provider consciously makes an effort to distance
themselves from the client (Figley, 2002). Radey and Figley (2007) believe that social workers
should not only attempt to avoid compassion fatigue, and instead attempt to seek fulfilment
through our work and handle energy from compassion stress to transform into a sense of
flourishing.
Self-care is a common term used to identify a way to combat compassion stress and
compassion fatigue. According to Harms and Pierce (2011), self-care skills are essential for
social workers and it is important to identify and reflect on the differences of personal self-care
and professional self-care. Professional self-care is addressing workplace stressors and gaining
support while personal self-care is participating in activities outside of work to address stress
(Harms & Pierce, 2011). Radey and Figley (2007) state that although there is little empirical

15
literature on the role of self-care on the overall well-being of social workers, they believe it
simply makes sense to take care of ourselves in order to help others.
Interestingly, a study conducted by Killian (2008) showed that there is no evidence
demonstrating a correlation between coping strategies and reported levels of compassion stress,
fatigue, and burnout. Results of the study showed that many therapists thought self-care was
important, but they did not get enough clinical training or professional development in that area
(Killian, 2008). The findings of this study also supported previous findings, which showed that
individuals are not allotting enough time to self-care while aware of its necessity (Killian, 2008).
These findings can help us understand that it is not a mere absence of knowledge or awareness of
self-care; it is also the lack of behaviours and action.
Post-Traumatic Stress Disorder (PTSD)
Much of the literature on PTSD focuses on combat-related PTSD. However, there are
many other cases of PTSD that are not combat related in both military and civilian settings. With
a wide range of causes and treatment, it is important to have a good understanding of PTSD.
Symptoms of Post-Traumatic Stress Disorder
Symptom relief seems to be a common theme among studies on PTSD. The first priority
is seen as resolving symptoms that we can easily see and identify in order for a veteran to heal.
According to the DSM-5, the diagnostic criteria of PTSD are summarized as: exposure to a
stressor, intrusion symptoms, avoidance of stimuli, negative alterations in cognitions and mood,
alternations in arousal and reactivity, duration of the disturbance, clinical significance of
disturbance, and the disturbance is not a result of substance use or other medical conditions
(American Psychiatric Association, 2013, p. 271-272). The main symptoms of PTSD are
intrusive thoughts or images, sleep disturbances, nightmares, dissociative flashbacks, poor

16
concentration, or severe distress on reminders (Creamer, Wade, Fletcher, & Forbes, 2011).
Creamer, Wade, Fletcher and Forbes also note the overlapping of symptoms between PTSD,
depression, and generalized anxiety, and acknowledge the issue of possible comorbidity.
Sleep disturbances such as nightmares or insomnia are some of the biggest issues that
individuals with PTSD experience. Pruiksma et al. (2016) found that insomnia was the most
prevalent and persistent problem among those receiving treatment for PTSD and emphasized the
importance of focusing treatment towards better sleep patterns. Insomnia was the most prevalent
lingering symptom after receiving treatment; whereas, nightmares and other symptoms were
shown to decrease (Pruiksma et al., 2016). According to Van der Kolk (2015), our body is
interconnected and fundamental functions such as sleeping, eating, bowel movements, and
breathing, are crucial in maintaining mental balance. In addition to experiencing a lack of
balance, sleep deprivation can cause impairment to the “medial prefrontal cortex of the brain,
which then causes our limbic system to take over and rational thinking [becomes] diminished”
(Hoge, 2010, p. 57). In the context of combat-PTSD, sleep deprivation is used as a tool in
combination with being in a combat zone (Hoge, 2010). When a person is working in a combat
zone and is sleep deprived, it causes physical changes in their body that create stress hormones,
adrenaline, and the body becomes hyper-alert, which is ideal in combat (Hoge, 2010). However,
when soldiers fail to decompress, their heightened state becomes harmful and unsuitable for noncombat environments (Hoge, 2010). Not only does hyper-alertness create dissonance in their
environment, it also causes imbalance in their fundamental functions such as proper sleep cycles
and digestion (Hoge, 2010).
According to Van der Kolk (2015), individuals with PTSD have physiological symptoms
which become engrained in their body. According to Van der Kolk’s examples, some individuals

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do not remember the trauma they experienced as a child, but their bodies still react as if they
were traumatized recently (2015). Van der Kolk (2015) conducted scans of the brain recalling
traumatic incidents and found that other than the expected areas such as the limbic area and
amygdala, Broca’s area in the left frontal lobe was also affected. The scans showed that there
were significant decreases in that area of the brain that were similar to the brains of stroke
victims (Van der Kolk, 2015). These scans gave answers to why traumatized people have such a
hard time speaking about their experiences, and why after years of living with the memories they
still have tremendous difficulty talking about it (Van der Kolk, 2015). In addition to affecting
Broca’s area, scans from other individuals who have been traumatized revealed a breakdown in
the right and left thalamus during flashbacks (Van der Kolk, 2015). This breakdown explains
why individuals remember traumatic incidents as “isolated sensory imprints: images, sounds, and
physical sensations” (Van der Kolk, 2015, p. 70) rather than being remembered as a full story
with a beginning, middle, and end.
The results of the scans are a good example of why post-traumatic stress disorder should
be re-named Post-Traumatic Stress Injury (PTSI). According to Keynan and Keynan (2016),
changing the term to PTSI from PTSD would make combat veterans eligible for the Purple Heart
in the U.S., and help deconstruct the existing stigma that surrounds PTSD. Keynan and Keynan’s
notion is that changing the term will help begin to eliminate the stigma surrounding PTSD
(2016). If the term PTSD was reconstructed to PTSI, it would be perceived as a combat injury
and not a disorder, and veterans and current serving members might be more likely to seek help
and feel less ashamed to admit they need support. I believe that mental illness should always be
treated like a physical illness. The physiological effects of trauma go beyond memories and leave
behind a mark that can be felt every day.

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There are many different avenues of treatment available to individuals with PTSD such as
counselling, psychotherapy, use of prescription medication, use of marijuana, and alternative
methods of therapy. Korn (2009) highlighted mindfulness, self-soothing, distancing,
containment, grounding, emotion regulation, interpersonal effectiveness, and cognitive self-talk
as some of the fundamental coping skills that individuals with PTSD need to develop.
Psychotherapy
In the literature, it was evident that many authors agreed upon the notion that individuals
with PTSD do not seek treatment. Fikretoglu, Brunet, Guay, and Pedlar (2007) found that twothirds of veterans with PTSD sought mental health treatment and that only 50% reported
continuing to seek treatment after their first appointment. This study supported previous findings
that showed one-third of civilians and military members with PTSD seek any type of mental
health treatment and found that military members sought treatment in the military health setting
(Fikretoglu, Brunet, Guay, & Pedlar, 2007).
Many forms and methods of psychotherapy utilize evidence-based therapies. Cognitive
Behavioural Therapy (CBT), Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) and
Eye Movement Desensitization and Reprocessing (EMDR) are the most common forms of
psychotherapy used and involve a combination of exposure therapy, analysis of thinking
patterns, and body relaxation techniques (Hoge, 2010).
Cognitive behavioural therapy (CBT) can be defined as focusing on the interaction of
behavioural, emotional, and cognitive responses, that characterize mental disorders (Williams &
Bernstein, 2011). In addition, the basic premise of CBT when working with trauma is that it is
generally assumed that telling the story of the trauma in great detail will help people leave it
behind (Van der Kolk, 2015). Furthermore, Van der Kolk (2015) describes the preference of

19
CBT in trauma counselling among academics to be because behavioural treatment can be broken
down into steps and manual protocols. Cognitive Behavioral Therapy in the context of the
military would consist of focusing on helping veterans become more aware of thoughts and
beliefs that trigger feelings of guilt (Beder, 2012). Through self-monitoring and assistance from
the therapist, the hope is that veterans are able to realize that the traumatic event was completely
out of their control (Beder, 2012). In addition to reducing guilt, cognitive-behavioral therapy
may also help increase self-compassion and acceptance (Beder, 2012). Behavioural work is
frequently used to treat trauma, and trauma-focused definitions have been created to specify this
line of work.
Trauma-focused Cognitive Behavioural Therapy (TF-CBT) can be defined as assisting
the person to confront their traumatic memories, as well as external situations that remind them
of their trauma that they fear or avoid (Forces et al., as cited by Creamer, Wade, Fletcher, &
Forbes, 2011). This form of therapy attempts to address interpretations and beliefs about these
situations that may be interfering with recovery, and the strongest evidence within TF-CBT
includes prolonged exposure and cognitive processing therapy (Creamer, Wade, Fletcher, &
Forbes, 2011). The idea behind prolonged exposure is that if victims of trauma are repeatedly
exposed to the stimulus and the bad things they imagine will happen do not occur, they will
gradually become less upset every time the stimulus is presented (Van der Kolk, 2015).
Regardless, exposure sometimes helps deal with fear and anxiety, but it has not been proven to
help with the complex emotions of PTSD (Van der Kolk, 2015).
Lastly, EMDR includes exposure components and works by enhancing the process of
trauma memory with new connections that have positive associations with the memory (Beder,
2012). Hoge (2010) believes the exposure component of EMDR is simply effective because the

