Caring for Caregivers: Personal, Supervisory, and Organizational Approaches to Addressing Compassion Fatigue
by Christina L. Scanlon, reprinted from REFOCUS, Vol. 18, 2013
Along with countless others in the helping field, those working in residential treatment are charged with the role of compassionately responding to those in need of care. Often, we find ourselves providing care and treatment for children and youth who have experienced significant trauma in their lives. In doing so, we encounter both positive and negative aspects of working in such an emotionally demanding field. When considered together, these positive and negative aspects of a person’s professional life comprise that person’s overall professional quality of life (Stamm, 2010).
Stamm (2010) defines professional quality of life as the “quality one feels in relation to their work as a helper” (p. 8). As residential workers, our professional quality of life hangs in the balance between the satisfaction and stress that we feel as a result of working with challenging children and youth. Such positive and negative experiences in the helping fields are called compassion satisfaction and compassion fatigue (Stamm, 2010).
While compassion satisfaction refers to the pleasure one derives from working to help others, this article focuses on the more nefarious component of professional quality of life: compassion fatigue.
Compassion Fatigue: The Cost of Caring
In 1995, Charles Figley coined the term compassion fatigue to refer to the "cost of caring" experienced by those working with people affected by traumatic experiences or suffering. Compassion fatigue consists of two elements: burnout and secondary traumatic stress (Figley, 1995).
Burnout refers to a state of exhaustion resulting from repeated exposure to emotionally demanding situations (Maslach, Schaufeli, & Leiter, 2001; Pines & Aronson, 1988). The concept of burnout has been studied extensively by organizational psychologists and has long been linked with the components of emotional exhaustion, depersonalization, and job dissatisfaction (Maslach et al., 2001). Whereas people intuitively seem to grasp the concept of burnout, secondary traumatic stress, the second element of compassion fatigue, is less well understood and is unique to the helping professions.
Before being able to fully understand the concept of secondary traumatic stress, one must first understand what might constitute a traumatic event. Per the American Psychiatric Association (2000), a traumatic event involves some level of exposure to an incident that involves actual or threatened death, injury, or harm. Directly experiencing, witnessing, or learning about any such events may result in traumatic stress for an individual (APA, 2000). Most people recognize that direct personal experience or first-hand witnessing of traumatic events connect to the experience of acute or post-traumatic stress. However, few recognize that second-hand, or vicarious, experiences of someone else’s trauma can result in traumatic stress as well. When a person experiences traumatic stress as a result of learning about someone else’s trauma, they are facing secondary traumatic stress.
Figley (1995) defined secondary traumatic stress as “the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other—the stress resulting from helping or wanting to help a traumatized or suffering person” (p. 7). Simply stated, those who work with the traumatized may in turn become traumatized themselves as a result of their vicarious exposure to trauma.
This secondary traumatic stress mimics the symptoms of post-traumatic stress, with the only difference between the two being the level of exposure to trauma (Figley, 2002a). When traumatic stress as a result of direct exposure to trauma causes significant impairment to an individual’s ability to carry out normal functions or activities, a person may be diagnosed with post-traumatic stress disorder (APA, 2000). Similarly, if a professional in the helping field experiences significant stress or impairment in relation to secondary exposure to trauma, they are said to be experiencing secondary traumatic stress disorder (Figley, 2002a), a term inextricably linked to compassion fatigue.
Thus, compassion fatigue is the combination of the emotional exhaustion associated with burnout and traumatic stress resulting from vicarious exposure to trauma. Because many of the children entering residential treatment have histories that include trauma in addition to the intense emotional and physical demands of the residential milieu, it is safe to assume that residential treatment workers are likely to experience compassion fatigue.
Compassion Fatigue: Signs and Symptoms
The effects of compassion fatigue permeate both professional and personal life. Figley (2002b) described numerous cognitive, emotional, behavioral, spiritual, relational, somatic, and professional impairments that were related to the compassion fatigue. The main symptoms of compassion fatigue as tension, preoccupation with trauma, intrusive imagery, avoidance, hyper-arousal, anxiety, and emotional numbing (Figley, 2002a, 2002b).
