Treating Compassion Fatigue

Charles R. Figley

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135454593
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

In recent years, much has occurred in the field of traumatology, including the widening of the audience and the awareness of PTSD (post-traumatic stress disorder). This book from celebrated traumatology pioneer Charles Figley, further clarifies the concept of compassion fatigue through theory, research, and treatment. The basic thesis of this book is the identification, assessment, and treatment of compassion fatigue and this is done over eleven chapters, each from distinguished researchers in the field.

Part I

CONTEMPORARY VIEWS AND FINDINGS

Introduction to Part I: Contemporary Views and Findings

The five chapters in this section help from the empirical, theoretical, and assessment basis for the volume. The first chapter promotes the wholist perspective. This perspective promotes the importance of viewing the traumatized as attempting to use all of the various systems to survive. In contrast to his previous books, here Valent attends to the special circumstances of being traumatized through our work. The next three chapters, although focusing on three different contexts, report similar results of their studies: that helping the traumatized is hard work and exacts an emotional toll. The final chapter of the section is the beginning of doing something about the problem of compassion fatigue. Here, Stamm emphasizes the importance of using a new self-test that measures not only the degree to which the respondent is at risk of burnout and compassion fatigue, but also satisfaction: how satisfied respondents are in their work with the suffering. It is the sense of work satisfaction that is the antidote to both burnout and compassion fatigue and makes the rest of the book especially important.

1

Diagnosis and Treatment of Helper Stresses, Traumas, and Illnesses*

PAUL VALENT

In the last two decades it has become accepted that people can be secondarily affected by the sufferings of others. The attunement and effort needed to help others in trouble may provide great rewards for helpers when they meet with success. But when they are strained, or worse, when they fail, helpers may be the next dominoes who follow primary victims in suffering themselves.

Although secondary stress and trauma have become widely recognized in traumatology, efforts to conceptualize them have taken place only recently. The purpose of this chapter is to overview these efforts and to extend some of my own recent conceptualizations of (primary) stress and trauma disorders (Valent, 1995, 1998a, 1998b) to secondary ones.

BACKGROUND

Soon after the recognition of traumatization and the need for early help for victims in the late 1970s and early 1980s, it became clear that helpers became secondarily affected. For instance, Berah, Jones, and Valent (1984) noted that helpers in a disaster outreach team suffered shock, depression, sadness, fatigue, sleep disturbance, and dreams about helpers being victims in the disaster. They also suffered reminders of past traumas and a variety of physical symptoms, colds and flus, as well as minor accidents.

The Scope of the Problem: A Wide Variety of Symptoms

A great variety of symptoms was described over the years, and one may say came to parallel the similar great variety of symptoms in victims. For instance, a selection from the previous volume of Compassion Fatigue (Figley, 1995a) described a heterogeneity of physiological and physical symptoms, some extending to serious illnesses, and ultimately a higher mortality rate among helper professionals than among controls (Beaton & Murphy, 1995). A similar heterogeneity of psychological symptoms included sadness, grief, depression, anxiety, dread, horror, fear, rage, and shame; intrusive imagery in nightmares, flashbacks, and images; numbing and avoidance phenomena; cognitive shifts in viewing the world and oneself, such as suspiciousness, cynicism, and poor self-esteem; and guilt for survival and enjoying oneself (Dutton & Rubinstein, 1995). Social problems included drug abuse and relational problems (Beaton & Murphy, 1995). Figley (1988) noted early that families also become secondary victims.

To add to the complexity of symptoms, it has been pointed out that they appear differently in different disaster phases (Beaton & Murphy, 1995; Valent, 1984), and they range from reflex responses to moral and philosophical dilemmas (Herman, 1992), existential meanings, and spirituality (Lahad, 2000; Pearlman & Saakvitne, 1995a, 1995b).

A Wide Variety of Helper Treatments

In parallel to the wide variety of helper symptoms, a wide variety of treatments has been advocated for helpers. Yassen (1995) suggested that the following provide resistance against helper stress and trauma: management of vital functions, such as sleep, food, exercise, rest, and recreation; contact with nature; maintaining structures of work; and limiting exposure to traumatic situations. Others have suggested peer, institutional, and personal help and support (Dutton & Rubinstein, 1995), whereas Munroe et al. (1995) suggested a special team that provides outside perspective and mediates helpers’ roles in the community. A number of workers emphasize the advantages of proper training, including helpers’ ability to read and care for their own stress responses.

For helpers who have been involved in traumatic situations, a variety of programs has been advocated. In order of proximity to the traumatic situation, they have included decompression, defusion, and a variety of debriefing programs ranging from single sessions to relatively ongoing care with peer support or professionals (McCammon & Allison, 1995). These programs vary in their educative, cognitive, emotional, and existential approaches.

Finally, some workers recommend supervision and personal therapy, especially for helpers who are involved in deep psychotherapy with clients with multiple early life traumas (e.g., Pearlman & Saakvitne, 1995a, 1995b).

Helper Stress and Trauma Conceptualizations

In order to make sense of the wide variety of symptoms and methods of treatment, some researchers have postulated phenomenological categorizations and mechanisms of symptom formation.

Regarding phenomenological categorizations, Figley (1995b) suggested that PTSD should be called primary posttraumatic stress disorder, whereas the same symptoms appearing secondarily to victim care in helpers should be called secondary traumatic stress disorder (STSD). The only difference between PTSD and STSD was that, in the latter, exposure was to the traumatized person(s) rather than to the traumatic event itself, and intrusion and avoidance symptoms related to the primary victim’s experience, not to one’s own. Figley (1995c) gave a special name, compassion fatigue, to the specific STSD resulting from deep involvement with a primarily traumatized person. Next, in parallel to the concept of (primary) stress, Figley delineated compassion stress (secondary traumatic stress, or STS). Here, helpers knew about, and were affected by, traumatizing events, but this did not reach traumatic STSD proportions.