20
combat veteran is telling their story and the eye movements might not be necessary. Previously,
Albright and Thyer (2009) found that EMDR might have too little empirical evidence to be
offered as a method of treatment for military members with PTSD. Since the review was
published in 2009, other authors seem to agree that EMDR is an effective and popular method of
therapy for PTSD in combat veterans. Van der Kolk (2015) describes PTSD as a memory that
has failed the process of integrating into our life events and remains stuck, undigested, raw, and
has a life of its own. Therefore, EMDR can be successful as it helps integrate the traumatic
material as we would with regular memories (Van der Kolk, 2015). According to Wesson and
Gould (2009), EMDR can be more beneficial in combat PTSD when it is used as an early
intervention technique while soldiers are still in combat zones. In some cases, EMDR proved to
be more successful than Prozac when treating individuals with PTSD who also suffer from
depression (Van der Kolk, 2015).
Prescription Medications
Individuals may have preconceived notions and feelings about using medication as
treatment from hearing others’ experiences and their own past experiences. The stigma that
exists around prescription medication ranges from the perception of appearing weak or being
seen as an addict and many clients are fearful of adverse side effects (Cigrang et al., 2011).
The use of prescription medications when treating PTSD is generally for sleep assistance
to subdue insomnia and nightmares. Traumatized individuals generally prefer benzodiazepines
such as Klonopin, Valium, Xanax, and Ativan, which have a calming and soothing effect (Van
der Kolk, 2015, p. 227). According to Van der Kolk (2015), prescription medication only
dampens the experience of trauma temporarily without “curing” trauma and prescription
medication does not teach self-regulation. Other authors agree that medications did not seem to

21
help with insomnia or nightmares, and cognitive-behavioural approaches may be more effective
in providing lasting changes (Pruiksma et al., 2016). Although medications are not a permanent
solution and psychotherapies may be a better lasting option, medications can help with
immediate issues and provide relief for individuals. Even if that relief is short term, those
interventions may be crucial in keeping individuals from giving up on treatment.
Medical marijuana is a common topic in today’s society. Many states in the United States
of America are legalizing medical marijuana and the number of supporters is growing for the
legalization of recreational marijuana. Currently, all of Canada has legalized medicinal
marijuana, and the legislation of the legalization of recreational marijuana has received final
approval and will come into full effect on October 17, 2018 (Tasker, 2018). Medical marijuana is
now commonly used to treat PTSD, and marijuana-related businesses are thriving. Medical
marijuana is also sought out by patients suffering from other conditions such as chronic pain, and
a study found that 23% of first-time medical marijuana seekers tested positive for PTSD
(Bohnert et al., 2014). Similar to prescription medication, medical marijuana is commonly used
as a sleeping aid for veterans with PTSD. According to Bonn-Miller, Babson, and Vandrey
(2014), this may cause long-term issues because cannabis users may develop a tolerance to the
sleep-inducing effects, causing a higher frequency of cannabis use.
Coping-oriented use of marijuana is discouraged by some authors because the sudden
discontinuation of medical marijuana can be problematic (Bonn-Miller, Babson, Vujanovic, &
Feldner, 2010). Bohnert et al. (2014) found that the positive PTSD group had higher percentages
of previous prescription opioid use of 55% and prescription sedative use of 41% compared to the
non-PTSD group in first-time medical cannabis users. Therefore, many individuals who turn to
medical marijuana have likely already tried prescription medications. According to Jobe-Shields,

22
Flanagan, Killeen, and Back (2015) having children residing in the home is associated with
higher use of marijuana and higher symptom severity in veterans with PTSD. This shows that
there are more factors to explore and analyze before concluding that all individuals who use
marijuana become dependent users or high-frequency users.
Alternative Methods
Hoge (2010) provides a list of Complementary and Alternative Medicines (CAM) which
include drugs such as MDMA as well as non-medication treatments such as neurofeedback,
dance therapy, massage, Reiki, herbal supplements, yoga, and pet therapy. It is interesting and
encouraging to see prescription medications that are commonly seen as problem-causing to be
repurposed for positive treatment use and listed in the same category as other forms of therapy
with positive reputations.
Bensimon, Amir, and Wolf (2008), conducted a study presenting a music therapy group
with six soldiers diagnosed as suffering from combat or terror-related PTSD. Data were collected
from digital cameras which filmed the sessions, open-ended in-depth interviews, and a selfreport of the therapist. Results showed that some reduction in PTSD symptoms was observed
after drumming, and participants felt an increased sense of openness, togetherness, belonging,
sharing, closeness, connectedness, and intimacy (Bensimon, Amir, & Wolf, 2008).
Consequently, the music therapy group achieved a non-intimidating access to traumatic
memories, facilitating an outlet for rage, and regaining a sense of self-control (Bensimon, Amir,
& Wolf, 2008).
The reason behind the success of music therapy with individuals with PTSD is based on
the nature of how traumatic memories are presented as flashbacks and nightmares rather than one
continuous story (Bensimon, Amir, & Wolf, 2008). Traumatic memories are stored in a primitive

23
and visual way, presenting in the form of fragments whenever they are stimulated by a similar
sensory input (Bensimon, Amir, & Wolf, 2008). Due to the nature of how traumatic memories
are stored and presented, it is difficult for individuals diagnosed with PTSD to translate their
emotions or memories into words, and creative acts such as drumming can assist in creating a
detour to access them in a non-invasive and non-intimidating manner (Bensimon, Amir, & Wolf,
2008).
Similar to music therapy, art therapy has similar reasons behind its success. Avoidance is
a key feature of PTSD, and art therapy assists in overcoming this by creating a non-threatening
environment to tune into the trauma memory (Lande, Tarpley, Francis, & Boucher, 2010). By
tapping into a person’s nonverbal work through the use of various symbols that are used in
artistry, it provides an opportunity for participants to express their personal thoughts and feelings
through a pictorial depiction (Lande, Tarpley, Francis, & Boucher, 2010).
Many animals can play a significant role in animal-assisted therapy. Stern et al., (2013)
conducted a study looking at the beneficial effect of living with an animal. They found that
respondents indicated that they experienced improvements in several areas including feeling
calmer, less lonely, and less depressed since adopting an animal into their home (Stern et al.,
2013). The results of this study suggest that living with any animal, regardless of their training
certification, may help relieve some forms of psychological distress that are associated with
PTSD (Stern et al., 2013).
Substance Use Disorder and Alcohol in the Context of PTSD
In the context of combat PTSD, alcohol misuse is likely the most common form of
Substance Use Disorder (SUD) that combat veterans exhibit. Research indicates that 50% of men
with PTSD reported alcohol misuse or dependence, and 63% of Operation Iraqi Freedom (OIF)

24
and Operation Enduring Freedom (OEF) veterans with alcohol use disorder meet the criteria for
PTSD (Angkaw et al., 2015). Alcohol misuse can be a consequence of attempting to selfmedicate through excessive substance use to cope with symptoms of PTSD (Jobe-Shields,
Flanagan, Killeen, & Back, 2015). Other substances are also commonly used by combat veterans
with PTSD such as marijuana and cocaine. Marijuana is used to deal with insomnia and to numb
anxiety while cocaine may appeal to those who want to relieve depression, hypomania, and
hyperactivity (Beder, 2012). As previously mentioned, the history of substance use disorders
with marijuana and illegal drugs created obstacles for research and experimentation with using
these drugs for PTSD treatment. The stigmatizing notion that addiction and misuse are inevitable
when using illegal drugs is what deters those who may benefit from them. It is crucial that
research done on the long-term effects of substances such as marijuana and MDMA stay
unprejudiced and be conducted without any predetermined negative beliefs. Like any other
research, studies and researchers must stay unprejudiced in order to truly determine the benefits
and disadvantages of repurposing illicit substances.
Rural Social Work
In preparation for my practicum, the rural component of my experience was overlooked
by my focus on mental health and interest in PTSD. Once beginning my practicum, I quickly
realized the significance of rural social work practice ideologies and theories within my ongoing
practice. The knowledge on rural, remote, and northern social work practice that I gained
through the University of Northern British Columbia proved to be extremely beneficial as a
foundation of understanding while I was immersed in rural practice.

25
Definition
Defining the term rural is important for one main reason: context. Without clarifying the
definition of rurality, notions may be misinterpreted. The term rural is not consistent throughout
the practice of social work because there is an unclear definition of what defines communities as
rural and non-rural (Cooper, Streeter, & Scales, 2013). This is similar with the concept of ‘north’
in social work practice (Schmidt, 2000). With many definitions of rural existing in
environmental and economic contexts, social work is much more complex and requires a
multidimensional framework (Cooper, Streeter, & Scales, 2013). According to Cooper, Streeter,
and Scales (2013) moving away from a rural-urban dichotomy and asking the residents if they
think of themselves as a rural community will help us develop a framework that is more
behaviorally based. This notion is incredibly useful because it is shifting the focus from the
physical environment while redirecting the decision power to the residents and utilizing a more
client-based approach. Cooper, Streeter, and Scales (2013) introduce a multisystem model that
combines the person-in-environment and systems-based perspective and they believe that the
interactions between different systems are important for reflecting the complexity of rural
people.
Similarly, Zapf (2009) describes an alternative term for person-in-environment as the
expression is fundamentally an ecological term used to represent the relationships between the
person and the social environment. Zapf (2009) suggests that we use the term ‘people as place’
which is a phrase that conveys unity and holism (p. 39). Zapf (2009) argues that the physical
environment is often forgotten in social work, and social workers tend to focus on social
environment as the integral portion of an individual’s life. The grammatical structure and
vocabulary used in ‘person-in-environment’ shows that the ‘person’ and ‘environment’ are two

26
different units and highlights Western society’s views that the physical environment is an object
that is separate from people (Zapf, 2009). Separating ourselves from the environment we are in
and suggesting that we are affected by our environment causes us to neglect the notion that we
affect our environment as well.
The use of place “combines location and physical environment with character, meaning,
and emotional significance for people; it is a multidisciplinary concept [… and] social
components cannot be easily extracted” (Zapf, 2009, p. 39). The term ‘geopsyche’ is when a
place that individuals have occupied for a long period of time assumes human traits (Zapf, 2009).
This term is fascinating because it makes the relationship between people and place so much
more intimate and creates a sense of respect. In rural areas, individuals may find a deeper
connection to their place in comparison to urban areas. This can be explained by a rural identity
rooted within a sense of belonging and attachment to place created by a shared history and
lifestyle (Zapf, 2009). Contextualizing the concept of rural using a critical lens will allow us to
gain a deeper understanding of our client’s experiences and remain open-minded rather than
defining their rurality as an outsider of the community.
Culture Shock
Zapf (1993) describes culture shock as an experience where an individual is unable to
connect or interact in a new environment in a meaningful way. Culture shock is common among
social workers in rural and remote areas, and “misunderstandings and conflict are inevitable
because of the differences in meanings, rules, and values between the two cultures” (Zapf, 1993,
p. 696). This notion of culture shock from someone going from urban to rural and vice versa is
crucial to recognize for the context of rural social work.