Other notable symptoms of compassion fatigue include decreased self-esteem, irritability, inability to concentrate, withdrawal from friends and family, depression, sleep disturbances, anger, and fear (Figley, 2002a, 2002b). While there are too many symptoms to provide a complete list in this article, you will recall that the symptomology of secondary traumatic stress align directly with those of post-traumatic stress.
In addition to Figley’s work, a large body of literature addresses the effects that compassion fatigue has on professional capabilities. Compassion fatigue affects a caregiver’s ability to provide care due to increased risk of poor professional judgments (Bride, Radey, & Figley, 2007), and high levels of compassion fatigue can lead to decreased quantity and quality of work, low motivation, higher likelihood of mistakes, avoidance of trauma-related tasks, and obsessive attention to details (Yassen, 1995).
Furthermore, those experiencing compassion fatigue and burnout are prone to absenteeism, chronic lateness, and resignation (Collins & Long, 2003; Meldrum, King, & Spooner, 2002). It should come as no surprise that in environments where staff members are experiencing compassion fatigue, staff morale is compromised (Meldrum et al., 2002). Interestingly, both those experiencing compassion fatigue and their non-afflicted co-workers report low morale in these environments.
Finally, compassion fatigue has been shown to affect the relationship between the caregiver and the client (Valent, 2002). Valent (2002) proposed a cycle in which a caregiver’s compassion fatigue may manifest in “nonrecognition, denial of client traumas, fragmented attention, lack of empathy, intellectualization, dehumanization of victims as cases or research subjects, and partial and foreclosed diagnoses and treatments” (p. 29). Because the caregiver-client relationship is reciprocal, these caregiver behaviors result in changes in the client, and the client may begin to view their caregiver as “naïve, ignorant, limited, patronizing, denigratory, unsympathetic, lacking understanding and compassion, and at worst more traumatic than the original trauma” (Valent, 2002, p. 29). Client’s views of caregivers experiencing compassion fatigue may spawn negative client interactions, including client “distress, acting out, intensification or symptoms, decompensation, and premature termination of treatment” (Valent, 2002, p. 29). These factors create a more tenuous work environment, likely contributing to the caregiver’s continued experience of compassion fatigue.
Clearly, the symptoms associated with compassion fatigue not only affect caregivers personally and professionally, but they also have a detrimental impact on the client-caregiver relationship that impedes progress in a treatment program.
Addressing Compassion Fatigue
The emergence of compassion fatigue symptoms in those who work with disturbed or traumatized people is likely, and these professionals have an increased risk of negative changes occurring in their own psychological functioning (Chrestman, 1995). With compassion fatigue affecting caregiver well-being and potentially the efficacy of treatment programs, the prevention and management of both burnout and secondary traumatic stress is a critical component of maintaining a therapeutic environment. The following paragraphs outline how individuals, supervisors, and organizations can address compassion fatigue.
Many researchers endorse self-care practices in order to treat and prevent symptoms of compassion fatigue (Eastwood & Ecklund, 2008; Figley, 1995, 2002a; McCrea & Bulanda, 2008; Meyers & Cornille, 2002; Radey & Figley, 2007). Eastwood and Ecklund (2008) provided a comprehensive list of suggestions for preventing and coping with compassion fatigue, with most of their suggestions falling into one of four categories of general practice:
• Develop and use a social support network;
• Make time for yourself, both while at work and at home;
• Take care of yourself physically and emotionally; and
• Seek help when you need it.
Eastwood and Ecklund also offered more specific strategies for engaging in self-care, suggesting practices such as taking vacations, taking short breaks while at work, engaging in hobbies, planning activities with friends and family, eating well, exercising, getting enough sleep, and evaluating the meaningfulness of the helping profession through conversations with supervisors and coworker support. Stamm (2010) reiterates the importance of reflecting upon the meaningfulness of one’s work as a helper, emphasizing the role of compassion satisfaction in one’s professional quality of life.
