Compassion Fatigue

Coping With Secondary Traumatic Stress Disorder In Those Who Treat The Traumatized

Charles R. Figley

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134862610
• Edition: 1
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

First published in 1995. Traumatology, or the field of traumatic stress studies, has become a dominant focus of interest in the mental health fields only in the past decade. Yet the origin of the study of human reactions to traumatic events can be traced to the earliest medical writings in Kunus Pyprus, published in 1900 B.C. in Egypt. Many factors account for the recent emergence of this field, including a growing awareness of the long-term consequences of shocking events. Among these consequences are violence toward others, extraordinary depression, dysfunctional behavior, and a plethora of medical maladies associated with emotional stress. This is the latest in a series of books that have focused on the immediate and long-term consequences of highly stressful events. The purposes of the book, then, are (a) to introduce the concept of compassion fatigue as a natural and disruptive by-product of working with traumatized and troubled clients; (b) to provide a theoretical basis for the assessment and treatment of compassion stress and compassion fatigue: (c) to explain the difference between compassion fatigue and PTSD, burnout, and countertransference; (d) to identify innovative methods for treating compassion fatigue in therapists, and (e) to suggest methods for preventing compassion fatigue.

1

Compassion Fatigue as Secondary Traumatic Stress Disorder: An Overview

CHARLES R. FIGLEY

There is a cost to caring. Professionals who listen to clients' stories of fear, pain, and suffering may feel similar fear, pain, and suffering because they care. Sometimes we feel we are losing our sense of self to the clients we serve. Therapists who work with rape victims, for example, often develop a general disgust for rapists that extends to all males. Those who have worked with victims of other types of crime often “feel paranoid” about their own safety and seek greater security. Ironically, as will be noted later, the most effective therapists are most vulnerable to this mirroring or contagion effect. Those who have enormous capacity for feeling and expressing empathy tend to be more at risk of compassion stress.

Mary Cerney (Chapter 7) notes that working with trauma victims can be especially challenging for therapists, since some may feel that they, in the words of English (1976), “… have taken over the pathology” of the clients (p. 191). Cerney suggests:

This affront to the sense of self experienced by therapists of trauma victims can be so overwhelming that despite their best efforts, therapists begin to exhibit the same characteristics as their patients—that is, they experience a change in their interaction with the world, themselves, and their family. They may begin to have intrusive thoughts, nightmares, and generalized anxiety. They themselves need assistance in coping with their trauma.

The professional work centered on the relief of the emotional suffering of clients automatically includes absorbing information that is about suffering. Often it includes absorbing that suffering itself as well.

Over the past 10 years, I have been studying this phenomenon. Although I now refer to it as compassion fatigue, I first called it a form of burnout, a kind of “secondary victimization” (Figley, 1983a). Since that time, I have spoken with or received correspondence from hundreds of professionals, especially therapists, about their struggles with this kind of stressor. They talk about episodes of sadness and depression, sleeplessness, general anxiety, and other forms of suffering that they eventually link to trauma work.

This chapter and those that follow represent our best efforts to understand, treat, and prevent compassion fatigue. We begin with a discussion of the conceptual development of the concept of trauma and related terms and ways of knowing about them.

Paul Valent (Chapter 2) presents a framework for the next century of investigation of traumatic stress. “Survival strategies” are assigned to each of the eight types of traumatic stressors, and each strategy is considered within the three reaction domains: biological, psychological, and social. This synthesis of decades of research and theoretical work appears to be a very useful framework for categorizing traumatic stress reactions, including secondary traumatic stress (STS) and secondary traumatic stress disorder (STSD) among therapists and others who care for victims.

This chapter proposes a reconfiguration of post-traumatic stress disorder (PTSD) that is consistent with the current, scientifically based views of the disorder, as specified in the revised third edition of the DSM-III (American Psychiatric Association [APA], 1987) and of the new version described in DSM-IV (APA, 1994) and ICD-10. As noted in the introduction to this book, the criteria of a traumatic event in these diagnostic manuals take note of but do not discuss the implications of a person's being confronted with the pain and suffering of others. It will be suggested later that PTS and PTSD retain the same set of symptoms, and thus methods of assessment, but that parallel symptoms and methods of assessment must be developed for STS and STSD. This chapter draws on the research and theoretical literature, primarily presented in the chapters to follow, to support this new configuration.

