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This book is part of the Psychosocial Stress Series, edited by Charles R. Figley.

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Library of Congress Cataloging‑in‑Publication Data

Mathieu, Françoise, 1969-The compassion fatigue workbook : creative tools for transforming compassion fatigue and vicarious traumatization / Françoise Mathieu. -- 1st ed.

p. cm. -- (Routledge psychosocial stress series)Includes bibliographical references and index.ISBN 978-0-415-89790-7 (pbk. : alk. paper)1. Mental health personnel--Mental health. 2. Caregivers--Mental health. 3. Secondary traumatic stress. 4. Stress management. I.

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RC451.4.P79M38 2011616.89’0230078--dc23 2011029457

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vii

Contents

Series Editor’s Foreword ......................................................................... ix

Acknowledgments ................................................................................... xi

1 Introduction ....................................................................................... 1

2 Understanding the Cost of Caring ..................................................... 7

3 The ProQol: Professional Quality of Life Self-Test .......................... 25

4 How Many Helpers Develop Compassion Fatigue and Vicarious Trauma? ........................................................................... 33

5 Low-Impact Debriefing: How to Stop Sliming Each Other .............. 41

6 Warning Signs of Compassion Fatigue and Vicarious Trauma ........ 47

7 Contributing Factors: Understanding How Your Job Is Impacting You ................................................................................. 63

8 The Toxic Workplace ........................................................................ 71

9 Addressing CF and VT: Strategies.................................................... 77

10 The Four Steps to Wellness .............................................................. 85

11 Step One: Take Stock—Track Your Stressors at Home and at Work ..........................................................................................89

12 Step Two, Part One: Work/Life Balance .......................................... 97

13 Step Two, Part Two: Self-Care ........................................................ 105

14 Step Three: Developing CF Resiliency Through Relaxation Training and Stress Reduction Techniques ................................... 121

15 Step Four: Making a Commitment to Change ................................ 133

16 Compassion Satisfaction: Reconnecting With the Rewards of the Work ........................................................................................ 135

17 Getting Help .................................................................................. 139



viii ◾ Contents

Appendix A: Vicarious Trauma: What Can Organizations and Managers Do? ........................................................................................145

Appendix B: Standards of Self-Care Guidelines ....................................149

Appendix C: Additional Recommended Books .....................................153

Bibliography ..........................................................................................157

Index .....................................................................................................159

About the Author ...................................................................................167



47

Chapter 6

Warning Signs of Compassion Fatigue and Vicarious Trauma

Whenyou’reintheredzoneofcompassionfatigue,abathain’tgonnacutit!

—Robin Cameron(Personal communication, 2003)

Inthischapter,youareinvitedto:

◾ Gainaclearerunderstandingofyourownwarningsignsofcompassionfatigue(CF)andvicarioustrauma(VT)

◾ Developanearlydetectionsystemforyourwarningsigns◾ Identifyyour“redzone”ofCFandVT

Iwasrecentlyatthedrugstorewithmy10-year-oldson.1Iwaspayingformypurchasewhenanelderlymanapproachedthecounter.Heappearedtobeinhislate80sandhaddeepredbagsunderhiseyes.Helooked,inaword,absolutelyterrible.Withashakinghand,hetookaphotooutofhispocketandshowedittousandtothewomenbehindthecashregister.“Thisismywife,”hesaid.“Shedied2daysago;weweremarriedfor58years.Shewastheloveofmylife.NowIcan’tsleepandthedoctorwantsmetotakethesepills.”Weallfellsilentforaminute,andthenIhadalittlechatwithhim.Hetoldmehischildrenalllivedoutoftownandthathewascompletelyalone.WhenIleftthestorewithmysonintow,IfeltregretthatIdidnotdomore.MyheadwasalreadybuzzingwithallthecommunityresourcesIknowabout,howtolinkhimwiththerightones,howweshouldhavetakenhimoutfortea,andmore.Iwasdyingtocasemanagethismanintogettingsup-portrightonthespot,butIalsohadtogohomeandcookdinnerandtakecareofmyfamily.



48 ◾ The Compassion Fatigue Workbook

Thisistheconstantchallengewefaceashelpers.Painandsufferingisallaroundus;it’snotjustatwork.Wheredoyoudrawtheline?Doyoutakeeveryelderlywidoweroutfortea?Doyoutelleverypersonwithafunny-lookingmoletogogetitcheckedout?Doyourescueeverykittenyousee?Sowhatwedoistryourbesttofigureoutboundaries.SometimesweovercorrectandwebecomelikeFortKnox,notlettingasinglepersoninsideourwalls.Sometimeswegotoofarintheotherdirectionandbecomeambulancechasers,fosteringtoomanypetsandbakingforeverylittleoldladyonourstreet.

Weneedtogainabetterunderstandingofourownwarningsignsalongthecontinuumofcompassionfatigue.Usingtrafficlightsasananalogy,thegreenzoneiswhereyouarewhenyouareatyourverybest(Isometimesjokethatyouareonlyinthegreenzonewhenyou’vebeeninthefieldfor2weeksorwhenyouhavejustreturnedfroma5-monthyogaretreatinTahiti).Theyellowzoneiswheremostofuslivemostofthetime.Wehavewarningsignsemergingbutweoftenignorethem.Theredzoneisthedangerzone.Thefarendoftheredzonefindsusonstressleave,clinicallydepressedortotallywithdrawnfromothersandwrackedwithanxiety.