27
New social work graduates are likely the most prone to culture shock, as they move to
different areas in search of work with little experience. Gillespie and Redivo (2012) found four
themes that attract clinicians to their rural practice setting: “mainly professional opportunity,
mainly community characteristics, a combination of professional opportunity and community
characteristics, and a desire to move to Canada or British Columbia” (p. 36). Those who go
mainly for professional opportunity and who wish to live in British Columbia may not always
know exactly what the area they will be working in will be like unless they have previous rural
experience. This creates the perfect setting for culture shock. They may struggle with “issues of
professional values and personal integration with the community [… which] is not a unique
challenge for social workers, as other groups of professionals and workers also experience
difficulties related to living and working in the north” (Schmidt, 2000, p. 342). Although culture
shock occurs in workers who move to rural and remote areas, professionals dealing with
confidentiality can run into additional issues such as dual relationships.
Dual Relationships
According to Pugh (2007), dual relationships are used to describe the relationships social
workers form outside the work setting with service users. Distinguishing between a dual
relationship that is ethical and unethical can be challenging, as it is the nature of the relationship
that is in question and not the existence of a dual relationship itself (Pugh, 2007). According to
Gillespie and Redivo (2012), some of the major difficulties for rural social workers include
balancing personal and professional boundaries. This was especially the case for those who were
recruited from within the community where they acquired work; whereas, social workers
recruited from outside the community identified challenges surrounding isolation (Gillespie &
Redivo, 2012). Due to the nature of the close proximity to all community members in rural and

28
remote settings, it is safe to say that dual relationships can be inevitable and simply avoiding
them might not be the answer.
Once social workers have built the skills to decipher between acceptable and
unacceptable dual relationships, they are faced with the challenge of how to address each
situation. Pugh (2007) states that there is little guidance on how to manage social invitations in
social work literature. Similarly, Gillespie and Redivo (2012) suggest that in social work
academic programs there is little preparation or practical experience on how to manage dual
relationships. Literature in northern and remote social work has suggested the need for including
northern practices in mainstream social work education (Brown & Green, 2009). The inclusion
of this topic in all social work academic programs will have a long-term benefit for future social
workers.
According to Gillespie and Redivo (2012), isolation can be a result of attempting to
manage or avoid dual relationships for clinicians who were recruited from outside of the
community. These clinicians reported that building a social support system and making friends to
create a social peer group was their most frequent initial challenge when working in a rural
community (Gillespie & Redivo, 2012). These social workers may also feel subconscious
pressure to stay disconnected from the community in attempts to protect service users’ privacy.
The consequence of isolation can also have an impact on social workers’ retention in rural social
work practice. Schmidt (2000) and Cheers, Darracott, and Lonne (2005) all reference isolation in
the high turnover rate of social workers in rural and northern communities. Schmidt (2000)
addressed culture shock, lack of integration into the community, and urban educated social
workers as some main concerns regarding retention. Cheers, Darracott, and Lonne (2005)
corroborated this through their longitudinal Australian study, focusing more on the positive

29
effect of community bonds rather than the negative effects of disconnection. Additionally, they
shed light on issues surrounding employer-related factors and the effect on early departure of
rural social workers (Cheers, Darracott & Lonne, 2005).
The purpose of this literature review was to create a solid foundation for my practicum
experience through understanding mental health, PTSD and rural social work in greater detail.
The literature review was an important aspect of preparing for my practicum because I was able
to explore specific areas of my interest, and it helped in my learning process by creating room for
questions and points to reflect on during my practicum. Through this literature review, I found
that in clinical social work, it is important to decrease stigma and increase awareness for selfcare and compassion fatigue. The section on PTSD allowed me to become more familiar with the
symptoms and different methods of treatment. Lastly, the section on rural social work was an
extension of my knowledge from the Issues in Northern/Remote Social Work course I took at the
University of Northern British Columbia. The opportunity to connect the literature to practical
experience was extremely beneficial and interesting.

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Chapter 4: Practicum Experience and Learnings
The overall objective of my practicum was to further develop my clinical social work
skills in different settings. My main focus was individual counselling for mental health issues
while also learning more about the different realms of social work practice within a clinical
setting. This focus creates specific goals within my overarching learning objective of clinical
social work, and I have identified the main goals along with the activities I believe have helped
achieve these goals below.
Learning Objectives
I.

Learn how each agency works differently under the same umbrella of Horizon Health
Network and become familiar with the different policies and protocols the agency
structures require
a. Review agency policies and Horizon Health Network policies and procedures.
b. Ensure my work is being completed to the correct standards both practically and
administratively.
c. Work cohesively with supervisors and coworkers in different professions.

II.

Learn to work in an interdisciplinary team and work collaboratively with nurses, doctors,
and other health care professionals at each clinic.
a. Communicate clearly and respectfully and be straight forward with questions.
b. Keep in mind that different health care professions have different scopes so
differences may need to be addressed and acknowledged.

III.

Continuously work on developing my professional social work identity and learn to
identify clients’ issues in a clinical setting.
a. Continue developing my clinical social work lens and working toward defining it.

31
b. Practice working from a structural, feminist, solution-focused, and anti-oppressive
lens.
c. Consistently practice reflecting upon experiences and new knowledge and
routinely document these reflections.
IV.

Continue to develop clinical social work skills.
a. Observe individual counselling sessions and carry a small caseload once I feel
comfortable and my supervisors have agreed upon autonomy.
b. Become familiar with theories and practice methods that are practiced by
supervisors and become comfortable applying them to my own practice.
c. Learn how to adapt my practice to be more client-centered.
d. Develop administrative skills that come with clinical social work such as case
management skills and keeping up with paperwork required by the agency.
e. Continue growing clinical skills such as intake, assessment, treatment planning,
and successful termination.
f. Learn to make referrals to the necessary supports when needed
g. Co-facilitate group sessions managed by my supervisors to build groupfacilitations skills.

V.

Develop a better understanding of therapeutic modalities to treat PTSD
a. Become familiar with PTSD symptoms, treatment options, and screening tools.
b. Continue to research and explore different methods of treatment of PTSD.
c. Explore trauma-informed therapy methods and develop, practice common
methods such as CBT, and become more comfortable with trauma-related work.

32
VI.

Maintain Self-Care strategies that have helped my social work practice and education
thus far to support my emotional and mental wellbeing
a. Continue self-care methods such as exercising, cooking, journaling, spending time
with family, and regular stress-relieving massages.
b. Remember to talk about self-care with supervisors during regular supervision
meetings and add any other strategies that may prevent burnout
How Practicum Objectives Were Achieved
Practicum objectives were achieved through observation, carrying my own case load

while consulting with my supervisor, and engaging in interdisciplinary care with Nurse
Practitioners. Through frequent discussion with my agency supervisor I was able to practice my
skills and become more confident in my role as a social worker. My MSW supervisor, Audrey
Cochrane, was always available to me for questions and concerns and was a helpful resource
throughout my practicum. Prior to beginning my social work education, I thought that social
workers and counsellors were the experts and clients were to listen to their advice on
relationships, life, and mental wellness. I have been to many counsellors who took this stance
and gave me their own personal opinion on my life and I did not find it helpful. Now, after years
of social work education and some practical experience, I know that my preferred technique is to
help and guide my clients to learn to help themselves and figure out their own solutions. Having
someone listen and act as a sounding board about obstacles in life is sometimes all a client is
looking for.
Observation
At the beginning of my practicum, I sat in with my supervisor and observed her sessions.
I observed her with new clients to learn how assessments are done and also sat in with clients she

