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Compassion Fatigue, Secondary Traumatic Stress, Vicarious Trauma and Burnout

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Jolie Kerenick

on 16 May 2016

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Transcript of Compassion Fatigue, Secondary Traumatic Stress, Vicarious Trauma and Burnout

SOLUTIONS!
prevention toolkit
Burnout, Compassion Fatigue, Secondary Traumatic Stress, Vicarious Trauma:

What are they?
Do I Have Them?
What Can I Do About It?

definitions
burnout: a state of physical, emotional, psychological, and spiritual
exhaustion
resulting from occupational stress. For mental health professionals, this can look like stress occurring due to chronic exposure to (or practice with) populations that are vulnerable or suffering.
Vicarious Trauma
,
Secondary Traumatic Stress
,
and
Compassion Fatigue
are all terms that describe negative psychological reactions that can be experienced when working with traumatized clients. The terms are often used interchangeably but they are in fact 3 distinct conditions.
compassion fatigue: the natural, treatable, predictable and preventable, unwanted consequence of working with suffering people
secondary traumatic stress: natural and consequential behaviors and emotions resulting from knowing about a traumatizing event experienced by a client and the stress resulting from helping the traumatized person, particularly after bearing witness to the intense or horrific experiences of the person's trauma. The symptoms of Secondary Traumatic Stress mirror the symptoms of Post Traumatic Stress Disorder.
vicarious trauma: a process of cognitive change resulting from chronic empathic engagement with trauma survivors.

SELF-ASSESSMENT
symptoms, risk factors, assessment...
Resources
Thank You!
(Pines and Aronson 1998)
(Rothschild and Rand, 2006)
ex: changes in world views about key issues such as safety, trust and control and changes in spiritual beliefs.
(Pearlman, 1999)
(Pearlman, 1998)
(Figley, 1995)
(Figley, 1995)
SYMPTOMS of BURNOUT
emotional exhaustion
depersonalization (cynicism)
reduced feelings of personal accomplishment
depression
boredom
loss of compassion
discouragement

FACTORS CONTRIBUTING to BURNOUT
Agency Factors
excessively high caseloads
lack of influence over agency policy
unfairness in organizational structure and discipline
low peer and supervisory support
poor agency and on the job training
Individual Clinician Factors
conflictual relationships with co-workers
individual personality and coping styles
difficulty interacting with clients
Client Factors
difficult to treat
chronically needy
severe psychiatric or social problems
Important differences between
BURNOUT
and
COMPASSION FATIGUE
BURNOUT
is a progressive state that occurs cumulatively over time. It is related to contributing factors on an agency level, an individual clinician level and (in the mental health field), a client population level. Although burnout can occur when working with trauma survivors, it is not dependent upon working with trauma survivors. It is an occupational hazard related to low job satisfaction and feeling powerless and overwhelmed at work.
BURNOUT
can be a component of
COMPASSION FATIGUE
.
COMPASSION FATIGUE
also often occurs cumulatively over time. It arises when a clinician becomes unable to replenish their stores of empathy and refuel emotionally to keep caring for others because caring for others has exhausted them.
COMPASSION FATIGUE
may or may not be related to working with trauma survivors.
(Newell and MacNeil, 2010)
Signs and Symptoms of COMPASSION FATIGUE
exhaustion
reduced ability to feel sympathy and empathy
anger and irritability
increased use of alcohol and drugs
dread of working with certain clients
diminished sense of enjoyment of career
hypersensitivity or insensitivity to emotional material
difficulty separating work life from personal life
absenteeism
impaired ability to make decisions related to care of clients
difficulty in personal relationships
(Mathieu, 2007)
Factors Contributing to COMPASSION FATIGUE
Clinician related factors
poor self-care
unresolved trauma
inability to control work stressors
lack of job/career satisfaction
anxiety or mood disorder
maladaptive coping skills
Agency related factors
inadequate supervision
lack of client resources
high caseloads of trauma survivors
lack of peer/colleague support
agency culture related to clinician experience of compassion fatigue
(Lerias and Byrne, 2003)
(Cattherall, 1995)
Symptoms of SECONDARY TRAUMATIC STRESS
The symptoms of Secondary Traumatic Stress mirror the symptoms of Post Traumatic Stress Disorder.

intrusive thoughts
traumatic memories or nightmares associated with client trauma
preoccupation with clients' problems
emotional numbing
insomnia
chronic irritability
angry outbursts
fatigue
difficulty concentrating
avoidance of clients and client situations
hypervigilance
physical symptoms such as headaches, muscle tension and back problems

(Newell and MacNeil, 2010)
Distinguishing
SECONDARY TRAUMATIC STRESS
from
VICARIOUS TRAUMA
VICARIOUS TRAUMA
is characterized by changes in a clinician's
thoughts
and
beliefs
about the world resulting from direct practice with trauma survivors.