What follows is an explication of STS and STSD, later called compassion stress/fatigue, because they have received the least attention from traumatology scholars and practitioners. This is followed by an illustrative review of the theoretical and research literature that supports the existence of STS. The last section of the chapter discusses the implications of the proposed reconfiguration for diagnostic nomenclature, research and clinical assessment, and theory development.

CONCEPTUAL CLARITY

The diagnosis of PTSD has been widely utilized in mental health research and practice, and its application has influenced case law and mental health compensation (Figley, 1986; Figley, 1992a, b). In a report of the review of trauma-related articles cited in Psychological Abstracts, Blake, Albano, and Keane (1992) identified 1,596 citations between 1970 and 1990. Their findings support the view that the trauma literature has been growing significantly since the advent of the concept of PTSD (APA, 1980). However, most of these papers lack conceptual clarity. They rarely consider contextual and circumstantial factors in the traumatizing experience or adopt the current PTSD nomenclature.

As noted in the introduction to this volume, although the psychotraumatology field has made particularly great progress in the past decade, the syndrome has an extremely long history. A field devoted exclusively to the study and treatment of traumatized people represents the culmination of many factors. One was the greatly increased awareness of the number and variety of traumatic events and their extraordinary impact on large numbers of people. As noted in the introduction, many identify the publication of the American Psychiatric Association's DSM-III in 1980 as a major milestone. It was the first to include the diagnosis of post-traumatic stress disorder.

With the publication of DSM-III, for the first time the common symptoms experienced by a wide variety of traumatized persons were viewed as a psychiatric disorder; one that could be accurately diagnosed and treated. Although a revision of DSM-III modified the symptom criteria somewhat (APA, 1987), the popularity of the concept among professionals working with traumatized people (including lawyers, therapists, emergency professionals, and researchers) grew, as did the accumulation of empirical research that validated the disorder.

After well over a decade of use, the term PTSD is more commonly applied to people traumatized by one of many types of traumatic events. Yet a review of the traumatology literature yields the following: Nearly all of the hundreds of reports focusing on traumatized people exclude those who were traumatized indirectly or secondarily and focus on those who were directly traumatized (i.e., the “victims”). But descriptions of what constitutes a traumatic event (i.e., Category [criterion] A in the DSM-III and DSM-III-R descriptions of PTSD) clearly indicate that mere knowledge of another's traumatic experiences can be traumatizing.

People are traumatized either directly or indirectly. The following excerpt is taken from the PTSD description in DSM-IV (APA, 1994) of what constitutes a sufficiently traumatic experience.

The essential feature of posttraumatic stress disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves threatened death, actual or threatened serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associates (Criterion A1). Italics added; [p. 424]

The italicized phrases emphasize that people can be traumatized without actually being physically harmed or threatened with harm. That is, they can be traumatized simply by learning about the traumatic event. Later it is noted:

Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life-threatening disease, [p. 424]

This material has led to a conceptual conundrum in the field, although few have identified it. For example, I have pointed out (Figley, 1976; 1982; 1983a,b) that the number of “victims” of violent crime, accidents, and other traumatic events is grossly underestimated because only those directly in harm's way are counted, excluding family and friends of the victims. In a presentation (1982) and subsequent publications (1983b; 1985a,b; 1989), I noted a phenomenon I called “secondary catastrophic stress reactions,” meaning that the empathic induction of a family member's experiences results in considerable emotional upset. Parallel phenomena exist: fathers, especially in more primitive societies, appear to exhibit symptoms of pregnancy out of sympathy for those of their wives (i.e., couvade; see Hunter & Macalpine, 1963); a psychiatric illness can appear to be shared by the patient's spouse (folie à deux; Andur & Ginsberg, 1942; Gralnick, 1939). Other parallels have been reported in the medical and social science literatures, including copathy (Launglin, 1970); identification (Brill, 1920; Freud, 1959); sympathy (Veith, 1965); and hyperarousal, “mass hysteria,” or psychogenic illness, which appears to swe...