33
had seen for years. I took notes and shared them with my supervisor and learned how the
charting system worked at the agency. I began to chart on all the sessions I sat in on and my
supervisor signed them after review. This process helped me learn what the expectations were
when writing notes for charting in the Horizon Health Network records and I became
comfortable with taking notes and charting on my own cases quickly. Through this observation
and practice, I also quickly learned to work within the client-centered and collaborative method
of Horizon Health Network’s mandate.
In addition to observing one-on-one sessions, I attended meetings and events with my
supervisor to observe what my supervisor did outside of clinical counselling. I attended a social
work day event for all the social workers who work in the area, staff meetings, a methadone
program meeting, an ISD meeting, inter-professional consultations, and a compassion fatigue
workshop run by my supervisor.
The social work day event for all Horizon Health social workers in the area was filled
with different workshops and created an environment for all the social workers to discuss
different methods and bring forward case examples they wanted input on. It was a great
opportunity to network and meet the social workers working in rural and urban areas of
Fredericton. There were a couple of presenters from other government organizations to share
their available resources that might help our clients, such as an employment counsellor who
helps individuals find jobs and ways of funding further education. The event was informative,
and the opportunity to discuss different case scenarios was beneficial for all attendees.
The monthly methadone program meeting is held to discuss the progress and recent
events of the members of the program. The meeting consists of all the professionals involved in
the program, which is nearly the entire clinic staff. At this meeting the physician, nurse

34
practitioners, nurses, clerks, and social worker, discuss how a methadone patient is doing in the
program by consulting about the patient’s attendance at appointments, mental health state, how
many ‘carries’ they have, their drug test results, and other relevant information. Due to the nature
of the small community, many methadone patients are often seen outside of the clinic at social
events, and the team is also able to have insight on their social interactions as well as how they
seemed when at their appointments. Sitting in on a meeting gave me an opportunity to learn that
the team at CMCHC really look at the whole picture when working with methadone patients and
take a client-centered approach when making decisions. It was incredible to see the amount of
time and care it takes to go over each patient’s progress and it was very evident how passionate
and caring the team were towards the patients.
The ISD meeting I attended was held at the Central New Brunswick Academy, and the
meeting consisted of the principal of CNBA, an ISD representative, guidance counsellors,
teachers, nurse practitioner, and social worker (my supervisor). The meeting was the first
attended by both ISD and my supervisor, who have had some overlap in students and had some
miscommunication issues with other members of the ISD team. This meeting was a great help in
opening up communication lines and beginning to work collaboratively rather than as separate
units between ISD and the existing social work resource. It was also a space to bring up any
issues or causes of concern that the principal or other members of the faculty had about students.
The compassion fatigue workshop was an event held by my supervisor where she
discussed and spread awareness about compassion fatigue to health care providers at a clinic in
Fredericton. The workshop included self-assessment quizzes to determine levels of stress and
self-care and the presentation provided information on how to detect symptoms of compassion
fatigue. My supervisor used her personal examples of compassion fatigue she experienced

35
throughout her career and opened the space up for more conversation on the subject. I attended
the workshop nearing the end of my practicum and realized that I was experiencing many of the
symptoms my supervisor was explaining during the presentation. This allowed me to take a
better look at my self-care and look back to my learning goals.
Discussion
My supervisor was available to discuss my clients with me frequently, and throughout my
practicum I used her expertise to debrief on all my clients and ask questions on a regular basis.
Some of my clients were individuals who saw her before and switched over to me to get a fresh
start so I ensured that I kept my supervisor updated. The most beneficial part of this ongoing and
frequent conversation was the feeling of being supported and having someone to speak to about
my ideas and thoughts. My supervisor also asked me questions that got me thinking about certain
scenarios and what I could have done differently. She also gave me similar examples of her
previous experiences and educated me on what she did in those situations. My supervisor was
there to support me in more difficult situations, such as calling child protection and speaking
with the child’s parent about the report. Debriefing after those phone calls was crucial and she
even called me later on at home to ensure I was doing okay and doing some self-care. Our
conversations were often about specific clients, but they also included many discussions on the
experiences of a rural social worker and the different situations and unique methods that come
with them. For example, during a particularly heavy snow storm, my supervisor was being
driven to work by her father in his truck, and during the drive he received a phone call from an
individual in the community asking him to plow her out of her home. She explained to him that
she needed to be plowed out so she could take her counselling appointment with his daughter and
would appreciate the help. This situation would be very unlikely to occur in an urban setting and

36
shows the interconnectedness of the community. An example of rural contact that affects her
practice is when there is a conflict of interest. During my practicum, I was able assist Lynsey in
avoiding conflict of interest by taking clients that were related to her. My supervisor and I
discussed that when she does not have a student or another social worker in the clinic working
with her, she has no choice to refer individuals to Fredericton, Saint John, or Moncton. Through
this process, I learned that it can be a difficult task to refer out family members, close friends,
and other individuals that cannot be seen by the sole social worker and it can create certain
barriers for the clients and social worker. Through many years of experience, my supervisor has
finessed the process to make it as smooth as possible for the clients. This skill of effective
communication to clients in this context and dealing with the logistics of rural contact was a
great lesson for my future practice.
Throughout my practicum, some of my sessions with clients were observed by my
supervisor. We informed my clients that she would be observing me and not them to ensure their
comfort, and she observed my sessions with minimal interjections. These observation sessions
were an important aspect of building my confidence in my clinical social work skills. Being able
to answer questions on my techniques and explain my thought processes gave me a sense of selfassurance and external validation.
My supervisor treated me as a professional peer and as a friend in her supervisory
method. This was my preferred method of supervision prior to beginning my practicum. Treating
the supervisee as a professional peer allows for a more professionally orientated approach which
focuses on enhancing professional growth with respect to skills and knowledge (Tsui, 2005).
Additionally, treating the supervisee as a friend as well as a colleague creates a space for more
discussion about personal concerns and feelings and the supervision will be more supportive in

37
nature (Tsui, 2005). Both types of supervisory relationships have room to facilitate a more
autonomous practice for the supervisee and my supervisor maintained the necessary boundaries
in our supervisory relationship while creating a safe space for both of us to consult each other.
The nature of my practicum location caused the professional peer relationship to occur
organically, as we were the only two social workers working together in the community. This
resulted in mutual reliability to consult and debrief throughout my time there.
Interdisciplinary Consultation
The opportunity to be part of an interdisciplinary team allowed me to gain insight about
the importance and benefits of joining forces with other healthcare providers and educators. The
ability to consult with another health professional who already had background knowledge on a
client was both useful and efficient. I consulted with nurse practitioners who gave me
information and insight on medications and different medical intervention strategies that were
outside of my field of knowledge. Instead of waiting for a response to an email or a phone call,
the ability to walk down the hall and get the professional opinion of a nurse practitioner made
consulting extremely accessible. Having multiple health care professionals work towards a
treatment plan and get on the same page for one individual is so powerful and valuable. Working
collaboratively proved to be beneficial when one of my clients’ parents continuously questioned
her medication while trying to lower the client’s dosage. Knowing that it wasn’t my field of
expertise, I discussed the situation with the nurse practitioner working with the client and came
up with a way to explain the treatment plan to the parent.
Working at a school also meant that communication and collaboration with teachers and
administrative staff was a crucial aspect of my practice. Many students seeking support for
mental health issues also faced obstacles in their school and personal life. Working at the school

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and becoming familiar with the principal and other staff members created a positive and more
comfortable atmosphere in consultation and collaboration. Consulting with teachers and the
principal over specific issues brought forward by students allowed for collaborative plans to be
created not only with mental health treatment in mind, but with academic goals as well. This
eased the stress for many of my students and having the school support and be a part of the plan
was successful. Learning to work in an inter-professional team was a great way to learn about the
roles of other professionals and gain insight on how the differing roles can collaborate to create a
client-centered approach.
Case Examples
During my practicum, I carried a manageable caseload at CNBA, CMCHC, and the
Boiestown Health Center. Having my own caseload and being responsible for schedules,
charting, entering stats, and treatment plans was eye-opening. Below I have included case
examples of two individuals I worked with throughout the duration of my practicum. For
confidentiality purposes their names have been changed to Jane and John. I have several clients
who came to see me for support and were able to gain what they needed and I ‘closed’ their file.
The two examples I will give are not those clients. These two are the clients I had the most
difficulty with and who I believed I learned the most from. Both clients had been previously
working with my supervisor and my supervisor thought it would be beneficial for them to have a
fresh start with a new face. I chose to share and document these clients because they were my
first clients who had been with me for the full duration of my practicum and I learned immensely
from working with them both.

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Jane
Jane is a sixteen-year old student I met during my first month of practicum. She was
struggling with anxiety and depression and had a hard time feeling happy. She lost interest in
things that used to make her happy and felt that nothing could get her in a good mood. During
our first few sessions, we spent time talking about her life and some of the obstacles she was
facing in order to slowly build rapport and trust.
The main issue Jane experienced during the beginning of our sessions was that her
mother got angry at her a lot because she was missing school. Jane explained that her mother did
not seem to understand what she was going through at all and the lack of understanding hurt her
deeply and frustrated Jane on a daily basis. We worked on different ways to convey to her
mother about her feelings and thoughts, and Jane and I did some role play to act out some ways
of communication that might work better. Jane even tried showing her mother different YouTube
videos of other women explaining depression and anxiety. Jane’s efforts did not have an impact
on her relationship with her mother, so Jane brought her mother in for a meeting with me in
attempts to get her to understand her better. At this meeting, I educated Jane’s mother on the
realities of depression and anxiety, and spoke with her about the challenges Jane faces on a daily
basis. Jane’s mother replied with challenges of her own and being unsure of the balance between
being supportive and being strict on school attendance. The meeting was effective and
communication lines between Jane and her mother were opened. Jane’s mother was more
involved in treatment plans and began to understand her daughter better.
Throughout my practicum, Jane went through ups and downs. I tried giving her
homework such as: journaling, going to the gym to boost endorphin levels, doing yoga through
an app or online videos, went over sleep hygiene, muscle relaxation, and taking more baths to