SECONDARY TRAUMATIC STRESS
is characterized by the presence of
Post Traumatic Stress Disorder
like
symptoms
after engaging in an empathic relationship with a trauma survivor and bearing witness to the intense and/or horrific experiences of that client's trauma.

VICARIOUS TRAUMA
and
SECONDARY TRAUMATIC STRESS
may occur independently of each other or concurrently.
Clinician related factors
current life circumstances
personal history of trauma or abuse
personality style
coping skills
Work related factors
paperwork demands
environmental stress related to change
competing priorities
changing demands
(Mathieu, 2007)
Factors contributing to
SECONDARY TRAUMATIC STRESS
symptoms of
VICARIOUS TRAUMA
burnout is not specific to the mental health field, and in fact was first described in the industrial field.
(DeAngelis, 2002)
who is at
RISK ?
SECONDARY TRAUMATIC STRESS:
Any professional in a position to hear the recounting of traumatic experiences is at risk.
Risk is higher if you:
are a woman
are highly empathic by nature
have unresolved trauma
carry a high caseload of traumatized clients
are socially or professionally isolated
feel compromised due to inadequate training
(National Child Traumatic Stress Network, 2011)
Studies show that from 6-26% of therapists working with traumatized populations are at high risk of developing Secondary Traumatic Stress.

50% of clinicians who work with trauma survivors report feeling distressed by their work.

30% of clinicians who work with trauma survivors report experiencing "extreme distress".
(National Child Traumatic Stress Network, 2011)
the focus of
Vicarious Trauma
is less on trauma symptoms, and more on the cognitive changes that occur following the exposure (acute or cumulative) to another person's traumatic material
the primary symptoms of
Vicarious Trauma
are disturbances in the clinician's cognitive frame of reference with regard to trust, safety, control, esteem and intimacy
(National Child Traumatic Stress Network, 2011)
(Meichenbaum, 2007)
Vicarious Trauma
can detrimentally affect one's:
Relationship with meaning and hope
Ability to get one's psychological needs met
Sense of humor
Ability to protect oneself
Memory/Mental imagery
Existential sense of connection to others
the
stressors
are accepted as real and legitimate;
the
problem
is viewed as a problem for the entire group not limited to a specific individual;
the general approach to the problem is to
seek

solutions
, not to assign blame;
there is a high
tolerance
level for individual
idiosyncrasies
;
support
is expressed clearly, directly, and abundantly in the form of
praise
,
commitment
, and
affection
;
communication
is open and effective; there are few sanctions against what can be said,
the quality of
communication
is
good
,
messages
are clear and direct;
the group is highly
cohesive
and there is considerable
flexibility
of roles;
resources
– material, social, and institutional – are utilized efficiently;
there is
no
subculture of violence and
no
substance abuse
(Catherall, 1995)
the environments that are most likely to promote
HEALING
from
Secondary Traumatic Stress
/
Vicarious Trauma
contain the following:
No one who, like me, conjures up the most evil of those half-tamed demons that inhabit the human beast, and seeks to wrestle with them, can expect to come through the struggle unscathed.