Wewillallvisitthelessextremeendoftheredzoneseveraltimesinourcareer—itisanormalconsequenceofdoingagoodjob.

Whatsuffersfirstisouremotionalandphysicalhealth,ourfamilyandfriends,ourcolleagues,andeventuallyourclients.Theypaythepriceaswebecomelesscompassionateandirritable,andmaymakeclinicalerrors.

Learningtorecognizeyourownsymptomsofcompassionfatigueandvicarioustraumahasatwofoldpurpose:First,itcanserveasanimportantcheck-inprocessifyouhavebeenfeelingunhappyanddissatisfiedbutdidnothavethewordstoexplainwhatwashappeningtoyou;andsecond,itcanallowyoutodevelopawarningsystemforyourself.Developingthiswarningsystemallowsyoutotrackyourlevelsofemotionalandphysicaldepletion.Italsooffersyoutoolsandstrate-giesthatyoucanimplementrightaway.Letmegiveyouanexample:

Saythatyouweretolearntoidentifyyourcompassionfatiguesymptomsonascaleof1to10(10beingtheworstyouhaveeverfeltaboutyourwork/com-passion,and1beingthebestyouhaveeverfelt).Then,youlearntoidentifywhatan8ora9lookslikefor you. Forexample,“WhenI’mgettinguptoan8,InoticeitbecauseIdon’treturnphonecalls,Ithinkaboutcallinginsickalot,andIcan’twatchanyviolenceonTV,”or“IknowthatI’mmovingtowarda7whenIturndownmybestfriend’sinvitationtogooutfordinnerbecauseI’mtoodrainedtotalktosomeoneelse,andwhenIstopexercising.”Beingabletorec-ognizethatyourlevelofcompassionfatigueiscreepinguptotheredzoneisthemosteffectivewaytoimplementstrategiesimmediatelybeforethingsgetworse.

Butlookbacktowhatalsoemergesinthisprocess:youarestartingtoiden-tifythesolutionstoyourdepletion.

IfIknowthatIamgettingclosetoan8,Imaynottakeonnewclientswithatraumahistory,Imaytakeadayoffaweek,orImayreturntoseekmyowntherapist.



Warning Signs of Compassion Fatigue and Vicarious Trauma ◾ 49

Backtomystoryabouttheelderlymaninthedrugstore—Iwouldnothavealwayshadthiswarmcompassionatereactiontothisman.Infact,myreac-tionisactuallyasignformethatIamwelloutoftheredzoneofcompassionfatigue(forthetimebeing!).Yousee,therehavebeentimeswhereIhavefeltsodepletedbyallmyworkdemandsanddifficultstoriesthatIwouldhavehard-enedmyselftothisoldman’sstoryandnottalkedtohimatall.Haveyouevernoticedthatinyourself,orthought,amItheonlyhard,crustypersonoutthere?Conversely,forsomeofyou,beingintheredzonewouldmeanyouwouldhavejumpedintorescuingthismanandneglectedyourfamily’sneedsfortheevening.

Researchshowsthatcompassionfatiguehitshardestamongthoseofuswhoarethemostcaring.2Ashelpers,wehaveahomingdeviceforneedandpaininoth-ersandwehavethisfromchildhoodonward(formanyreasons:familyoforiginissues,birthorder,heredity,etc.)Sooftenforhelpingprofessionalsthemainchal-lengeintheirpersonallifeissettinglimitsandnotbeingahelperorrescuertoeveryonearound.Buteventually,compassionfatiguemakesusdetachfromothers:oftenourcolleagues,family,andfriendssufferfarbeforeourclientsandpatients.AlthoughIamnotproudofit,IknowthatIalwaysseemtosavethebestforworkandgivetheremainingcrumbstomylovedones.Inmyclinicalwork,Ifeelpres-ent,warm,andlovingtowardmyclients,evenwiththemostchallengingsoldierwhohasneverwantedtocometocounselingandhatesbeingthere.ButwhenIamintheredzone,Iavoidmyneighbors,duckingintomyhouseasquicklyaspossibletoavoidachat,feelingslightlyguiltyandirritatedatthesametime.

Eachofuswillhavedifferentwarningsigns.Thekeytodevelopinganearlyinterventionplanistogetbetteracquaintedwithyourownwarningsigns.

Your Symptoms

Todevelopyourwarningscale,youneedtodevelopanunderstandingandanincreasedawarenessofyourownsymptomsofcompassionfatigueandvicari-oustrauma.CFandVTwillmanifestthemselvesdifferentlyineachofus.InTransforming the Pain, SaakvitneandPearlmanhavesuggestedthatwelookatsymptomsonthreelevels:physical,behavioral,andpsychological.Hereisalistofwarningsignsbasedonareviewoftheliteraturetodate.3Isuggestthatyoubeginbyreadingthroughthesignsandsymptomsbelowandcirclethosethatfeeltruetoyou.Remember,thisisnotadiagnostictestbutratheraprocesswherebywebegintounderstandourownphysicalandpsychologicalreactionstotheworkthatwedo.

Physical Signs of Compassion Fatigue

◾ Physical exhaustion. Feelingexhaustedwhenyoustartyourday,draggingyourfeet,comingbacktoworkafteraweekendoff,andstillfeelingphysicallydrained.Lipskycallsit,“feelingfatiguedineverycellofyourbeing.”4It’salso




importanttomakethedistinctionbetweenfeelingtiredandfeelingdepleted.IknowthatoneofthewaysformetoknowthatI’mstrugglingwithdepletionisthatIlosemysenseofhumorathomeandIturnintoadrillsergeant.WhenI’msimplytired,Imayneedtoslowthingsdownathome,butIamstillapersonIlike.Sometimesweareexhaustedbothemotionallyandphysicallybythework.

