Wednesday, January 23, 2019

Thinking about Compassion Fatigue, Vicarious Trauma, Secondary Stress and Burnout



I was asked by a Health Care Professional if I thought that the terms compassion fatigue and vicarious trauma were still contestable today.  I was thankful for the question and wrote a blog on it in 2015.  My research and experience since then have led me to develop it.  

Up until relatively recent decades it had been contested whether exposure to armed combat and other seriously threatening situations is a definite cause of PTSD.  During the last century other concepts were put forward as an explanation, implying that 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.  It was argued that the benefits were fueling the problem.

Therefore, the idea that a person may experience compassion fatigue or vicarious trauma, as a result of 'merely' working with people in need would inevitably be contested.  However, there now seems to be a general acceptance that the concepts are a reality that needs to be taken seriously.  

Compassion fatigue, secondary stress and vicarious trauma clearly imply being involved with people, whereas the more general term burnout can be applied to many situations.  For example, truck drivers are often under significant stress, which may lead to burnout.  On the one hand they may feel pressure to put in the hours and miles but are also often worried about being away from family and home.  It is an isolated kind of job. On top of that they may witness traumatic events on the roads they travel (Balay and Shattell, 2016).

A few years ago, I was watching a market trader selling meat.  Instead of the usual humorous sales banter he started throwing meat out at the gathered crowd and ranting that he hadn’t had a holiday in years and had to get up at five every morning. This behaviour fits with burnout, which includes qualities such as lethargy, depression, and cynicism – it is more than simply being exhausted.

Compassion fatigue, vicarious trauma and secondary stress are typically related to those who have a role in working with and caring for others who are suffering. Compassion fatigue may be related to roles such as being a care worker for the elderly or a doctor.  Figley (2015) refers to it as the natural, predictable, treatable, and preventable unwanted consequence of working with suffering people.

Vicarious trauma is more related to working with people who have suffered trauma. Bloom (2003) describes it as the cumulative transformative effect on the helper of working with survivors of traumatic life events. The symptoms of vicarious trauma are like those of PTSD. 

Whereas vicarious trauma is cumulative, secondary traumatic stress can happen quickly in relation to a traumatic event happening to another. It could be caused by the severity of the situation and/or a personal trigger.  Bloom (2003) says it is the, 
…natural, consequent behavior and emotions that result from knowledge about a traumatizing event experienced by another and the stress resulting from helping or wanting to help a traumatized or suffering person.
Again, the symptoms are almost identical to those of PTSD.  The symptoms of PTSD include disruptions and distortions to a person’s view of the world and themselves. He or she may experience a loss of identity and view the world and those in it as more dangerous and malevolent, untrustworthy, exploitative, or alienating.  While we can agree to the reality of these four concepts, the specific language we use frames 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 reality.  It is metaphor, but on its own does not explain everything involved.  

It is 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, hyper-vigilant traumatized person can quickly ‘get under one’s skin’.  As can spending time with a depressed, withdrawn person in a different way.  It may even be a necessary part of the work that the 'other' is able to get under our skin.  Some young people I have worked with would carry on with their difficult behaviour until they knew they had got through and made an impact.  Otherwise their sense of insignificance and worthlessness would be affirmed.  Getting someone angry or upset at least meant being alive and visible, rather than insignificant and invisible.   

It is how the impact is responded to that is the critical issue for all involved - the worker, ‘client’ or other and the wider context, family, team, organization, etc.  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 there are too many people to look after, or maybe the caseload is too big?

However, as in all demanding, stressful and potentially threatening situations, 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 or she is managing.  However, this focus could feel persecutory and unhelpful, especially if the person felt blamed. 


Every person also has their unique defence mechanisms and levels of resilience. This is very significant to how a person responds to stressful situations and what can be managed.  Some defence mechanisms may be helpful, enabling a natural protective response. Others may be less helpful leading to reactions that need to be managed. The important thing is that a person develops an awareness of their own tendencies and brings them into consciousness. This will help make responses and reactions more manageable and less likely to add further stress into the situation (Tomlinson and Khaleelee, 1997).

Friedman (1999) claimed that the empathetic focus on the other is unhelpful when it leads to a neglect of one’s self and own needs.  He argued that the focus on the other and his or her feelings, not only shifts attention away from what one needs for oneself, but also often removes a sense of responsibility from the other. This may undermine resilience, making matters worse.