-Sigmund Freud
FORMAL assessment
INFORMAL assessment
Professional Quality of Life Scale

(ProQOL)
30 item questionnaire
items are rated on a 1-5 scale

items are divided into 3 separate scales
Compassion Satisfaction Scale
Burnout Scale
Secondary Traumatic Stress Scale
each scale is given a level of low, average or high
1=never 2=rarely 3=sometimes 4=often 5=very often
Stamm, B.H. (2010). The Concise ProQOL Manual, 2nd Ed. Pocatello, ID: ProQOL.org.
(Stamm, B.H., 2010)
easy to use
great way to start a conversation
stable over time
research based
not designed for diagnosis purposes
questions to ask yourself:
How am I doing?
What do I need?
What is hardest about this work?
What worries me most about my work?
What changes, if any, do I see in myself that I do not feel comfortable with?
Am I experiencing any symptoms of Vicarious Trauma/Compassion Fatigue/Secondary Traumatic Stress/Burnout?
What is my sense of personal accomplishment in my work?
What barriers get in the way of my having more satisfaction, and how can I address the barriers?
What am I doing to take care of myself?
Am I utilizing my social supports? How can I use them more effectively?
Is there anything about my work experience that I have not told anyone, that I am keeping secret? What is the impact of doing so?
(Meichenbaum, 2007)
questions to really challenge yourself with:
What are my own issues, and how do they play out in my therapeutic work?

How do I find balance between caring too much and not caring enough?

How do I handle situations in which what is in my best interest is in conflict with what is in my client's best interest?

How can I keep growing personally and professionally while working with my clients?
(Kohlenberg, 2006
The most positive outcomes for addressing secondary traumatic stress result from a multidimensional approach to prevention and intervention involving the
individual
,
supervisors
and
organizational policy.

(NCTSN, 2011)
It is likely not possible to completely avoid Secondary Traumatic Stress, therefore, creating Resiliency becomes crucial.
Individual
Approaches:
KEYS to RESILIENCY
maintaining balance in your life
maximizing self-care
finding time for fun
setting realistic goals
educating yourself
becoming aware of the signs and symptoms
seeking out ongoing education about working with trauma
seeking support
utilizing supervision
relying on colleagues
(NCTSN, 2011)
Organizational
Approaches:
TRAUMA INFORMED SYSTEMS of CARE
TRAUMA INFORMED SYSTEMS
of
CARE
:
recognize the
impact of secondary trauma
on the workforce
recognize that
exposure to trauma is a risk
of the job of serving traumatized individuals
understand that
trauma can shape the culture
of organizations in the same way that it shapes the world view of individuals
understand that a
traumatized organziation is less effective
in managing the trauma of others
develop the capacity to
translate knowledge
of working with trauma into
meaningful action
,
policy
and
improvements

in

practice
Supervisory Approaches
: an
ACTIVE ROLE
NURTURE
awareness
balance
connections
BALANCE
the composition of caseloads
PROMOTE
debriefing
ADDRESS
boundary issues
CREATE
a supportive culture
avoid blame
normalize clinician responses to trauma in clients
provide opportunities for case consultation
provide ongoing training and clinical supervision
(Meichenbaum, 2007)
(NCTSN, 2011)
"Physician, heal thyself."
(Luke 4:23)
what gets in the way:
self-blame
: "It's just me"
shame
: "I'm embarrassed to admit it"
self-sacrifice
: "I don't want to bother anyone"
denial
: "If I ignore it, it'll go away"
job security
: "I can't seem weak"
pressure
: "I don't have time for this"
cost
: "I can't afford to take time off"
(University of Iowa, 2009)
BALANCE
SELF-CARE
balanced nutrition
adequate sleep
exercise
spirituality
creative outlets
stress-reduction activities
utilize vacation time
FINDING TIME for FUN
hobbies
friends and family
SETTING REALISTIC GOALS
this means not just knowing the signs in general, but being aware of how they manifest in
you
, and being able to notice changes over time
AVOID
backhanded compliments
an ongoing culture of crisis, where solutions are not formulated because all resources go to putting out fires
authoritarian decision making and rigid hierarchies
a culture of shaming, blaming and judgementalism
maintenance of order through isolation, splitting, over-control, manipulation and deceitful practices
development over time of a culture of toughness or meanness
denial that any real problems exist
a high degree of hypocrisy in daily functioning
active discouragement of confronting reality
Vicarious Trauma
/
Secondary Traumatic Stress
in dysfunctional systems
often dysfunctional systems can be characterized by:
this type of dysfunction may be a
fundamental
contributing factor
to the development of
Vicarious Trauma
or
Secondary Traumatic Stress
in clinicians
(Bloom, 2003)
most of us would likely agree that it is important to advocate for the reduction of stigma in mental illness
honestly ask yourself if you advocate as steadfastly to minimize that stigma for clinicians
What will
YOU
put in your
TOOLKIT
?
consider these possibilities:
regularly scheduled self check ins
personal warning signs including descriptors of different points on a likert scale
reminders of what you truly have control over, and what you should let go of
stress relief strategies you enjoy
reminders of your successes
a lunch date out of the office (don't talk about work)
a new hobby
meditation, yoga, other mindfulness breaks
what if prevention and resiliency aren't enough?
TREATMENT is a GOOD OPTION
:
particularly cognitive behavioral and mindfulness based approaches which are emerging as best practice.