◾ Insomnia or hypersomnia.Difficultyfallingasleep,earlymorningawak-ening,oroversleeping.

◾ Headaches and migraines.◾ Increased susceptibility to illness.Gettingsickmoreoften.◾ Somatization and hypochondria. Somatizationreferstotheprocesswherebywetranslateemotionalstressintophysicalsymptoms.Examplesaretensionheadaches,lowbackpain,gastrointestinalsymptoms,stress-inducednausea,unexplainedfaintingspells,andsoforth.Theailmentsareveryreal,buttherootcauseislargelyrelatedtoemotionsandstress.SomeoneIknowhasanupsetstomacheverytimesheisanxiousorstressed.Sheusedtothinkitwasfoodpoisoningbutfinallyhadtocometotheconclusionthatnotallrestaurantsinourfinecitycouldpossiblyhavetaintedfood.

Thinkaboutwhichpartofyourbodytellsyouthatyouareoverloaded.Whatdoyounormallydowhenyougetthatmigraine,eyetwitch,orheart-burn?Mostofustakeapill,ignoreit,andkeepgoing.However,eventually,thebodykeepsthescore(toborrowanexpressionfromBesselvanderKolk).InhisbookWhen the Body Says No: The Cost of Hidden Stress,GaborMatéwritesabouttheconnectionbetweenchronicstress,repressedemo-tions,andphysicalillnessandstates:“Ourimmunesystemdoesnotexistinisolationfromdailyexperience.”5Hecitesnumerousstunningexamplesofwaysinwhichtheimmunesystemisdepletedbychronicstress.

Hypochondriasisreferstoaformofanxietyandhypervigilanceaboutpotentialphysicalailmentsthatwemayhave(oraboutthehealthofourlovedones).Whenitissevere,hypochondriacanbecomeadebilitatinganxietydisorder.Mildversionsofhypochondriacanhappentomanyofuswhoworkinthehealthcarefield.Ifyouworkincancercare,particularlyatthediagnosticend,youmayfindyourselfoverworriedabouteverybumpandbruiseonyourchildoryourself,oryoumaythinkthateveryonewithaheadachehasabraintumor.ThemediaandtheInternetcanfueltheflamesofhypochondria.ManypeoplewholiveinOntariosaythattheyhadsomemildphantomsymptomsoflisteriaduringthesummerof2008followingalarge-scalerecalloftaintedmeatduetocontamination.

Again, any of these symptoms do not, on their own, constitute a serious prob-lem. The goal here is for you to begin to notice your own susceptibilities and how the work that you do may be contributing to these vulnerabilities.




Behavioral Signs and Symptoms

◾ Increased use of alcohol and drugs. Thereisevidencethatmanyofusarerelyingonalcohol,marijuana,orover-the-countersedativestounwindafterahardday.Haveyouseenthesizeofwineglassesthesedays?Someofthemarebiggerthanmyfishbowl.Sothe“oneglassafterwork”youarehavingispossiblyhalfabottleofwine.Evenifyouarenotaddictedtodrugsoralcohol,ifyouarerelyingonadrinkorothersubstanceeverynighttounwind,thenyouarelikelyself-medicatingyourstressaway.

Thedifficultywithincreasedrelianceondrugsandalcoholisalsothattheremaybealotofshameassociatedwithit,anditisnotsomethingthatwenecessarilyfeelwecandisclosetoanyone.Isthechildprotectionworkergoingtotellhissupervisorthathesmokesabigfatjointeverynightwhenhegetshometounwind?IsthenursegoingtotellhercolleaguesthatshetakesafewPercocetshereandtherefromhermother’smedicinecabinet?

◾ Other addictions(shopping,workaholism,compulsiveovereating).◾ Absenteeism(missingwork).◾ Anger and irritability. Angerandirritabilityareconsideredtwoofthekeysymptomsofcompassionfatigue.Thiscancomeoutasexpressedorfeltangertowardcolleagues,familymembers,clients,chroniccrisisclients,andothers.Youmayfindyourselfirritatedwithminoreventsatwork:hearinglaughterinthelunchroom,announcementsatstaffmeetings,thephoneringing.Youmayfeelannoyedandevenangrywhenhearingaclienttalkabouthowtheydidnotcompletethehomeworkyouhadassignedtothem.Youmayyellatyourownchildrenfornottakingoutthegarbage.Thelistgoesonandon,anditdoesnotadduptoaseriesofbehaviorsthatmakeyoufeelgoodaboutyourselfasahelper,aparent,oraspouse.

Trythis:Spendafulldaytrackingyourangerandirritability.Whatdoyouobserve?Anythemesorrecurrences?Anysituationsyouregretinhindsightorwhereyourirritabilitywasperhapsoutofproportion?

