The Art and Science of Caring for Others without Forgetting Self-Care
Charles R. Figley1
Each day as we read accounts of our American troops fighting, dying, and getting hurt in the current wars so far away, my heart goes out to them and their families. But my heart also goes out to the physicians, nurses, and technicians who will be working with these war fighters. It was with them in mind that I offer this brief article on compassion fatigue.
We helpers are professional commiserators. We share in life's sadness and stressors; we must understand when no one else might; metaphorically, at least, we stand between our clients and the cruelties they face daily. This brief article is about the price we pay as commiserators. The price is worth it, of course. Most of us love our job and our life work. But perhaps some perspective offered here may insure that the price is not so high.
"Thanks for the work you do," Bob said from behind me. He had been the one in the back of the room who couldn't sit still. I figure he was a first responder, probably fire fighter or in some type of rescue service. They often come to my workshops on compassion fatigue. There is often a mixture of service providers to the traumatized. Many of them are traumatized themselves.
Bob's eyes were sad. His shoulders drooped, matching his self confidence and mood. He had avoided my eyes at the morning break. Another clue he was not a helper. I was wrong on all counts. He was a helper not a first responder. He was very sad, however. I was right about that.
Bob was a 30 year veteran of clinical psychology and a frequent volunteer with the Red Cross, including the September 11th deployment to Washington, DC. His family had urged him to take this workshop. He later said in front of the group (he had volunteered to talk about his story) that he had not been the same since 9/11. But his work even before that was a source of pain and rarely inspiration and joy. He learned during the workshop that it was not so much the two weeks working non-stop in New York at the Red Cross Family Support Center, but the cumulating of painful experiences he had dealt with throughout his career - particularly the children. I will get back to Bob shortly. First some background about trauma and compassion fatigue.
Graduate Education at Penn State
My major professor in graduate school at Penn State was Ted Huston who taught me the science of psychology. Bernie Guerney taught me the art of psychology. His treatment approach is well known (Guerney, 1970) and remarkable in it simplicity; enabling people and couples to work through extraordinary complex and distressing issues without needing the therapist's interpretations and directions other than following the protocol of the treatment approach. Few who practice this approach experienced the focus on this article: Compassion fatigue. This fact became obvious to me as I completed a book on helping traumatized families (Figley, 1989).
After nearly 10 years working with the new diagnosis of PTSD I began to notice the turnover in helpers and others who worked with the traumatized. Some stayed in the field but became supervisors who became once removed from working with the traumatized. It became clear to me that they left because of the emotional toll of working with the traumatized.
By the time I joined the faculty here at Florida State University and directorship of the Interdivisional PhD program in Marriage and Family I began to conduct research on this phenomenon I had originally called secondary victimization (Figley, 1982) applied to families with members they lived with and loved who had been traumatized. During the 1980s a group of researchers in Israel were studying combat stress reactions and began to recognize the secondary effects of the wives of these combat veterans when they returned from war. Zahava Solomon and her colleagues (cf Solomon, 1993) in a series of studies confirmed the transmission of war trauma from veteran to family member.
My first effort at investigating the trauma transmission from client to therapist was soliciting comments through professional newsletters. I noted that I was finding a large number of fellow practitioners who had experiences with a form of burnout and asked anyone to write me if they had any stories to tell.
At the same time I took advantage of the dozens of presentations on treating the traumatized that I was making in the late 1980s to focus on the costs of caring. Also, I began to distribute a questionnaire on the topic that includes both qualitative and quantitative items. My first and second published paper on the topic was in a publication like this one (Figley, 1993a; 1993b). It was the first time I applied the concept of "compassion fatigue" to the phenomenon of secondary traumatic stress reactions. It was at that time that I contacted my publisher to add the concept to the working title already in press: "Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized" (Figley, 1995). The book became the 23rd in the Brunner/Mazel Psychosocial Stress book series.
Today, more than 12 years after the publication of the book and more than 20 years after starting work in this area of work-related secondary trauma, it is gratifying to see how far we have come. Yet, we still have far to go.
My wife, Kathy, and I talk with, train and are trained by mental health professionals from all over the world. They have worked with traumas and the dramas of life not just the major events like the recent horrific shootings at Texas Tech, Hurricanes like Katrina, 9/11, and the tsunami. Many things these helpers share are their passion for the work of caring for others and the knowledge that their caring pays off. We are gratified and inspired by our clients. Many of us are drawn to the work as a calling.
To say the least, our work often brings us joy. But the work of helpers can also be emotionally toxic. The same tendencies we have for helping others make us especially vulnerable to overlooking our own needs. It is as if we have a self care blind spot as counselors. This brief article is about recognizing and doing something about it in order to avoid compassion fatigue, the ultimate cost of caring.
Here I would like to first provide some definitions relevant to work-related compassion fatigue, then cite some definitive research that justifies our concern about the costs of caring. This introduction and overview is, by necessity, brief but we have included here some useful references and resources for readers who wish more details.