SELF CARE GROUPS
: promote healing particularly when individuals encourage each other to balance stressors and utilize healthy coping.

ADJUSTING RESPONSIBILITY
: through changing roles, or even seeking out a new job, may be necessary.

Special Case Consideration: Working with Suicidal Clients
full time psychotherapists will average 5 suicidal clients per month, especially among clients with a history of trauma
1 in 2 psychiatrists and 1 in 7 psychologists report losing a client to suicide
1 in 6 individuals who die by suicide, die while in active treatment
work with suicidal clients is considered the most stressful of clinical endeavors
such distress can be further exacerbated by legal actions as 25% of family members of suicidal clients take legal action against the client's treatment team
(Meichenaum, 2007)
Preparing for the potential for Suicide in trauma survivors
be informed about possible warning signs
conduct ongoing risk assessments
implement best practice guidelines for managing suicidal clients
seek clinical guidance and supervision
(Meichenbaum, 2007)
RESPONDING to CLIENT SUICIDE
Procedural Responses (immediate)
contact all who need notification according to your agency policy
consider attending the funeral
Emotional Responses (soon)
attend to your need to mourn
seek support from your supervisor, colleagues, personal supports
use cognitive strategies to dispute dysfunctional self-statements and beliefs
Educational Responses (later with superviosr or colleagues)
write a case summary including course of treatment
review case formulation, identifying risk and protective factors
review intervention strategies
(Meichenbaum, 2007)
Mathieu, F. (2007). Running on empty: Compassion fatigue in health professionals.
Rehabilitation and Community Care Medicine
, (16) 1.
Meichenbaum, D. (2007). Self-care for trauma psychotherapists and caregivers: Individual, social
and organizational interventions. Retrieved from http://www.melissainstitute.org/documents/
Meichenbaum
Newell, J.M. & MacNeil, G.A. (2010). Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue: A review of theoretical terms, risk factors, and preventive methods for clinicians and researchers.
Best Practices in Mental Health
, 6 (2).

National Child Traumatic Stress Network, Secondary Traumatic Stress Committee. (2011). Secondary traumatic stress: A fact sheet for chil-serving professionals. Los Angeles, CA, & Durham, NC: National Center for Child Traumatic Stress.
DeAngelis, T. (2002). Normalizing practioners' stress.
Monitor on Psychology
, 33 (7).
McCann, L. & Pearlman, L.A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3 (1).
(NCTSN, 2011)
Figley, C.R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C. R. Figley (Ed.),
Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized
(pp.1-20). New York, NY: Brunner/Mazel.
Pines, A. & Aronson, E. (1988). Career burnout: Causes and cures. New York: Free Press.
Pearlman, L.A. (1998). Trauma and the self: A theoretical and clinical perspective.
Journal of Emotional Abuse
, 1 (1).
Pearlman, L.A. (1999). Self-care for trauma therapists: Ameliorating vicarious traumatization. In B. Hudnall Stamm (Ed.),
Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators.
Baltimore, MD: Sidram Press.
Rothschild, B. & Rand, M. (2006).
Help for the helper, self-care strategies for managing burnout and stress: The psychophysiology og compassion fatigue and vicarious trauma
. New York: W. W. Norton.
Catherall, D.R. (1995). Preventing institutional secondary traumatic stress disorder. In C. R. Figley (Ed.),
Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized.
New Yoir, NY: Brunner/Mazel.
Kohlenberg, B. S., Tsai, M., & Kohlenberg, R.J. (2006). Functional analytic psychotherapy and the treatment of complex posstraumatic stress disorder. In V.M. Folletter & J.I. Riezek (Eds).
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