◾ Exaggerated sense of responsibility. “Ican’tleave;peoplearecountingonme.”6InherbookTrauma Stewardship,LauravanDernootLipskysug-geststhathelperscandevelop“aninflatedsenseofimportancerelatedtoone’swork”andbecomeaddictedtotheneedtobeneeded:“Manypeoplegethookedoninvolvementinothers’lives:solvingtheirproblems,becom-ingapowerfulfigureforthem,gettingincreasinglyattachedtothefeelingofbeingneededanduseful.”7

◾ Avoidance of clients. Examplesofthiscanbenotreturningaclient’sphonecallinatimelyfashion,hidinginabroomclosetwhenyouseeachallengingfamilywalkingdownthehall,delayingbookingaclientwhoisincrisiseventhoughyoushouldseethemrightaway.Again,thesearenotbehaviorsthatmostofusfeelproudoforthatwearecomfortablesharingwithourcolleaguesandsupervisors,buttheydosometimesoccurandthenwefeelguiltyorashamed,whichfeedsintothecycleofcompassionfatigue.




Manyofusworkwithsomeverychallengingclients.Ifyoudodirectcli-entwork,Iamsurethatyoucaneasilyconjureup,rightnow,theportraitofanindividualorafamilythathasseverelytaxedyourpatienceandyourcompassion.OnetelephonecrisisworkerIoncespoketoputitperfectly:“Whyonearthisitathousandtimeseasierformetotalkto25differentcrisiscallersinadaythanifthesamecallercallsme25timesinarow?Iam,afterall,paidtoanswerthephoneandtalktoindividualsincrisisfor7hoursaday.That’smyjob.Whatissodepletingaboutthechroniccaller?”And,Iwouldadd,whydowestartfeelingparticularlyirritated,avoidant,andunempathetictowardthechroniccaller?Thefactofthematteristhatthereissomethinginherentlydepletingaboutchroniccrises.Thebestsolu-tion,ifwecannotcontrolourcaseload,istoseekmoretraining.Themoreweunderstandchronicity,themorecompassionwecanretain.

◾ Impaired ability to make decisions. Thisisanothersymptomthatcanmakeahelpergounderground.Helperscanstartfeelingprofessionallyincompetentandstartdoubtingtheirclinicalskillsandabilitytohelpoth-ers.Amoresevereformofthiscanbefindingyourselfinthemiddleofaninterventionofsomekind,andfeelingtotallylost,unabletodecidewhatshouldhappennext.Ioncehadamildversionofthisindecisivenessinthemiddleofagrocerystoreforwhatfeltlikehoursafteragruelingclinicalday(Iwasworkingasacrisiscounseloratthetimeandwasdealingwithveryextremesituationsandaverylargevolumeofdemand).Irememberstand-inginthemiddleofthegrocerystorethinking,shouldIbuythechocolatechipcookiesorthelemoncreams?andbeingunabletodecidebetweenthetwoforwhatfeltlikehours.Difficultymakingsimpledecisionscanalsobeasymptomofdepression.

◾ Forgetfulness. Manyofusleadbusy,hecticlives.Forgettingtoturnoffthecoffeemakeronceinawhileisnormalforallofus,butleavingthehousewithoutthebabycanbeasignofoverload.

◾ Problems in personal relationships. Avoidingsocialeventswithfriends;notreturningphonecallsfromyourlovedonesbecauseyouaretootiredoremotionallyexhausted;hearingcomplaintsfromyourfamily,whofindthatyouarefrequentlyirritableandemotionallyunavailable.Overtime,youcanbecomemoresociallyisolatedandloseimportantconnectionswithothers.

◾ Attrition. Helpersleavingthefield,eitherbyquittingorbygoingonextendedsickleave.

◾ Compromised care for clients. Thiscantakemanyforms:usingthelabelborderlineforsomeclientsasacodewordformanipulativeisonecommonexample.Wheneveradiagnosisisbeingusedinawaythatpigeonholesaclient,weareshowingourinabilitytoofferthemthesamelevelofcareasotherclients.ThereisevidencethatclientswithaBPDlabel(borderlineper-sonalitydisorder)frequentlydonotreceiveadequatecareinhospitals,arenotassessedforsuicidalideationproperly,andareoftenignoredandpatron-ized.Granted,clientswithpersonalitydisorderscanbeextremelydifficult




toworkwith,butwhenwelosecompassionforthemandstarteye-rollingwhenweseetheirnameonourroster,somethinghasgoneawry.

IfyoueverhavetheopportunitytogohearDr.JohnBrierepresent,Ihighlyrecommendthatyoudo.DrBriereisaleaderinthefieldoftraumatreatmentandresearch,withaparticularspecializationinworkingwithindividualswhohaveexperiencedchildhoodtrauma.HeisthedirectorofthepsychologicaltraumaprogramatLosAngelesCountyandUniversityofSouthCaliforniamedicalcenter.Duringhistalks,Dr.Brierepresentsawon-derfulperspectiveontheuse(orrather,themisuse)ofthediagnosisofBPD.Hebelievesthatthetermisusedtolabelclientswhoareinchronicemo-tionaldistressasdifficultanddraining(whichtheycanbe)butthatthefieldisalsomisusingitasadismissiveanddamaginglabel.HearguesthataverylargeproportionofclientsdiagnosedwithBPDhaveinfactcomplexpost-traumaticstressdisorder(PTSD),notBPD,andareverydamagedbecauseoftheirtraumaexperiences.Theyendupbeingrevictimizedbyasystemthatcannotcopewiththeircomplexandfrequentneeds.8

TherearemanyotherexamplesofcompromisedcareforclientsbutIthinkthisisaparticularlyillustrativeone:

“WE DON’T GET ENOUGH TRAINING:” A STORY OF COMPLEX PTSD

“Anne”isa51-year-oldwomanwhohadanumberofmedicalproblemsforwhichshewasregularlyinandoutofthehospital.Shehadbeenseenbyanumberofphysiciansoverthepreviousyears.Shewasawomanwithseverelungdisease,COPD(chronicobstructivepulmonarydisease).Shehadbeeninandoutofemer-gencyandICUattimesforherlungissues.Shealsohaddiabetes,chronicpain,highbloodpressure,depression,andanxiety.