Compassion can be understood as, to feel or suffer with. If anyone spends a lot of time with those who are suffering, an important question is how much suffering can be borne. Apparently when the 14th Dali Lama was asked how he managed to be in touch with so much suffering in the world, he said, in glimpses. In other words, compassion needs to have limits put around it.  
Givers have to set limits because takers rarely do (Irma Kurtz, 2003).
A person who is overwhelmed with compassion is not much use to anyone.  A friend in the air flight business, gave me 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 need to look after ourselves if we are to be of any use to someone else.  This can seem counter-intuitive, the natural reaction of a parent is often the other way around.  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.  Friedman says there is more to it than putting one’s own oxygen mask on first, 
This is not merely a matter of putting one’s own oxygen mask on first.  It has to do with leaders, (or parents or healers) putting their primary emphasis on their own continual growth and maturity……the focus on empathy, because it encourages primary emphasis on others, subverts the nature of that self-differentiating process.
In some cases, compassion may not be the most helpful ingredient.  In the case of parenting he argues, 
Parents cannot produce change in a troubling child, no matter how caring, savvy, or intelligent they may be, until they become completely fed up with their child’s behaviour.
Being completely fed up with a child doesn’t sound very compassionate!  But as Friedman says there are times when it may be necessary and helpful.  An excessive focus on compassion may well lead to compassion fatigue. Having compassion should not exclude having boundaries, expectations and holding someone responsible. 

Similarly, in the way it orientates our focus, the concept of self-care may also be unhelpful. It could be taken to mean that we enter demanding situations and then look after ourselves afterwards and in-between. Make sure we eat well, exercise, enjoy relaxing activities, etc. These are all important but not no more so than how we manage and develop ourselves in every aspect of our life, including the demanding situations we are in. 

Self-management may be a more useful focus than self-care.  For example, how do we respond to a challenging young person? With a focus on empathy and/or an expectation of responsibility? In general life, how do we consider our ways of responding? How do we healthily assert ourselves? How we manage ourselves is a critical factor in preventing burnout, compassion fatigue, vicarious trauma and secondary stress.  Friedman goes as far to say, and one could apply this more universally,

That all leadership begins with the management of one’s own health.

And when Friedman refers to leadership, he uses the phrase “from parents to presidents”. 

There are always three variables involved in the issues we are thinking about – the event(s), the environment (home, family, work, community, society) and self.  Self is the one variable that we are most responsible for and can do most about. That doesn’t mean we don’t need the help and support of understanding others.  However, we do need to have a strong sense of self-management and development.

Similarly, to Friedman, Menzies Lyth (1979) argues that management must be clear about task, roles and responsibility. When this is done effectively, workers can experience the satisfaction of doing their job well. It is better to achieve a realistically defined task rather than continuously fail at an impossible task. It could be argued that one of the contributions to compassion fatigue and burnout is unrealistic framing - wanting and aiming to do more for the other than is possible.  It can be exhausting and demoralizing to feel that one has never done enough.  There needs to be a well-defined match between what is to be achieved and the resources available.   This is true for organizations and individuals.  Being realistic in this way might even feel as if it is uncaring and lacking compassion.  

Menzies Lyth argued that this is especially a major challenge for managers and workers in the human services. The feelings involved in the work can lead to a lack of authoritative management.  The very real painful issues that are often involved in working with people who are suffering can also lead to unconscious defensive responses.  These defence mechanisms, whilst protecting against anxiety and emotional pain, necessarily also avoid and distort the real issues. Therefore, to prevent this from becoming unhelpful to everyone there must be a quality of support available that makes the pain bearable.      

As well as each person being different, each situation is also unique. The environment a person is in will have a big influence on how he or she experiences whatever takes place. Leadership and support are key issues in any environment. The psychoanalyst Wilfred Bion worked in a therapeutic community for soldiers having difficult in resettlement following WW2.  He said that whether a soldier developed panic in battle, depended on how the battle was managed. Trauma is in the system not the event. The system includes the individual and everything he or she is related to, directly or indirectly. 