40
calm anxiety. Jane always reported back that she forgot her homework and the only thing that
stuck was taking frequent baths to calm her mood. Jane seemed to be doing better initially after
working on validating her feelings and working on communication with her mother. She was
social again and finding joy in hanging out with her friends. However, her parents stopped her
many times from being social if she had missed any school and the arguments led her to stop
wanting to go out with friends and I had to have a conversation with her mother again. After
months of generally low mood and anxiety over school, the nurse practitioner at the school and I
collaborated and suggested that it might be beneficial if Jane saw a psychiatrist at mental health.
Jane had issues with attending school and being at school heightened her anxiety and
lowered her mood immensely. Jane was missing multiple days a week and finding it unbearable
to sit in class most days and it was starting to affect her grades. After discussing her class
schedule with Jane, I set up a meeting with the school’s principal, Jane, and her mother to try to
come up with a plan. During the meeting Jane was unable to express her feelings, but privately
was able to discuss options. I suggested that Jane move to half days at school, and slowly
incorporate full days when she was ready. All parties agreed to these terms initially, but Jane told
me that her mother and grandmother only supported half days for less than a week before
suggesting she go back for full days. This constant back and forth was an issue for a while before
she got on a steady schedule.
Jane is still on half days at school and still finds those days to be difficult to maintain.
The plan initially worked very well and we saw some progress, but currently she is still having a
very hard time attending school and still experiences very low mood. She will be followed by the
ISD team who have a direct relationship with mental health in Fredericton and she will continue
to be followed by a psychiatrist for her medication.

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Jane was the first client that I had where I sought the help from nurse practitioners and
educators and the experience was empowering and helpful. Jane’s situation is one that I have felt
distraught over many times in the past and present. I felt that I failed because she is not happy
and healthy as she once was and I felt that there was more that I could do for her. Upon
discussion with my supervisor and personal reflection, I know that I did not fail, and that I did do
everything in my power at the time to help her. I went to the school on days that I was not
scheduled to try to see her if she was not at school on my regular day, I called her at home and
called her into CMCHC for last-minute appointments. I learned through this that in this
profession, it is easy to think that our job is to ‘fix’ every aspect of an individual’s life and have
control over the outcome when that is not the case.
John
John is a 23-year-old man who experienced trauma and sought support with my
supervisor for a year prior to meeting me. John’s employer required him to drive in extremely
snowy conditions on a very dangerous road which was traumatizing and he felt that his life was
in constant danger. Since then he has been diagnosed with PTSD and was experiencing low
mood and some suicidal ideation when he first met with me. John suffers from many other
medical conditions that require to him to take medications which consequently have a negative
effect on his mood. He has a case worker with social development and a psychiatrist that follows
up with him for this medication to treat his insomnia and depression. The first thing John and I
did was start from the beginning of his story and engage in narrative work. John was the first
client that I met with and he was very willing to work with a new social worker. John had known
my supervisor since high school and my supervisor and I both agreed that a new face would be
beneficial for him.

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John instilled trust in me very quickly and found the sessions to be helpful with his mood.
We spent many of the first sessions talking about his experiences and his perception of life as
well as his thoughts of others’ perception of him. We began incorporating behavioural work in
order to reduce his feelings of guilt and increase self-compassion. John felt guilty towards the
event that led to his PTSD diagnosis, which eventually led to the loss of his job. This guilt
towards the notion of failure left him with debilitating self-doubt and low self-esteem. We
worked a lot on self-esteem as well as empowerment as John began to see himself in a more
positive way. In addition to low self-esteem, John struggled with anger, communication with his
wife and family, financial issues, and career goals. I wanted to find a step-by-step program for
him, but quickly found that rather than a structured program with lots of homework (which he
did not enjoy), John gained more from narrative therapy and behavioural work.
As autumn was ending and it started to get colder, John’s past symptoms of flashbacks
and nightmares returned as he began to fear driving in snow again. His suicidal thoughts became
much more severe and the verbal contract of staying safe was no longer sufficient to ensure his
safety. We decided to bring his wife into a session to get her on board with a more vigilant safety
plan, and she agreed to lock up all his tools, knives, and guns that he enjoyed using
recreationally. Upon meeting his wife, we decided it would be beneficial for her to come in for
her own sessions as well to discuss some obstacles she was facing with her husband’s situation. I
began to see her separately as well for her own issues as well as having sessions with both John
and his wife to discuss how they are doing as a couple. John started cancelling more
appointments when there was snow on the ground, and I encouraged him to start driving short
distances in little snow with his wife present rather than avoid driving in snow all together.

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Once John and I built trust and comfort, we started to work on some specific aspects of
his life. First, we worked on more effective communication and anger management with him and
his wife as well as his parents. We implemented some calming techniques for his anger which
ended up making him even more angry, so we used a strengths-based and solution-focused
method of finding ways he can face a problem rather than becoming angry. This seemed to work
much better and also boosted his self-esteem. John began to become more accepting of his past
and focus on the future, while actively reducing his self-deprecating thoughts of guilt.
He quickly reported back that his relationships with his parents and wife were getting
much better and he was having a better time containing his emotions and expressing them in a
more productive way through communication rather than yelling. The issue of finances
remained, as he and his wife were living on social assistance. Throughout my time at CMCHC,
John was reluctant to try new career paths even after many sessions of searching together for job
possibilities, different career options, and training.
John and his wife became visibly happier, and most of their issues came from financial
difficulty rather than their relationship and John reported better mood and sleep. Nearing the end
of our sessions, he informed me that he felt ready to go back to work and start driving trucks
again after a good offer was given to him in Alberta. He told me he thought the offer through
carefully and had thought of a clear plan on how he was going to make it work for him. On our
last session, John informed me that he had a different job offer which was better for him and had
bought his plane ticket to leave at the end of the month. He said he felt excited about this job and
very little nervousness, and felt he was ready to take on a new challenge. He said he feels
confident that he will overcome similar situations in the future as he overcame this one, and he
feels comfortable seeking support when needed.

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Working with John reinforced the notion that there are many different ways of working
with a client. I may want to follow a strict plan with specific goals for each session with
homework and learning goals, but sometimes that is not what works for the client. Plans and
treatment plans are meant to be followed while also maintaining flexibility for the clients’ needs.
Flexibility is crucial to maintain client-focused and it is important to not remember to avoid
feeling I am not making progress because we got off track.
Reflection
Many of my reflections can be detected throughout this report, and I found it helpful to
revisit my reflections while writing. Doaktown is located a little over an hour drive from my
home, and I used this driving time to reflect. At first I did not enjoy the long drive, but once I
used it as my own space to prepare myself for the day or to decompress after a particularly
difficult day, the drive became quicker and easier. In order to use my time efficiently, I recorded
my thoughts and emotions during my drive by filming myself talk about my day. The recordings
were meant to act as a journal, and the reason I chose to film myself rather than only record my
voice was because I wanted to capture my raw and unedited emotions while telling stories and
reflecting on my day. Watching the recordings months later, I was able to identify some themes
and interesting thoughts I had during my experience.
Recordings
In September, the majority of my recordings showed that I was excited, and in awe of the
work that my supervisor did at CMCHC. I was also emotional and shocked by the level of
poverty in a community only an hour away from my home. Upon reflection, I realized that the
fact that I was shocked was a significant indication of my naivety and privilege. I felt angry and

45
frustrated, mostly at myself, and partially at life and society for being unfair. The initial months
of my practicum was a crucial start to reflect on my privilege on a regular basis.
In October, I could see that I started to understand the frustrations when working with
outside resources that are further away. Quickly it became increasingly evident that many clients
who need additional support or resources from Fredericton are often forgotten about. Funding
was cut for a mental health social worker to come to Doaktown from Fredericton Addiction and
Mental Health Services every two weeks, which had a great impact for clients who were unable
to find transportation to Fredericton regularly. At this time, I also began to feel more confident
with my clinical skills and expressed in my recordings that I was getting more comfortable with
assessments and clinical notes. I spoke about my conversations with my supervisor, and how I
appreciated the honest discussions surrounding the life of a social worker outside the clinic and
the importance of self-care, self-awareness, and reflection. I learned that being aware and
cognizant of my own triggers within my practice was important and working with clients who
experience similar events or hardships as myself can be very difficult. Self-reflection was crucial
to ensure that I was practicing within my own boundaries and the recording helped a lot during
this time to talk aloud some of my own thoughts and concerns.
In November, I began to doubt myself because the different treatment plans I was making
for my clients did not seem to be ‘working’. I was having trouble getting my clients to stay
focused on the goals and activities I had planned out and was getting stressed out. This is when I
realized that it isn’t always about meticulous planning and stressing over not staying on track is
making the counselling experience about my own agenda rather than going with a client-centered
approach like I had intended.