Annewasonhighdosesofpainkillersforherjointandmusclepain.Herdiagnosiswasarthritisbutherpainwasoftenmuscularaswell.WhenIfirstmether,IexplainedthatIfoundthatshewasonalotofmedicationsandthatwhenIseesomeonewhohasalotofpainissuesthatarenotwellcontrolledinspiteofadequatedosesofpainmedications,Ialwaysaskaboutahistoryofabuseortrauma.

Inthisfirstclinicvisitwithme,Annebrokedownanddisclosedthatshehadbeensexuallyassaultedbyheruncleandthenherbrotherfromage7toage14.Hermotherdidnotbelieveherwhenshetoldher.Annefinallyranawayattheageof14.Annestatedthatshehadnevertoldanyoneotherthanhercurrenthusbandaboutthis.Shestatedthatthemultiplemedicalprovidersthatshe




◾ The silencing response. EricGentryandAnnaBaranowsky—pioneersinthefieldofcompassionfatigueresearch—putforwardaconceptcalledthesilencing response.Thesilencingresponseisaprocesswherebyweunknowinglysilenceourclientsbecausetheinformationtheyaresharingwithusistoodistressingforustobear.Themorewesufferfromcompas-sionfatigue,themorelikelywearetousethesilencingresponse:“TheSilencingResponse…isaninabilitytoattendtothestories/experiencesofourclientsandinsteadtoredirecttomaterialthatislessdistressingfortheprofessional. Thisoccurswhenclient’sexperiences/storiesareover-whelming,beyondourscopeofcomprehensionand desiretoknow,orsimplyspiralingpastoursenseofcompetency. ThepointatwhichwemaynoticeourabilitytolistenbecomingcompromisedisthepointatwhichtheSilencingResponsehasweakenedourclinicalefficacy.”9

Someexamplesofthesilencingresponseare:“changingthesubject,avoidingthetopic,providingpatanswers,minimizingclientdistress,bore-dom,feelingangrywiththeclient,usinghumortochangeorminimizethesubject,fakinginterestorlistening,notbelievingclientsandnotbeingabletopayattentiontoyourclients.”10Anexcellentfull-lengtharticlebyAnnaBaranowskyaboutthesilencingresponseappearsinCharlesFigley’sbookTreating Compassion Fatigue.

Psychological Signs and Symptoms

◾ Emotional exhaustion.Ahallmarkofcompassionfatigue.◾ Distancing. Youfindyourselfavoidingfriendsandfamily,notspendingtimewithcolleaguesatlunchorduringbreaks,andbecomeincreasingly

hadcomeincontactwithhadneveraskedheraboutahistoryoftrauma.

AsIgottoknowAnne,shedisplayedtheclassicbehaviorsofcomplexPTSDwiththeanxiety,affectdysregulation,depression,somatization.Iwasverysurprisedanddisappointedthatthemedicalsystemthatshewasinvolvedinregularlyhadfailedtoidentifythismajorunderlyingissue.Thiscaseverymuchexem-plifiesthatcompletelackofunderstandingoftheissueofcom-plexPTSD.MedicalprofessionalsarenottrainedtounderstandcomplexPTSD.Manyhaveprobablyneverevenheardofitandyetthese“problem”patientsareofteninteractingwiththetradi-tionalmedicalsystemwheretheirsomaticissuesarepoorlydealtwith,onlytorecuragainandagain.

—As told by a family physician




isolated.Youfindthatyoudon’thavethepatienceortheenergyorinteresttospendtimewithothers.

◾ Negative self-image. Feelingunskilledasahelper;wonderingwhetheryouareanygoodatthisjob;feelingnegativeaboutyourselfasaspouse,apar-ent,orafriend.

◾ Depression. Depressedmood,difficultysleepingoroversleeping,impairedappetite,lossofinterestinactivities,fatigueandlossofenergy,feelingsofhopelessnessandguilt,suicidalthoughts,difficultyimaginingthatthereisafuture.

◾ Reduced ability to feel sympathy and empathy. Thisisaverycommonsymptomamongexperiencedhelpers.Somedescribefeelingnumborhighlydesensitizedtowhattheyperceivetobeminorissuesintheirclientsortheirlovedones’lives.Theoldstereotypeisthedoctorwholetshischildwalkaroundwithabrokenarmfor3daysbeforetakinghimtohospitalbecausehehasmissedthesymptomsandminimizedthemasaslightsprain,oroncologynurseswhodealwithpatientsinseverepainwhofeelangryorirritatedwhenafamilymembercomplainsofanon-life-threateninginjury.

Reducedabilitytofeelempathycanalsooccurifyouareworkingwithaveryhomogeneousclientpopulation.Afterseeinghundredsof20-year-olduniversitystudentscomethroughmycrisiscounselingoffice,Inoticedtwothingshappening:One,Iwouldsilentlyjumpaheadoftheirstoryandfillintheblanks(“Iknowwherethisstoryisgoing”).Two,ifIhadjustseensomeonewhoseentirefamilyhaddiedinanautomobileaccident,Ifounditverydifficulttosummonupstrongempathyforastudentwhoseboyfriendhadjustbrokenupwithherafter2weeksofdating.