However, just as for primary victims PTSD was insufficient to delineate and make sense of the wide variety of symptoms, so STSD did not heuristically delineate and make sense of the variety of symptoms described above. Figley (1995b) therefore distinguished two other commonly used terms that captured the significance of certain symptoms.

Burnout is a result of frustration, powerlessness, and inability to achieve work goals. It is characterized by some psychophysiological arousal symptoms, including sleep disturbance, headaches, irritability, and aggression, yet also physical and mental exhaustion. Other symptoms included callousness, pessimism, cynicism, problems in work relationships, and falling off of work performance. Burnout can result from the noxious nature of work stressors themselves or from hierarchical pressures, constraints, and lack of understanding.

Countertransference explains the mechanism of producing helper symptoms. It is described as the unconscious attunement to and absorption of victims’ stresses and traumas. The latter are often expressed nonverbally, such as through gestures and enactments. These are vehicles of transferring especially emotional information not readily expressible in words. Such transferring of information is called transference. On the receiving side, empathy is the vehicle whereby helpers make themselves open to absorption of traumatic information. The absorption and subsequent impulse to respond may be lifesaving in ongoing traumatic events. After the events, countertransference reads the relived transference information. This is done through one’s own affective reactions, cognitive unfoldings, and impulses to action (Wilson & Lindy, 1994) and helps helpers to understand their clients’ relived experiences and needs.

Such permeability to clients’ traumatic events of necessity leads to stress, called empathic strain by Wilson, Lindy, and Raphael (1994), or to trauma, called vicarious traumatization by Pearlman and Saakvitne (1995a, 1995b).

Wilson et al. (1994) divided empathic strain into two categories approximately corresponding to intrusive and avoidance features of PTSD. Intrusivetype countertransference strain includes loss of boundaries, overinvolvement, reciprocal dependency, and pathological bonding. Avoidance-type countertransference strain includes withdrawal, numbness, intellectualization, and denial. On the other hand, vicarious traumatization includes disruptions of self-capacities, beliefs, relationships, world view, and spirituality (Black & Weinreich, 2000; Pearlman & Saakvitne, 1995a).

Finally, a number of workers have recognized that the intimate relationship between helpers and victims is a two-way affair. Helpers also bring unconscious current and past stresses and traumas into their interactions with clients (Figley, 1995b). For example, helpers may be attracted to clients who suffer similar traumas to the helpers’ repressed ones. Helpers’ unconscious transference of their problems onto clients may evoke countertransference in the latter, which may compound their traumas.

Current Dilemmas

STSD and compassion fatigue were diagnoses waiting to happen, and they provided meaningful and respectful labels for affected trauma workers. However, like PTSD, they do not categorize or heuristically make sense of the wide variety of manifestations and symptoms (e.g., Blair & Ramones, 1996) that are relived or avoided, or explain why they should be suffered. Although countertransference responses explain the means of transmission and reason for suffering, countertransference responses do not classify or provide reasons why particular symptoms should be transmitted at any particular time. Burnout seems to go some way toward providing a reason for a particular cluster of symptoms, but it does not explain why they should occur and not others and it does not explain symptoms outside its cluster.

Often implied reasons for the nature of symptoms lie in survival strategies such as fight and flight. However, these two strategies are insufficient to explain the variety of symptoms.

In the last volume, I suggested that eight survival strategies provide a more extensive framework for diagnosing, classifying, and making sense of the wide variety of STS phenomena. Which particular ones were experienced at any one time depended on specific identifications with, or responding in complementary fashions to, victims’ needs and survival strategies (Valent, 1995).

In this chapter I intend to explain in greater detail how survival strategies provide a framework for the wide variety of STS and STSD manifestations and countertransference responses. It also will be suggested that two specific survival strategies (Rescue–Caretaking and Assertiveness–Goal Achievement) can heuristically delineate compassion fatigue and burnout, respectively.

A further tool, the triaxial framework, will be used to indicate how symptoms derived from survival strategies spread across the extensive field of traumatology, and how different treatments fit into its coordinates. Finally, treatment implications of the combined view of survival strategies and the triaxial framework (called the wholist perspective) will be examined.

SURVIVAL STRATEGIES AND CONCEPTUALIZATION OF SECONDARY STRESS AND TRAUMA RESPONSES

In this section survival strategies will be summarized and applied to STS and STSD, compassion strain and fatigue, burnout, and countertransference responses.

Survival Strategies

Survival strategies such as fight and flight are biopsychosocial templates that have evolved to enhance maximum survival within evolutionary social units. Their level of operation is in the “old mammalian” brain (MacLean, 1973), functionally between instincts and abstract functioning. In traumatic situations, they correspond to acute stress responses.

Although the arousal symptoms in PTSD imply that only fight and flight acute stress responses are relived and avoided, I suggest that they and six further such survival strategies contribute to reliving and avoidance responses. The eight survival strategies are Rescuing (Caretaking), Attaching, Asserting (Goal Achievement), Adapting (Goal Surrender), Fighting, Fleeing, Competing, and Cooperating. Further, it is their adaptive and maladaptive, biological, psychological, and social components that contribute to the wide variety of manifestations in traumatic stress. The survival strategies and their acute stress response manifestations are...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Contributors
• Introduction
• Part I: Contemporary Views and Findings
• Part II: Treatment and Prevention Innovations
• Epilogue
• Index