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In December, I experienced driving in snow to CMCHC for the first time and
experienced the inconvenience and difficulty of finding transportation to and from Fredericton.
Many of my recordings in December was reflecting on how to prepare my clients for the holiday
season as well as my absence during my vacation. Watching the recordings, it is very obvious
that I was nervous and worried about not seeing my clients on a regular basis and I was taking
those feelings home.
In January, my recordings were used as a tool to debrief to myself and think aloud about
the issues and struggles I was experiencing. I was doing more role-playing with my students at
CNBA to speak about their mental health more openly and speak with teachers in attempts to
break the stigma on mental health issues. I spoke about how everyone who works at CMCH
works extremely hard, and self-care is lacking. I expressed my ideas around needing self-care to
be incorporated into policies and be something that is supported more by the organization rather
than the responsibility be completely on the professional. My practicum recordings and personal
journal showed that I was getting frustrated more easily and I was distancing myself from social
events and friends because it felt like work to listen to their troubles. Now, I realize I was
showing signs of compassion fatigue during this time.
Self-Care and Compassion Fatigue
I didn’t realize I was experiencing compassion fatigue or burnout until I attended my
supervisor’s compassion fatigue workshop and I started writing the reflection portion of my
report. The workshop went through the definition and symptoms of compassion fatigue, and
although I knew most of the information already, I found myself deeply resonating with the
content of the presentation. I was in denial, but once I began writing it became clear that I was
experiencing compassion fatigue. I realized that my self-care portion of my learning goals were

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not being met very well and I had failed to be consistent with self-care throughout my practicum.
I had an injury that prevented me from going to the gym to exercise regularly, which is normally
my main method of self-care, and I did not replace the activity with anything else.
The other self-care activities I listed in my learning goals prior to starting my practicum
were cooking, spending time with family, journaling, and regular massages. Another lesson I
learned through this realization of my lack of self-care was that I was doing these activities I had
identified as self-care, but I was doing them mindlessly. I wasn’t getting regular massages and
only booked them when I had time or money, I was cooking only on Sundays when I mealprepped, and journaling was for the purposes of my practicum and not for myself. I was spending
time with family but had started to distance myself from social groups and friends and slowly,
my self-care strategies became chores. It is evident now that I was neglecting my self-care, and
the symptoms of compassion fatigue started applying to me long before I realized. Contrary to
my prior beliefs, I have learned that I am susceptible to compassion fatigue, and that no amount
of research can prepare us fully. I could not have predicted that I would care and empathize with
my clients to this extent. However, through this experience I learned that about myself and that
compassion fatigue can sneak up on any social worker if we are not vigilant about our own selfcare.
I noticed this pattern nearing the end of my practicum and started becoming more vigilant
about my self-care and revisiting the different strategies that might work for me. I tried new
hobbies and asked individuals around me what their self-care strategies were regardless of their
profession. Through discussing with my partner, parents, and friends, I realized that I was
missing a key aspect of self-care: rest. I was distracted trying to find active ways I can refill my
“cup of care” as my supervisor calls it, and I had forgotten the simplest way to rejuvenate the

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mind and body. Through self-reflection I realized that my own negative cognitions restrict the
amount of rest I give myself. I realized that when I am resting my thoughts are filled with to do
lists, anxious thoughts from previous social and professional exchanges, and criticizing thoughts,
telling myself that I need to be productive and stop being lazy. I continually tried to add more
things to my personal and professional life that I thought would make me a good social worker
that I forgot to take things away to lighten the load.
Rural Social Work Practice
Compassion fatigue and self-care are unique in rural areas for a couple reasons. I found
that through my observation of the Central Miramichi Community Health Center that the general
consensus of the staff is that self-care is important. However, due to the nature of being in a rural
community, I noticed it might be harder for health care providers to take sick, personal, or
mental health days. For example, there is only one social worker at CMCHC, so if that one social
worker is away from work due to sickness, personal, or mental health reasons, there is no social
worker at the clinic. This kind of responsibility combined with the high need of social work
services creates a very difficult internal environment for a social worker to take days off
comfortably. Feelings of guilt and concern surpass feelings of needing self-care and without
encouragement from others or very vigilant self-awareness, it becomes easy to overlook their
own care. Having a sole social worker also results in a long waiting list where the social worker
is booking client appointments months in advance. Therefore, if the social worker was to take a
needed day off, the clients' schedules for that day might have to be rescheduled to a much later
date which invites more feelings of responsibility and guilt. Succumbing to these feelings may be
beneficial to individual clients and the social worker in that moment. However, giving into

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feelings of guilt may lead to burnout and compassion fatigue and a longer stress-leave might be
required which ultimately leads to inefficiency.
Being the only social worker in a building also makes it increasingly difficult to engage
in frequent discussions and debrief with peers. Debriefing is a common method of professional
self-care as well as supervision and discussion (Killian, 2008; Radey & Figley, 2007).
Thankfully, technology can be utilized so that social workers in rural areas are able to contact
other social workers in surrounding areas. This is what my supervisor and other rural social
workers in the network utilize when needing a second opinion. However, it was evident that
having someone regularly accessible and face-to-face to debrief and discuss clients was
extremely helpful for both myself and my supervisor.
The literature highlights issues surrounding dual-relationships and the difficulty of its
management. However, through my practicum I have learned that if these relationships are
managed well, dual-relationships can be beneficial to creating a comfortable environment and
building effective rapport and trust. Through my practicum experience, I had the opportunity to
see dual-relationships first hand.
My supervisor is born and raised in the community that she works in and she knows
almost everyone and everyone knows her. I was interested to see how she manages her inevitable
dual-relationships and I found that most times, her dual-relationships were advantageous. She
was already familiar with individuals, or was able to make connections with them more quickly,
and it was evident that community members trusted her almost immediately. Not only was trust
built more quickly. I noticed that the stigma of going in to see a counsellor was very minimal
compared to previous experiences.

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During my first month at CNBA, I was often with my supervisor in the cafeteria during
break times with the students. While I hesitated to approach my students to talk to them about
appointment times, my supervisor was very nonchalant and talked to many students. I realized
that unlike my previous experience, where I was told not to approach clients in public in case
they did not want others to know they were seeing a counsellor, the students’ attitudes were very
different. As previously mentioned my supervisor is well known in the community and has been
consistently going to the school weekly since it opened in 2010. Due to my supervisor’s
familiarity around the school and existing relationships with many of the students, the students
did not seem to care that their peers knew they were going to see a counsellor. This was similar
in the adult population. Every time I entered the waiting room at CMCHC, it was full of people
chatting and I have heard clients tell others that they are coming in to see Lynsey multiple times.
Although there are some definite benefits to having a social worker who is very familiar
with the community, I also saw the situations that the literature warned us about. For example,
my supervisor was at a public social event and a client approached her to update her on recent
changes in the client’s life. Times like these are difficult to avoid and depending on the client it
might be harder to divert the conversation. Another unique difficulty is when family members or
people who are too close to my supervisor needed support. During my practicum I was able to
see these individuals, but when my supervisor is alone she has no choice but to refer them to
social workers or private counsellors who are generally far away. Through this observation, I
was able to see real-life examples of how inevitable dual-relationships can be managed with
finesse.

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Chapter Five: Implications and Recommendations for Social Work Practice
Being from a university that was outside of the area, I initially had difficulty securing a
practicum in New Brunswick. I went through the same difficulty during my Bachelor of Social
Work practicum, and in both instances I had to face rejection repeatedly before securing a
practicum. Although it was frustrating at the time, I am glad it led me to the practicum
opportunity at the Central Miramichi Community Health Centre with Lynsey as my on-site
supervisor. My practicum at CMCHC was to fulfil the requirements for my Masters of Social
Work, at the University of Northern British Columbia, and the experience allowed me to
strengthen my skills as a clinical social worker on a graduate level.
Completing my degree requirements in a rural area within an interdisciplinary team was a
great opportunity to connect the literature I studied to real-life, practical situations. I am grateful
for the team at CMCHC who were incredibly welcoming and treated me with respect and
kindness when I had questions or concerns. They helped me adjust and worked around me when
space was limited, and I instantly felt a part of the team. Additionally, the members of the
Doaktown community were welcoming and open to working with a new student. Seven months
is not a long period of time, but in the short time I completed my practicum at CMCHC and the
Central New Brunswick Academy, I felt like I was a part of the community. When speaking with
other health care professionals who work at CMCHC and other rural areas, this is the crucial key
to making professionals want to stay in the community. My last day was also the last day of a
nurse practitioner from Fredericton whose temporary contract was over. During our car ride back
to Fredericton we both agreed that we would go back and work in that clinic if the opportunity
presented itself because of the team and the community. I learned valuable lessons not only on

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my practical clinical social work skills, but in my personal identity and what it means to be a
social worker.
Implications for Practice
The opportunity to complete a practicum placement at CMCHC has instilled a level of
confidence in my clinical skills, while staying humble and aware of my constant development of
skills and knowledge. Throughout my practicum I faced obstacles where there was a discrepancy
between my ideal treatment plans and what worked with my clients and I faced similar issues
with my own social work identity. I was too focused on the development of my tangible skills
and got caught up in my practice rather than staying present and reflective. My experience has
given me the tools I need to stay balanced in my personal and professional identity as well as the
ability to remain a client-focused and anti-oppressive social worker.
An integral aspect of my learning was understanding the reality of intersectionality in my
clients’ issues as well as working from a structural perspective. Social issues are all connected
and interwoven in a way that allows oppressive social structures to stay existent (Bishop, 2002).
It is impossible to eradicate one form of oppression without affecting the other. As long as
competition, power, and hierarchy are the underlying priorities of society, the interwoven system
of the power structure will be maintained (Bishop, 2002). It is important to analyse our own
privilege and our stance as oppressor and oppressed while unpacking the underlying assumptions
and beliefs that surround our framework of practice. Bishop (2002) highlights the reality of how
oppressed groups fight and struggle with other oppressed groups to gain dominance and
compete, which causes the dominant and privileged group to continue reaping the benefits.
Pease (2010) stresses the importance of how this intersection of oppression affects all our
lives. According to Collins, “oppression operates on three levels: the personal, the cultural, and