Thereareofcourseinherentrisksassociatedwiththisreducedempa-thyandjumpingahead.Clientsarenotallthesame,andweriskmissingacrucialissuewhenwearethreestepsaheadofthem.Wealwaysneedtonavigatethefinelinebetweennotbeingambulancechaserswhothinkeverysinglepersonisasuicideriskandbeingnumbtothepointthatwefailtoaskbasicriskassessmentquestionstoeveryone,includingtheper-sonwholooksjustfine.Thegoodnewsisthatthesolutiontothisisverysimple:varyyourcaseloadtostayfreshandstayontopofyourprofessionaldevelopment.

◾ Cynicism and embitterment. Eye-rollingatthebrand-newnursewhoisenthusiasticallytalkingaboutanupcomingchangeorideashehastoimprovestaffmorale,groaningwhenseeingacertainclient’snameonyourroster,andcynicismtowardyourchildren’sideasorenthusiasm.

Unfortunately,cynicismisrampantinhigh-stressenvironmentssuchashealthcareandprisons.Youmayfindyourselffeelingcynicaltowardyourcolleagues,yourclients,andyourfamilyandfriends.Oryoumaybework-inginaverynegativeworkenvironmentwhereyouaresurroundedbycyni-calcolleagues.LauravanDernootLipskywrites:“cynicismisasophisticated




copingmechanismfordealingwithangerandotherintensefeelingswemaynotknowhowtomanage.”11

◾ Resentment. Resentmentofdemandsthatarebeingputonyoubyothers,offuneventsthatarebeingorganizedinyourpersonallife;feelingirritatedwithyourbestfriendforcallingyouonyourbirthday;resentmentofhav-ingtotakeanextrashiftbecauseyourcolleagueisawayonstressleave.Resentmentcaneatawayatuslikeapoisonandturnusintoangry,brittlepeople.Thisinturnhasadirectimpactontheworkplaceatmosphere(andthemoodinyourhome).

◾ Dread of working with certain clients. Doyoueverlookatyourrosterforthedayandseeanamethatmakesyourstomachlurch,whereyoufeeltotalanticipatorydread?Isthishappeningwithgreaterfrequency?

◾ Feeling professional helplessness. Feelingincreasinglythatyouareunabletomakeadifferenceinyourclients’lives.Beingunabletohelpbecauseofsituationalbarriers,lackofresourcesinthecommunity,oryourownlimitations.Someclientsituationsareverycomplexandthechaosintheirlivescanrundeep.Sometimesitisveryhardforusashelperstohangontoathreadofhope.

◾ Diminished sense of enjoyment/career (i.e.,lowcompassionsatisfaction).◾ Depersonalization. Dissociatingduringsessionswithclients.Again,thisisamatteroffrequency—manyofusspaceoutonceinawhile,andthisisnormal;butifyoufindthatyouaredissociatingonamorefrequentbasis,itcouldbeasymptomofVT.Haveyoueverdrivenhomeandnotremem-beredthedrivefromworktoyourhouse?Mostofushavedonethismorethanonce.Nowhowaboutthis:haveyouevendrivenhomefromwork,notrememberedthedrivehome,andfoundthatyourcarwasfilledwithgrocer-iesyouhadnorecollectionpurchasing?

◾ Disruption of world view/heightened anxiety or irrational fears. Thisisoneofthekeysymptomscausedbyvicarioustraumatization.Whenyouhearatraumaticstory,or500traumaticstories,eachoneofthesestorieshasanimpactonyouandyourviewoftheworld.Overtime,yourabilitytoseetheworldasasafeplaceisseverelyimpacted.Youmaybeginsee-ingtheworldasanunsafeplace.Someexamplesofthisare:Acounselorwhoworkswithchildrenwhohavebeensexuallyabusedbecomesunabletohireamalebabysitterforfearthatthesitterwillabuseherchildren.Aphysicianforbidshischildrentoeverchewgumafterseeingatragiceventhappenwithachildandgumathiswork.Aprisonguarddevelopsafearofhomeinvasionafterworkingwithaserialrapist.Anacquiredbraininjurytherapistdevelopsaphobiaofdrivingonthehighwayaftertoomanymotorvehicleaccidentrehabs.

Arecentworkshopparticipanttoldmethatafterworkingatayouthhomelessshelter,shebecameobsessedwithmonitoringherteenagechil-dren’severymove,convincedthattheywereusingdrugsandhavingunprotectedsex.Shefinallyrealizedshehadgonetoofarwhenshestarted




lecturingher10-year-oldson’sfriendsaboutmethamphetaminesandcon-doms,onlytoseetheirhorrifiedfacesatthebreakfasttable.

Someofthisisinevitable.WecallVTandCFoccupationalhazardsforthisveryreason:AsLaurieAnnePearlmansays,itisnotpossibletoopenourheartsandmindstoourclientswithoutbeingdeeplyaffectedbythestoriestheytellus.Butwhatisimportanttonoticeishowseverethesedis-ruptionshavebecomeforyou.Wecanalsosometimesmitigatetheimpactbydoingrestorativeactivities(e.g.,workingwithhealthychildren,workingonaquiltforpeoplewithAIDS).

◾ Increased sense of personal vulnerability. Seeabove.◾ Inability to tolerate strong feelings. Readaboutthesilencingresponseabove.Thiscanalsooccurwithfamily,friends,andcolleagues.