Because of the insidious nature of compassion fatigue and its intricate ties with the helping field, residential workers will often not recognize the warning signs of compassion fatigue in themselves; hence, it becomes vitally important for all staff to be knowledgeable about the signs and symptoms of compassion fatigue so as to recognize a coworker’s potential struggle (Figley, 2002a).
However effective self-care measures might be, individual self-care cannot be the only mediation against risk for compassion fatigue. Researchers have found that burnout in particular is based more on situational and organizational factors rather than on individual factors due to the different demands imposed upon the individual while in the work setting (Maslach et al., 2001). Collins and Long (2003) asserted that “personal, professional, and organizational support may provide protective factors to mediate against some of the risks relating to the development of secondary traumatic stress” (p. 423).
Lakin, Leon, and Miller (2008) stress the importance of education and prevention programs about compassion fatigue and call for management to play an active role in addressing the issue. In attempts to provide guidance for prevention and intervention for helpers experiencing compassion fatigue, Meyers and Cornille (2002), highlight five key elements for effective programming, including improving training, handling on-the-job victimization, providing a supportive work environment, limiting work hours, and encouraging personal care.
Several researchers have identified proactive strategies for addressing compassion fatigue from a supervisory perspective. For example, Eastwood and Ecklund (2008) emphasized the importance of open discussions about compassion fatigue and emotional competence, professional development, maintaining adequate staffing ratios, conducting thorough incident debriefings, and encouraging self-care.
Stamm (2010) advocates for the active monitoring of secondary traumatic stress, burnout, and compassion satisfaction using the Professional Quality of Life Scale (ProQOL). Available for free online (www.proqol.org), the ProQOL can be used as a means to promote self-monitoring amongst staff members. The ProQOL can also be used to gather information about a group of employees to discern general levels of secondary traumatic stress and burnout on an organizational level.
Figley (2002c) describes preventative institutional policies and procedures to proactively address compassion fatigue at an organizational level. Many of these policies and procedures, such as stress debriefings, stress management plans, and an awareness of the risks and costs of working with traumatized populations (Figley, 2002c), echo those outlines in popular trauma-informed care models. In addition, Figley (2002c) recommends that organizations
• Screen applicants for resilience and awareness of the way the field affects personal and family life;
• Promote the 5:1 ratio rule in which employees are encouraged to spend one hour of personal processing, whether during or after work, for every five hours spent working with cases of those who have been traumatized;
• Incorporate humor and stress reduction into daily routine;
• Encourage staff members to promote coworker health and self-care and discourage unhealthy coping strategies, such as substance abuse; and
• Routinely recognize personal and group achievement and accomplishments.
Figley’s (2002c) final suggestion for preventative strategies for organizations in regards to compassion fatigue is to encourage staff members to leave their work at work, emphasizing the role of the worker as devoted to personal life over their role as a helping professional. However, in my professional experience, the workplace mantra tends to be one where employees are expected to abandon personal and family life at the door on the way in to work, rather than to leave their work life behind when going home for the day. By recognizing that the personal circumstances of the employee outside of work outweigh the importance of work-related circumstances, organizations prioritize the personal over the professional, which in turn promotes self-care and a supportive organizational culture.
When on an aircraft, passengers are warned during safety protocol reviews that in case of a loss of cabin pressure, a person should apply his or her own oxygen mask before assisting others. As residential workers, assisting others is at the core of what we do; yet, as we strive to care for children and youth in residential treatment, we have to first remember to take care of ourselves. In doing so, we create an environment that supports the best interests of the child by supporting the best interests of those working in it.
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Christina Scanlon is a doctoral student and teaching fellow at the University of Pittsburgh where she studies Applied Developmental Psychology. During her seven year career in residential treatment, Christina has worked in direct care, supervisory, administrative, and training capacities. Currently, she works as a TCI trainer in the Pittsburgh area.