Perhaps a few definitions may be useful at this point and to contrast them with the focus of the issue of the Magazine: Secondary stress.
Burnout is defined in Merriam-Webster's Collegiate Dictionary as "exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration." It is something that gradually builds to a breaking point and the stress and frustration comes from all types of work-related sources.
Secondary Traumatic Stress (or Compassion Stress): a set of psychosocial and emotional factors caused by a specific event or series of events affecting helpers indirectly through another such as a family member, friend, or client. It sometimes takes just one case or situation to have a lasting effect.
Compassion Fatigue: "...state of exhaustion and dysfunction (biologically, psychologically and socially) as a result of prolonged exposure to compassion stress" (Figley, 1995). We become exhausted by the exposure to experience after experience of emotionally draining clients who look to us for help.
Compassion Fatigue or Burnout?
Based on the above definitions, compassion fatigue is more about the emotional fallout from actually delivering the services to clients and why it is a "secondary" trauma. As helpers we work with those who were in harm's way and we experience what they experienced secondarily. Certainly, the emotional wear and tear of this kind of stress can lead to burnout eventually. Most often, however, burnout takes longer and is a function of lots of things in addition to compassion fatigue: paperwork, the environment, colleagues, and the grind of work. The most important question to ask your self is this: Do I love my work? If the answer is" no", it is most likely that you are suffering from burnout. If the answer is "YES!" you are more likely suffering from Compassion Fatigue.
Also, it is more likely that we experience compassion satisfaction when we experience compassion fatigue. In contrast with those who are burned out (Pines, A. & Aronson, E. 1988), helpers experiencing compassion fatigue often love their job and the work they do. This was clear from a series of surveys among professionals and volunteers who work with animals (Figley & Roop, 2006). Indeed, the results of a survey of social workers working in the New York City region showed that working with traumatized people was unrelated to burnout out but highly related to the development of compassion fatigue. Both burnout and compassion fatigue were associated with poor social support by colleagues (Boscarino, Figley & Adams, 2004). Unlike burnout, compassion fatigue is accompanied by a rapid onset of symptoms and is likely to be more pervasive than burnout; it emerges suddenly with little warning; there is a sense of helplessness, shock and confusion; there is a sense of isolation, and; the symptoms seem disconnected from the real causes. Despite this, those who suffer from compassion fatigue often report an on-going sense of responsibility for the care of the sufferer and their suffering. There is a near failure on the part of compassion fatigue sufferers for getting or even knowing how to get relief from burdens of responsibility to those they tried help.
One definitive way of determining if you might have burnout, if you might have compassion fatigue, and your level of compassion satisfaction is to take a self-administered test. I have developed several measures over the years (e.g., Figley, 1995). However, I now recommend the Professional Qualify of Life Scale: Compassion Satisfaction and Fatigue Subscales-Revision IV (ProQOL) available at http://www.proqol.org/ProQol_Test.html. The ProQOL is a free and handy tool for us to complete in private, when we are ready that can give us some unbiased feedback about how we are doing in our career. The results may motivate you to do something now about your own self care.
What should you do about compassion fatigue?
Working with suffering people is both rewarding and hard to take sometimes. Most note that self care is critical. Where do you start? We have several suggestions.
1. Begin with ethical standards. Claudius Galen, born in 129 A.D. was the chief physician to the gladiator school in Pergamum and went on to serve five Roman Emperors. He was the first to use the adage, "Primum non nocere," first do no harm. This goal has guided all practitioners since then, including helpers. However, it is time to recognize that our perception of doing harm may be altered by our own mental fitness; that exposure to the distress of others, day after day, can take an emotional toll. Recently it was found that there was a correlation between compassion fatigue and ethical violations, for example (Gentry & Figley, 2007). Therefore, we helpers should consider an additional adage: First do no SELF harm!
As practicing helpers we are bound by the American Psychological Association's code of ethics (See http://www.apa.org/ethics/code.html). One of the most relevant sections is as follows:
- 2.06 Personal Problems and Conflicts
- (a) Helpers refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner.
- (b) When helpers become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties. (See also Standard 10.10, Terminating Therapy.)
Helpers are expected to be aware of personal problems such as secondary traumatic stress reactions (compassion fatigue) that prevent - or significantly impair our competence to practice. I view "taking appropriate measures" as reading articles like this one; taking a self test as noted above; seeking supervision and consultation, and; getting training. Later I will note some useful resources for enabling helpers to take such measures.
