Friday, March 20, 2015

Thinking about Compassion Fatigue, Vicarious Trauma and Burnout

I was recently asked by a health care professional if I thought that the terms compassion fatigue and vicarious trauma were still contestable. I am thankful for his question, which seems to have got me thinking and writing again after a period of blogger's block!

Up until relatively recent decades it has been contested whether exposure to armed combat and other seriously threatening situations is a definite cause of PTSD. During the last century various other concepts were put forward as an explanation, implying a weakness of character, a nervous disorder, a ‘fragile heart’ and even malingering as the more likely causes. In some cases the malingering concept was used to justify the withdrawal of financial benefits to war veterans, as the benefits were deemed to be fueling the problem.

Therefore, the idea that a person may experience compassion fatigue or vicarious trauma, as a result of working with people in need would inevitably be contested. However, these days there seems to be an acceptance that the concepts are a reality that need to be taken seriously. Compassion fatigue and vicarious trauma clearly imply being involved with people, whereas the more general term burnout can be applied to most work situations. For example, a Truck Driver may be temporarily ‘burnt out’, by driving too many miles or hours without adequate rest breaks. A few years ago I was watching a market trader selling meat. Instead of the usual sales banter he started tossing meat out to the gathered crowd and complaining that he hadn’t had a holiday in years and had to get up at 5am every morning.

While we can see and agree to the reality of compassion fatigue, vicarious trauma and burnout, the specific language we use will frame the problem in a certain way, influencing how we understand and respond to it. A term like ‘compassion fatigue’ is one way of saying something about a certain reality. It is like a metaphor for something, but on its own does not explain everything involved.

It is completely incontestable that people have an impact on each other for better and worse.  If someone spends most of their working day engaged with people, the needs and moods of those people can have a huge impact. Spending a few minutes with a highly distressed, traumatized person in an agitated state can quickly get under one’s skin. As, in a different way, can spending time with a depressed, withdrawn person.  It can actually be a necessary and vital part of the work that we are able to allow the other to have an impact on us and get under our skin. Some young people I have worked with would not give up agitating and provoking until they got a reaction.  They needed to know that they could get through and have an impact. Otherwise their sense of insignificance and worthlessness would be affirmed.

It is how the impact is responded to that is the critical issue for all involved - the worker, the ‘client’ or other and the wider context, family, team, organization, etc.  The language we use to understand the problem will influence our response.  If we use the term ‘compassion fatigue’ it suggests that the problem is caused by compassionately giving too much to others, who are therefore implied to be demanding. The term creates a focus on the demands involved, like maybe there are too many children to look after, maybe the caseload is too big?

However, as in all demanding, stressful and potentially threatening situations, different people respond differently. It may turn out that one person who has ‘compassion fatigue’ has been neglecting their own needs, maybe out of guilt or a lack of self-worth? There may be many different reasons. Looking at the problem from this angle, a term like ‘Self-Neglect Fatigue’ could be used. This would focus the issue more on the person suffering the fatigue and how he/she is managing the situation. This focus could become persecutory and unhelpful, especially if the fatigued person felt blame rather than empathy. It should also be added at this point that feeling upset, distressed and shocked among other strong emotions, are often normal, healthy reactions. However, when we are talking about fatigue it is the difficulty in returning to a sense of stability that is the problem.

A professional in the air flight business, gave the example anyone who flies on a plane will know. In the safety briefing, passengers are told that before fixing the oxygen mask on anyone else, including your own children, make sure yours is fixed first. In other words, we might need to look after ourselves if we are to be of any use to someone else. This can seem counter-intuitive as the natural reaction of a parent is often the other way round. The same can apply in the ‘human services’ where it might feel that self-care is somehow equal to neglecting the other, whose needs might seem overwhelming in comparison. Cultures based on guilt, self-sacrifice and martyrdom can become dominant.

This raises the further possibility of the context of support as another key factor. In this case, we could use a term like ‘Lack of Support Fatigue’. This term would create a focus more on the context, family networks, professional support, organization culture, etc. 

In reality, all of the above factors are related to any one situation.  It is the interplay between them that needs to be understood and worked with.  I think we do need to be aware of how language tends to frame how something is understood and thought about. A helpful way of thinking is one which encourages all relevant parties to acknowledge the reality, consider its roots and take appropriate responsibility. A narrow approach might lead to a tendency to shift the responsibility in one direction, i.e. onto the 'client', the worker or the organization; or the child, the parent, the family or the community. As Isaac Prilleltensky (2006) has argued, ‘There cannot be well-being but in the combined presence of personal, relational, and collective well-being’.

When understanding becomes too narrow the more likely it becomes contestable. It cannot be seriously contested that in virtually any workplace, the nature of the work experience is a key factor in the worker’s overall well-being. It is important to maintain our awareness and keep an open mind to the combination of factors that may be impacting upon us.  Then the challenges and stresses involved in the work, rather than leading to vicarious trauma, compassion fatigue and burnout, instead can lead to personal and professional growth and development.

Reference

Prilleltensky, I. (2006) Psychopolitical validity: Working with power to promote justice and wellbeing, Paper presented at the First International Conference of Community Psychology, San Juan, Puerto Rico, 10 June 2006

Comments

Traci Cimino, Social Worker/Consultant, Canada
Patrick thanks for highlighting the importance and influence of language. Your use of ‘Lack of Support Fatigue’ seems more encompassing, or at least less narrow. There is no inherent assumption on where the "lack" is coming from therefore allows for a more open exploration.

Sujata Jayaprakash, Co-Founder Of Kites Global & Manager Caring for Carers In Residential Homes, India
Thank you Patrick for sharing this article. It is so, so important and crucial before things get critical. In our work with caregivers in India we have been emphasizing on self-care and have started talking about Vicarious Trauma as part of our training and have introduced EQ group therapy for caregivers in homes, a skill that changes everything.

Janey Kelf, Training in Art Therapy, Australia
Yes good article helped me as now Oxygen mask could stand for yoga, fun with friends, a swim a nothing day for rest and relaxation filled with yummy food and nothing that must be done...

Clodagh King, Programme Manager, Carmona Residential Services, Ireland
Great piece- insightful. I am sure that staff working directly with individuals will be happy to have this quite simply recognised and affirmed. Delighted your bloggers block has come undone...

Neil McMillan, Head of Service (Independent Child Protection Consultant), Scotland
Nice piece. I liked the airline metaphor. With staff I often use the lifesaving metaphor for self-care, 'don't jump in to save a life when you can't swim’.
  


Thanks Neil - early in my career our clinical consultant at the time, Barbara Dockar-Drysdale told me when I was wondering if I could survive the extremely testing behavior of the young people - 'sometimes the most important thing you can do is to survive and be there the next morning'. It was good advice and seemed manageable! It was also an empathetic response as I didn't feel that much else was possible.