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the structural” and many people who are oppressed also have experienced some form of privilege
in their lives (as cited by Pease, 2010, p. 21). Many individuals find it easy to identify their
experience of being oppressed but find it more difficult to think about how their thoughts and
actions can oppress others (Pease, 2010). For social workers, a major part of structural social
work is identifying when oppression is taking place. As Payne (2014) says: “you have to live
structural practice – it is not a technique. Structural social work is inclusive because it is
concerned with all forms of oppression, one is not more important than the other” (p. 335). It is
crucial to acknowledge the different layers of oppression that we are located in and bring our
privilege into awareness. It is a difficult task to confront your own privilege and internalized
dominance, but this is a responsibility that we all have in order to become better advocates and
allies.
When listening to my client’s issues, many of them highlighted how they were oppressed
throughout their lives, and there were many intersectional issues that arose. For example, one
client who had issues at work because of their socioeconomic position felt oppressed due to their
gender. It was easy for clients to list their daily challenges and barriers but difficult for them to
understand their own privilege and their own position as an oppressor of others. Focusing on this
lack of understanding and attempting to educate my clients may not always be beneficial, but it
is important for me to understand the intricate intersectionality of their issues. This will allow me
to have a better understanding of the client’s positionality and approach their situation from a
not-knowing perspective.
In my future practice, I will continuously self-reflect and ensure I have a variety of selfcare tactics to prevent compassion fatigue and burnout. I learned through my practicum
experience that self-care activities must be done mindfully and can change over time. With this

54
in mind, I will make sure to include time to self-reflect on my mental, physical, and spiritual
wellness throughout my practice. Due to my tendency to focus on my physical health more than
my mental and spiritual health, I will set reminders for myself and begin to accumulate more
activities that surround mental and spiritual self-care. Seeking regular counselling, spending time
in nature, maintaining a social support system, and reading literature unrelated to work are all
self-care tactics that I have added to my list. I learned that in order to be an effective social
worker, self-care needs to be higher on my list of priorities, and I hope this realization will allow
for longevity in this field.
Recommendations: Self-Care Policy on an Organizational Level
Throughout my practicum, I had many ideas and thoughts about the lack of self-care in
the healthcare professions. I contacted a massage therapist school in the area to set up a day to
get massage students to the clinic to provide stress-relieving treatments to the staff. However,
due to the distance between the clinic and the school the coordinator was skeptical and
eventually the event did not happen. This idea sparked a series of questions that addressed the
need for self-care to be engrained into the policies of healthcare organizations. Burnout and
compassion fatigue prevention should be a core pillar in the well-being of health care
professionals. However, only some professionals are taught the importance of self-care
throughout their training. I believe the overarching organization should be implementing
strategies to incorporate self-care into their regular activities, rather than putting the
responsibility of compassion fatigue prevention solely on the worker.
Through conversations with other professionals and seeing the trends of topics on social
media, it seems that self-care is lacking in many areas of our society. Self-care can be perceived
as selfish, which is typically not an ideal characteristic in our culture. This notion causes many

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individuals to not prioritize self-care, and consequently experience burnout in many different
professional and personal situations. This notion combined with the caring nature of social work
and other healthcare professions is what results in compassion fatigue and burnout at higher
rates.
Common forms of individual self-care highlighted in the literature include: leisure time,
physical activity, socialization, self-reflection, and spirituality (Harms & Pierce, 2011; Killian,
2008; Radey & Figley, 2007). Additionally, Hesse points out that organizational self-care is a
way that agencies can utilize methods to facilitate self-care such as “limiting or diversifying
caseloads, and providing appropriate supervision, adequate benefits, and staff development
opportunities” (as cited by Radey & Figley, 2007, p. 201). Providing a warm and welcoming
atmosphere is another way to facilitate a space where discussing self-care and compassion
fatigue as a norm is also very important (Figley, 2002; Radey & Figley, 2007). Individual selfcare is often talked about in the social work profession, but organizational self-care is not a
common topic when discussing efforts to prevent and combat compassion fatigue.
From a structural perspective, it is important to address self-care at an organizational
level. Structural models of social work “aim to promote justice through changing oppressive and
discriminatory structures within the present social order” (Schmidt, 2000, p. 343). Structural
social work takes the issue from the individual and focuses on the whole picture, deconstructing
societal structure to reveal the rooted issues. Placing the responsibility of self-care solely on the
social worker and other health care professionals can be unintentionally oppressive if the
environment is not systematically designed to support it. A shift toward the shared responsibility
of healthcare staff may create an environment where healthcare professionals become much
more vigilant in carrying out their own self-care habits rather than only agreeing with the theory.

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In my experience at CMCHC, self-care and prevention of compassion fatigue and
burnout are a common topic and concern of the management as well as the staff. Despite a
positive view of self-care and awareness of compassion fatigue, it can still be easy to forget
about conducting self-care routines. Without the support of coworkers and their verbal
encouragement to take time for self-care, health care professionals fall into the habit of thinking
of the well-being of the patients, clients, and the clinic before their own. By sharing the
responsibility with the organization, the weight can be slightly lifted from the professional.
As highlighted in the literature review, studies show that the lack of awareness of selfcare is not a factor of levels compassion fatigue. I think if an organization created policies and
procedures surrounding obligatory self-care habits, healthcare professionals would be more
likely to prioritize their own well-being better and decrease levels of compassion fatigue. It is
important to note that while I believe the importance of policies on the organizational level, there
needs to be a coinciding level of autonomy for the professional staff to decide what works for
them. In future social work research, an in-depth look at different approaches to include self-care
in the organizational level would be a beneficial addition to research on self-care and compassion
fatigue.
Conclusion
My masters of social work practicum created an opportunity for me to learn what it
means to be a social worker in and out of the office. I learned to build rapport and use my
clinical skills while remaining empathetic towards my clients. This experience gave me more
than I expected and I also learned to be empathetic towards myself. By completing this
requirement for my MSW, this opportunity gave me insight towards my future as a clinical social
worker and expanded my knowledge on the healthcare system.

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My practicum reinforced my anti-oppressive and feminist theoretical framework and
allowed me to embrace being an eclectic social work practitioner. I effectively utilized solutionfocused methods while incorporating a strengths-based approach throughout my practicum. Prior
to this practicum, I had a preconceived ideal list of what were considered ‘skills’. I thought that
being genuine, building rapport, active listening, being transparent and open, and showing
empathy were all things that all social workers naturally did. During a discussion with Audrey,
my MSW supervisor, she informed me that all those traits that I considered to be natural were
actually social work skills that we need to learn and build on. I realized that I had taken the skills
that came naturally to me for granted and was stressing out about learning what I considered to
be skills such as teaching sleep hygiene, Cognitive Behavioural Therapy, narrative therapy, and
other tools used in social work practice. It was interesting and eye-opening to realize those innate
skills are important and need to be practiced and developed constantly as well.
The opportunity of working in a new and smaller community was such an enriching
experience both professionally and personally. I am confident that my time at CMCHC has
provided me with the knowledge and experience to accomplish my learning goals as well as
leave me with questions and thoughts for my own future practice. Experiencing the symptoms of
compassion fatigue first-hand has taught me the importance of self-care, and I will take what I’ve
learned throughout my practice and utilize my knowledge to prevent burnout and compassion
fatigue prevention. The experience also allowed me to strengthen my personal and professional
values and beliefs while reconstructing my professional framework and identity. I am extremely
grateful to the Doaktown and Boiestown community for being so welcoming, especially to the
Central Miramichi Community Health Centre family for their generosity and kindness. I thank
my supervisors, who were incredible throughout my learning process and remained patient,

58
compassionate, and supportive every step of the way. Lastly, I am incredibly thankful to my
clients, who allowed me to be a part of their healing process, and I am grateful for the knowledge
I will take forward in my future social work practice.

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References
American Psychiatric Association, & American Psychiatric Association. DSM-5 Task Force.
(2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.).
Arlington, VA: American Psychiatric Association.
Adams, R. E., Boscarino, J. A., & Figley, C. R. (2006). Compassion fatigue and psychological
distress among social workers: A validation study. American Journal of
Orthopsychiatry, 76(1), 103-108. 10.1037/0002-9432.76.1.103
Albright, D., & Thyer, B. (2009). Does EMDR reduce post-traumatic stress disorder
symptomatology in combat veterans? Behavioral Interventions, 1-19
http://dx.doi.org/10.1002/bin.295
Angkaw, A. C., Haller, M., Pittman, J. O. E., Nunnink, S. E., Norman, S. B., Lemmer, J. A., …
Baker, D. G. (2015). Alcohol-related consequences mediating PTSD symptoms and
mental health–related quality of life in OEF/OIF combat veterans. Military Medicine,
180(6), 670–675.
Armitage, A. (2005). Social welfare in Canada (1st ed.). Don Mills, Ont.: Oxford University
Press.
Beder, J. (Ed.). (2012). Advances in social work practice with the military. New York:
Routledge.
Bensimon, M., Amir, D., & Wolf, Y. (2008). Drumming through trauma: Music therapy with
post-traumatic soldiers. The Arts in Psychotherapy, 35(1), 34–48.
doi:10.1016/j.aip.2007.09.002