Borjanić Bolić (2018) in her research on residential caregivers provides evidence that these systemic issues, such as quality of leadership, support and training are all related to the likelihood of individuals developing burnout, etc. They effect morale and positive morale is a protective factor. She argues that qualities such as engagement and ‘compassion satisfaction’ are protective factors.  Interestingly, she found these qualities or the absence of them were more significant in relation to burnout, than the number of years worked or the level of a person’s responsibility. While the absence of these qualities could also be a symptom of burnout, it makes sense that where people have high levels of engagement and satisfaction, they are also likely to be more resilient. 

These findings are supported by research in other helping professions. It is therefore important to develop cultures where people feel valued and are helped to find meaningful satisfaction in their work.  To facilitate work engagement Bolić highlights the importance of, 
  • ·       providing access to support, training, supervision (individual and group) and reflective practice
  • ·       creating opportunities to use skills
  • ·       instilling a sense of control
  • ·       setting clear goals and expectations
  • ·       introducing variety and diversity to work roles
  • ·       providing sufficient pay
  • ·       maintaining physical safety
  • ·       helping staff feel valued 
I would add debriefing as a particularly important process following difficult incidents.  Where trauma is involved the support will need to be intensive, specialized and focused on the complex issues involved.  The aim is to provide a space where the difficult experiences and feelings involved can be expressed, reflected upon, processed and made sense of.  Working on the meaning a person attaches to an event is a vital part of the process.  As Van der Kolk and Newman (2007) state,

So, although the reality of extraordinary events is at the core of PTSD, the meaning that victims attach to these events is as fundamental as the trauma itself.

These principles related to support are likely to be helpful in any work environment. This highlights the issues of leadership, management, culture and support as key factors in the development of compassion fatigue, vicarious trauma, secondary stress and burnout.  In this sense, we could replace those terms with, ‘Lack of Support Fatigue’ or ‘Lack of Leadership Fatigue’, etc.  These terms would create a focus more on the context, professional support, organization culture, family and friends.  This may be more helpful if one considers burnout for example, as a symptom related to a systemic problem. Our approach, therefore, might be more focused on fixing the environment and not just the individual.  Highlighting the importance of the system or network Van der Kolk (2014) claims,

A good support network is the single strongest protection against becoming traumatized

It is the interplay between all these factors I have discussed 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 everyone 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 is too narrow the more likely it becomes contestable.  Today, 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.  If awareness of this is maintained, and we keep an open mind on the contributing factors, rather than leading to vicarious trauma, secondary stress, compassion fatigue or burnout - the stresses and challenges involved can lead to personal/professional growth and development.  Compassion satisfaction rather than fatigue is likely to be more common.

References
Balay, A. and Shattell, M. (2016) PTSD in the Driver’s Seat, The Atlantic, www.theatlantic.com/health/archive/2016/03/long-haul-trucking-and-mental-health/474840/

Bion reference – from, Menzies Lyth, I. (1998) Foreword, in Davies, R. (1998) Stress in Social Work, London and Philadelphia: Jessica Kingsley Publishers 

Bloom, S. L. (2003) Caring for the Caregiver: Avoiding and Treating Vicarious Traumatization, in Sexual Assault, Victimization Across the Lifespan, edited by A. Giardino, E. Datner and J. Asher. Maryland Heights, MO: GW Medical Publishing (pp. 459-470)

Borjanić Bolić, E. (2018) Secondary Traumatic Stress and Vicarious Traumatization in Child Welfare Professionals in Serbia, in Journal of Public Child Welfare, DOI: 10.1080/15548732.2018.1502117

Figley, C.R. (1995) Compassion Fatigue: Toward a New Understanding of the Cost of Caring, in Stamm, B.H. (ed) Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers and Educators, Lutherville MD: Sidran Press

Friedman, E.H. (1999) A Failure of Nerve: Leadership in the Age of the Quick Fix, New York: Church Publishing, Inc.


Khaleelee, O. and Tomlinson, P.  (1997) Intrapsychic Factors in Staff Selection at the Cotswold Community, Therapeutic Communities Journal, Vol 18 No. 4

Kurtz, I. (2003) in Cosmopolitan Magazine


Menzies Lyth, I. (1979) Staff Support Systems: Task and Anti-Task in Adolescent Institutions, in Containing Anxiety in Institutions: Selected Essay Volume 1, Free Association Books: London

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.


Van der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Viking: New York


Van der Kolk, B.A. and Newman, A.C. (2007) The Black Hole of Trauma, in van der Kolk, B. A., McFarlane, A. C. and Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press

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