◾ Problems with intimacy. AsacouplescounselorIheardmanystoriesaboutrelationshipchallengesincludingdifferencesofopinionaboutmoneymanagement,parenting,householdchores,in-laws,andsexandintimacy.Manyhelpersconfessthattheycomehomecompletelyuninterestedintheideaofhavingsexwiththeirspouses.Asoneclientsaidtome,“Icomehome,aftergivingandgivingtoallofmypatientsallday.ThenIgivetothekids,thenIcleanupandgetreadyforthenextday.Finally,it’s9:30p.m.andallIwanttodoiscollapseinbedwithatrashynovel.Thenmyhus-bandcomesupstairsandwantstohavesex,andIfeellikesaying,‘Areyoukiddingme?I’malldone.Pleaseleavemealone.’”Andthesearenotneces-sarilycoupleswithsignificantpreexistingmaritalproblems.Thedepletioncausedbythejobistheproblem.Ofcourse,bettercommunicationandedu-catingspousesabouttherealitiesofCFcanhelpgreatly.Helperswhoworkwithsexualabusesurvivorsmayalsofindthattheirworkintrudesontheirabilitytoenjoyahealthysexualrelationshipwiththeirpartner.

◾ Hypervigilance. WhenIrunworkshops,Icanalwaystellwhichpartici-pantsworkinlawenforcement:theyalwayssitwiththeirbackstothewallandaclearviewofthedoor.Whydotheydothis?Ifyouaskthem,theywilltellyouthatit’ssecondnaturetothem,theysimplyhaveareflextositsomewherewhereyoucanseeanyincoming(i.e.,potentiallythreatening)personandalsobeabletogetoutoftheroomrapidlyifthereeverwasanemergency.Thisisaformofhypervigilancethathasbeenlearnedonthejob.Someprisonstaffalsotellmethattheyaremorefearfulofhomeinva-sionsandhavedevelopedaritualtosecuretheirhomesasadirectresultoftheworktheydowithinmateswhospecializeinbreakingandenter-ing.Manycounselorswhoworkinthefieldofsexualabusedescribefeel-ingsuspicioustowardanymalesportscoach,cubleader,andsoforthwhoapproachestheirchild.

Traumasurvivorsoftenexperiencehypervigilanceduetopasttraumaevents(e.g.,youhadtohidewheneverasirensoundedandnowanysoundthatresemblesasirenmakesyougointoastateofpanic,orforamoment,withouteventhinkingaboutit,youmovetoduckunderadesk).Ashelping




professionals,wecaninternalizeourclients’highlevelsofalert.AsLipskysays,wecan“feellikewe’realways‘on.’Evenduringtimeswherethereisabsolutelynothingthatcanorshouldbedone.”12

◾ Intrusive imagery. Thisisanothersymptomofvicarioustrauma:Findingthatyourclients’storiesareintrudingonyourownthoughtsanddailyactivities.Someexamplesarehavingadreamthatdoesnotbelongtoyou;havingdifficultygettingridofadisturbingimageaclientsharedwithyou;beingunabletoseearopeasabenignrope,aftersomeonehassharedagraphicsuicidestorywithyou;orhavingcertainfoodsbeunappealingtoyouafterhearingaboutcertainsmellsorsoundsfromawarveteran.Itisnotunusualforthoseintrusiveimagestolastafewdaysafterhearingapar-ticularlygraphicstory,butwhentheystaywithyoubeyondformorethanacoupleofweeks,youarelikelyhavingasecondarytraumaticstressexperi-ence.(YoucanreadanexcellentdescriptionofthisinEricGentry’sarticleCompassion Fatigue:A Crucible of Transformation;seetheBibliographyformoredetails).

◾ Hypersensitivity to emotionally charged stimuli. Cryingwhenyouseethefluffykittensfromthetoiletpapercommercial;cryingbeyondmeasureinasessionthatisemotionallydistressing(wellingupisnormal;sobbingisnot).

◾ Insensitivity to emotional material. Sittinginasessionwithaclientwhoistellingyouaverydisturbingordistressingstoryofabuse,andyoufindyourselffakingempathy,whileinsideyouarethinkingeither,I’veheardmuchworse,or,Yup,Iknowwheresheisgoingwiththisstory;Iwonderwhat’sforlunchatthecanteen.

IknowawonderfulfamilydoctorwhoeventuallyrealizedthatshewasstrugglingwithVT.Sheusedtoshare,atourdinnertable,extremelygraphicstoriesofmedicalproceduresofhorriblegrowthsorcanceroustumors(usu-allyinthenetherregions)withour3-and5-year-oldchildrensittingwithus.Sheseemedcompletelyunawareofthechildren’shorrifiedlooksontheirfaces,nevermindtheadults.

Otherexamplesarefindingthatyouarewatchinggraphicallyviolenttele-visionanditdoesnotbotheryouintheslightest,whilepeoplenexttoyouarerecoilinginhorror.

◾ Loss of hope. Overtime,thereisarealriskoflosinghope—losinghopeforourclients(thattheywillevergetbetter)andmaybeevenhopeforhumanityasawhole.