Green Cross Academy of Traumatology website (www.greencross.org) and begin with two basics. 1. The Standards of Practice, Section II. 2. Responsible Caring states:
Traumatologists recognize that service to survivors of traumatic events can exact a toll in stress on providers. They maintain vigilance for signs in themselves and colleagues of such stress effects, and accept that dedication to the service of others imposes an obligation to sufficient self-care to prevent impaired functioning (see Figley, 1995; Pearlman & Saakvitne, 1995)
The Academy also has another set of standards: Standards of Self Care. Of special value is Section V.B. Standards for Establishing and Maintaining Wellness which calls us to make a formal and tangible commitment to, in effect, having a life outside of work. This and other sections provide good guidance for doing so.
2. Increase your knowledge base.
Just as you are reading this introduction and may be interested in the articles that follow in this issue, you may be interested in doing more to just help yourself. We urge you to consider getting training in this area to not only help yourself but learn to help others. There are a variety of courses that address basic stress management and self-care. Several websites offer free educational materials. Download free video clips from Gift From Within http://www.giftfromwithin.org/ Titles include When Helping Hurts: Sustaining Trauma Workers and When Helping Hurts: Preventing and Treating Compassion Fatigue.
3. Become Certified.
We recommend that you become certified via the Green Cross Academy of Traumatology.
4. Work towards systemic change.
Once trained and certified to educate others about secondary trauma and self-care, the next logical step is to educate and treat others about compassion fatigue. It is especially useful if you, yourself has experienced compassion fatigue and have recovered. In addition to training and treating others, it is important to have an impact on institutions, policies, and procedures that both create a climate for inducing compassion fatigue and for discouraging the assessment and treatment at the workplace.
Bob continues to see patients and is happier and better at it than ever. He is now a Certified Compassion Fatigue Educator who gives a dozen workshops a year in his and surrounding states. Many who attended his training have sought him out as a consultant and a few as his clients. They feel more comfortable seeking out fellow commiserators. They recognize like Bob that acquiring the credentials to practice psychology was the easy part - managing the emotional and potentially toxic client material week after week was far more challenging with little orientation in graduate school.
We need more helpers like Bob to break the conspiracy of silence about secondary traumatic stress reactions and the costs of compassion fatigue. More importantly, we need a concerted and systematic campaign to help transform the field toward positive psychology, as Marty Seligman and colleagues (Seligman, Steen, Park, & Peterson, 2005) would urge us to do in viewing and helping our clients: Focusing on increasing positive affect as well as decreasing unwanted symptoms and suffering. Thus, we focus on our efforts to enhancing positive affect, promoting self-care, resilience, and transformation among commiserators.
Life is short. The world will always need caring and passionate counselors. But to be really effective, compassionate helpers always abide by the motto of Hippocrates: First, do no harm. However, it is imperative that we first do no self-harm. We cannot depend on anyone else.
So I wish you helpers my best as you struggle to balance taking care of yourself with taking care of others. I again want to offer a special message of appreciation to those of you who work with these young people who are risking their lives for their country and who depend on you to keep them whole. Bless you.
Boscarino, J. A., Figley, C. R. and Adams, R. E. (2004). Evidence of Compassion Fatigue following the September 11 Terrorist Attacks: A Study of Secondary Trauma among Social Workers in New York. International Journal of Emergency Mental Health, 6:2, 98-108.
Figley, C.R. (1982). Traumatization and comfort: Close relationships may be hazardous to your health. Keynote presentation, Families and close relationships: Individuals in social interaction. Conference held at the Texas Tech University, Lubbock, March.
Figley, C.R. (1993a). Compassion Stress: Toward Its Measurement and Management. Family Therapy News, February, 1-2.
Figley, C.R. (1993b). Compassion Fatigue and Social Work Practice: Distinguishing Burnout from Secondary Traumatic Stress. Newsletter of the NASW Florida Chapter, June, 1-2.
Figley, C.R. (Ed.) (1995). Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. An Overview. 1-20. New York: Brunner/Mazel.
Figley, C. R. (2001). Renewing Spirits: Lessons From Thirty Years of Trauma Work, Invited keynote address to the William Wendt Center for Loss and Health Conference on Illness, Grief & Trauma, Washington, DC, October 6.
Figley, C. R. and Roop, R. (2006). Compassion Fatigue in the Animal Care Community. Washington, DC: The Humane Society Press.
Pines, A. & Aronson, E. (1988). Career burnout: Causes and cures. New York: Free Press.
Seligman, M. E. P., Steen, T. A., Park, N. & Peterson, C. (2005). Positive pspychology progress: Empirical validation of interventions. American Psychologist, 60:5, 410-421.
Solomon, Z. (1993). Combat Stress Reaction : The Enduring Toll of War. NY: Springer.
Professor Charles R. Figley, Ph.D., Editor of Traumatology: http://tmt.sagepub.com/
Fulbright Fellow and Professor, Florida State University Traumatology Institute Director,
Dr. Figley is a professor and Distinguished Chair in Disaster Mental Health at Tulane University. Email: firstname.lastname@example.org
Phone: 850-644-9598 Fax: 800-889-0168
Primum Non Nocere
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