60
Berzoff, J. & Drisko, J. (2015). What clinical social workers need to know: Bio-psycho-social
knowledge and skills for the twenty first century. Clinical Social Work Journal, 43(3),
263-273.
Bishop, A. (2002). Becoming an ally: Breaking the cycle of oppression (2nd ed.). Halifax, N.S.:
Distributed in the USA exclusively Palgrave.
Bohnert, K. M., Perron, B. E., Ashrafioun, L., Kleinberg, F., Jannausch, M., & Ilgen, M. A.
(2014). Positive posttraumatic stress disorder screens among first-time medical cannabis
patients: Prevalence and association with other substance use. Addictive Behaviors,
39(10), 1414–1417. doi: 10.1016/j.addbeh.2014.05.022
Bonn-Miller, M. O., Babson, K. A., & Vandrey, R. (2014). Using cannabis to help you sleep:
Heightened frequency of medical cannabis use among those with PTSD. Drug and
Alcohol Dependence, 136, 162–165. doi: 10.1016/j.drugalcdep.2013.12.008
Bonn-Miller, M. O., Babson, K. A., Vujanovic, A. A., & Feldner, M. T. (2010). Sleep problems
and PTSD symptoms interact to predict marijuana use coping motives: A preliminary
investigation. Journal of Dual Diagnosis, 6(2), 111–122.
doi: 10.1016/j.janxdis.2010.11.007
Brown, G., & Green, R. (2009). Inspiring rural practice: Australian and international
perspectives: Keynote address, 9th biennial rural remote social work conference,
Geelong, Victoria, Australia 30-31 July 2009. Rural Social Work and Community
Practice, 14(1), 63-70.
Central New Brunswick Academy. (2016). Central New Brunswick Academy School Profile.
Retrieved from http://web1.nbed.nb.ca/sites/ASD-W/CNBA/Pages/About-Us.aspx
Chang, H. V. (2008). Autoethnography as method (developing qualitative inquiry). Walnut

61
Creek, CA: Left Coast Press.
Cheers, B., Darracott, R., & Lonne, B. (2005). Domains of rural social work practice. Rural
Society, 15(3), 234-251. 10.5172/rsj.351.15.3.234
Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko-Mullen, A., &
Peterson, A. L. (2011). Treatment of active-duty military with PTSD in primary care:
Early findings. Psychological Services, 8(2), 104–113.
Cooper, H. S., Streeter, C. L., & Scales, T. L. (2013). Rural social work: Building and sustaining
community capacity. Hoboken, New Jersey: Wiley.
Creamer, M., Wade, D., Fletcher, S., & Forbes, D. (2011). PTSD among military personnel.
International Review of Psychiatry, 23(2), 160–165.
doi.org/10.3109/09540261.2011.559456
Epp, J. (1988). Mental health for Canadians: Striking a balance. Canadian Journal of Public
Health / Revue Canadienne De Santé Publique, 79(5), 327-349.
Figley, C. R. (2002). Compassion fatigue: Psychotherapists' chronic lack of self-care. Journal of
Clinical Psychology, 58(11), 1433-1441.
Fikretoglu, D., Brunet, A., Guay, S., & Pedlar, D. (2007). Mental health treatment seeking by
military members with posttraumatic stress disorder: Findings on rates, characteristics,
and predictors from a nationally representative Canadian military sample. Canadian
Journal of Psychiatry, 52(2), 103–10. Retrieved from
http://search.proquest.com/docview/222848124?accountid=14601
Gillespie, J., & Redivo, R. (2012). Personal-professional boundary issues in the satisfaction of
rural clinicians recruited from within the community: Findings from an exploratory study.
The Australian Journal of Rural Health, 20, 35-39.

62
Harms, L., & Pierce, J. (2011). Working with people: Communication skills for reflective
practice (Canadian ed.). Don Mills, Ontario: Oxford University Press.
Health Canada. (2016, September 30). Understanding the new access to Cannabis for medical
purposes regulations. Retrieved from http://healthycanadians.gc.ca/publications/drugsproducts-medicaments-produits/understanding-regulations-medical-cannabis-medicalescomprehension-reglements/index-eng.php
Hoge, C. W. (2010). Once a warrior, always a warrior: Navigating the transition from combat
to home - including combat stress, PTSD, and mTBI. Guilford, CT: Globe Pequot Press.
Horizon Health Network. (2017a). About Us - Horizon Health Network. En.horizonnb.ca.
Retrieved from http://en.horizonnb.ca/home/about-us.aspx
Horizon Health Network. (2017b). Central Miramichi Community Health Centre. Retrieved
from http://en.horizonnb.ca/facilities-and-services/facilities/central-miramichicommunity-health-centre.aspx
Jobe-Shields, L., Flanagan, J. C., Killeen, T., & Back, S. E. (2015). Family composition and
symptom severity among veterans with comorbid PTSD and substance use disorders.
Addictive Behaviors, 50, 117–123. doi.org/1016/j.addbeh.2015.06.019
Karpetis, G. (2014). Advocating the clinical social work professional identity: A biographical
study. Journal of Social Work Practice, 28(1), 23-41.
doi:10.1080/02650533.2013.806888
Keynan, I., & Keynan, J. (2016). War trauma, politics of recognition and purple heart: PTSD or
PTSI? Social Sciences, 5(4), 57. doi:10.3390/socsci5040057

63
Killian, K. D. (2008). Helping till it hurts? A multimethod study of compassion fatigue, burnout,
and self-care in clinicians working with trauma survivors. Traumatology, 14(2), 32-44.
10.1177/1534765608319083
Korn, D. (2009). EMDR and the Treatment of Complex PTSD: A Review. Journal of EMDR
Practice and Research, 3(4), 264-278. http://dx.doi.org/10.1891/1933-3196.3.4.264
Lande, R. G., Tarpley, V., Francis, J. L., & Boucher, R. (2010). Combat trauma Art Therapy
scale. The Arts in Psychotherapy, 37(1), 42–45. doi:10.1016/j.aip.2009.09.007
Levine, M. (2015). Children come first? A brief history of children’s mental health
services. American Journal of Orthopsychiatry, 85(5), S22-S28.
http://dx.doi.org/10.1037/ort0000115
McNeece, C., & Thyer, B. (2004). Evidence-based practice and social work. Journal of
Evidence-Based Social Work, 1(1), 7-25. http://dx.doi.org/10.1300/j394v01n01_02
Munson, C. E. (1993). Clinical social work supervision (2nd ed.). New York: Haworth.
New Brunswick Canada. (2018). Integrated Service Delivery (ISD) for children and youth with
emotional, behavioural, and mental health issues. Retrieved from
http://www2.gnb.ca/content/gnb/en/departments/education/isd.html
New Brunswick Canada. (2018). Education and early childhood development. Overview and
eligibility. Retrieved from
http://www2.gnb.ca/content/gnb/en/departments/education/isd/overview_eligibility.html
Payne, M. (2014) Modern social work theory. (4th ed.). Chicago, IL: Lyceum Books.
Pease, B. (2010). Undoing privilege: Unearned advantage in a divided world. London: Zed
Books.

64
Pruiksma, K. E., Taylor, D. J., Wachen, J. S., Mintz, J., Young-McCaughan, S., Peterson, A. L.,
… Resick, P. A. (2016). Residual sleep disturbances following PTSD treatment in active
duty military personnel. Psychological Trauma: Theory, Research, Practice, and Policy.
Advanced Online Publication.
Pugh, R. (2007). Dual relationships: Professional boundaries in rural social work. The British
Journal of Social Work. 37, 1405-1423.
Radey, M., & Figley, C. R. (2007). The social psychology of compassion. Clinical Social Work
Journal, 35(3), 207-214. 10.1007/s10615-007-0087-3
Schmidt, G. G. (2000). Remote, northern communities: Implications for social work practice.
International Social Work, 43(3), 337-349.
Stern, S. L., Donahue, D. A., Allison, S., Hatch, J. P., Lancaster, C. L., Benson, T. A., . . .
Peterson, A. L. (2013). Potential benefits of canine companionship for military veterans
with posttraumatic stress disorder (PTSD). Society & Animals, 21(6), 568-581.
doi:10.1163/15685306-12341286
Tasker, J. (2018). Trudeau says pot will be legal as of Oct. 17, 2018 | CBC News. Retrieved from
https://www.cbc.ca/news/politics/cannabis-pot-legalization-bill-1.4713839
Tsui, M. (2005). Social work supervision: Contexts and concepts. Thousand Oaks, California:
Sage Publications.
Van der Kolk, Bessel (2015). The body keeps the score: Mind, brain and body in the
transformation of trauma. London, United Kingdom: Penguin Books.
Werkmeister Rozas, L., & Grady, M. D. (2011). Making room for dynamics in evidence-based
practice: The role of psychodynamic theory in client-centered approaches. Journal of
Teaching in Social Work, 31(2), 210-223. doi:10.1080/08841233.2011.560534

65
Wesson, M., & Gould, M. (2009). Intervening early with EMDR on military Operations. Journal
of EMDR Practice and Research, 3(2), 91–97. doi: http://dx.doi.org/10.1891/19333196.3.2.91
Williams, I., & Bernstein, K. (2011). Military sexual trauma among U.S. female veterans.
Archives of Psychiatric Nursing, 25(2), 138–147. doi: 10.1016/j.apnu.2010.07.003
Zapf, M. K. (1993). Remote practice and culture shock: Social workers moving to isolated
northern regions, Social Work, 38(6), 694-704.
Zapf, M. K. (2009). Social work and the environment: Understanding people and place.
Toronto, ON: Canadian Scholars’ Press Inc.