◾ Difficulty separating personal and professional lives. Ihavemetmanyhelpingprofessionalswho,quitefrankly,havenolifeoutsideofwork.Theyworkthroughlunch,rarelytaketheirvacations,carryabeeperorsmartphoneatalltimes,andareonseveralcommitteesandboardsrelatedtotheirwork.Theyarealsoalwaysoncalltohelptheirfamilyandarethe“caregiverextraordinaire”foreveryonearoundthem.Ionceknewahelp-ingprofessionalwhocarriedherworkcellphoneatalltimes.Iusedtosee




heratdaycare,frequentlyansweringclientcallsat7:30a.m.whiledroppingherchildrenoff.Iwasverycuriousaboutthisandaskedherlaterwhatherworkinghourswereandshesaidproudly,“Oh,Istartat9a.m.butclientscanreachmeanytimeofdayornight.”Thispersonworkedatthelocalhos-pitalandbelongedtoalargerosterofsocialworkersthere,withtheiron-callbeepersonarotatingbasis.Noneoftheothersocialworkersatthehospitaltookclientcallsat7:30a.m.unlesstheywereatworkoroncall,butshehadlosttheabilitytoseparateherprofessionallifefromherpersonallife.

◾ Failure to nurture and develop non-work-related aspects of life. ManyofthehelpersthatImeetconfessthattheyhavelosttouchwiththehobbies,sports,andactivitiestheyusedtoenjoy.Sometellmethattheycollapseinbedattheendoftheirworkday,tootiredtoconsiderjoininganamateurtheatergroup,gocurling,orjoinabookclub.Yet“havingalife”hasbeenidentifiedasoneofthekeyprotectiveelementstoremaininghealthyinthisfield.

EXERCISE: DEVELOPING AN EARLY WARNING SYSTEM

Ibelievethatcompassionfatigueisanormalconsequenceofworkinginthehelpingfield.Thebeststrategytoaddresscompassionfatigueistodevelopexcellentself-carestrategies,aswellasanearlywarningsystemthatletsyouknowthatyouaremovingintothecautionzoneofCF.

Self-careisnotsomethingwefigureoutonceandforallandgetthecer-tificateandputitonourwall.Youcan’tsay,“IcompletedacourseandnowI’macertifiedexpertinmyownself-care.”

Youknowhowradiologytechnicianswearalittlewidget(calledadosimeter)thatmonitorshowmuchradiationtheyhavebeenexposedto?That’swhatIvisualizeweshouldallwear:alittleself-carewellnessdosim-eter,(Figure6.1).

Itwouldalwaysbeon,anditwouldbeeponcewhenwe’regettingslightlyoverloaded,twicewhenweareheadedforabigdoozyofaweek,andmaybegiveusanelectricshockwhenwe’reheadedforatotalcrash!

Iwouldnowliketoyoutrytovisualizeyourownself-carewellnessdosimeter:Whatwoulditlooklikeforyou?Whatwouldbeasymbolicwayforyoutoregularlytakestockandcheckinwithyourself?

Green Yellow Red

Figure 6.1 Self-care wellness dosimeter.




Mostofushaveabuilt-inwarningsystemforgeneralstress:forexample,IgettightintheshouldersandneckwhenI’mstartingtogetoverloaded;mybestfriendgetsamigraine.Youcanprobablynameyourownsymptoms,butdoyouknowwhatyourCFwarningsignsare?

Withtheimageofyourdosimeterinmind,trytovisualizethatyouplaceitbackinitsdockeverynight.Thisdockdownloadsthestressandtraumaexposureyouhavehadandgivesyouareading.

Inreality,thiscanbea2-minute“howamIdoingtoday?”process,ormaybeforyouit’sjournalingattheendoftheday,orasimple“howdidmydayrateonascaleof1–5?”

Thisiswhylearningtorecognizeone’sownsymptomsofcompassionfatiguecanserveasanimportantcheck-inprocess,asitcanallowustodevelopawarningsystemforourselves.Beingabletorecognizethatone’slevelofcompassionfatigueiscreepinguptotheredzoneallowsustoimplementstrategiesrapidlybeforethingsgetworse.

MAKING IT PERSONAL HOMEWORK

Afterreadingthroughthelistofwarningsigns,spend15minutescomplet-ingthiswritingexercise.Ifyouareworkingwithagroup,considersharingsomeofyoursignsandsymptomswithoneanother.

MY WARNING SIGNS: WRITING EXERCISE

1.Whatsignsandsymptomsstandoutmostforme? 2.WhatsignsandsymptomsdoIbringhomewithmemostoften? 3.WhatsignsandsymptomsdoIexperienceatwork? 4.WhatdoIhavetoloseifIdon’tdealwiththeeffectsofthisoccupa-

tionalhazard? 5.WhatdoIstandtogainifImovetowardimprovedself-care? 6.Whowillbethebiggestsupportersofmyself-care?




Endnotes

1.Mathieu,F.(2010).Adaptedfromablogpostpublishedonwww.compassionfatigue.ca.http://compassionfatigue.ca/moving-out-of-the-red-zone-of-compassion-fatigue-getting-feeling-back-in-our-toes/

2.Figley,C.R.(Ed.).(1995).Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized.NewYork:Routledge.

3. Saakvitne,K.W.,Pearlman,L.A.,&thestaffoftheTraumaticStressInstitute.(1996).Transforming the pain: A workbook on vicarious traumatization.NewYork:W.W.Norton;Pearlman,L.A.,&Saakvitne,K.W.(1995).Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors.NewYork:W.W.Norton;Figley,C.R.(Ed.).(1995).Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the trauma-tized.NewYork:Routledge;Gentry,J.E.,Baranowsky,A.B.,&Dunning,K.(1997).AcceleratedrecoveryprogramforCompassionFatigue.PaperpresentedatthemeetingoftheInternationalSocietyforTraumaticStressStudies,Montreal,Quebec,Canada;vanDernootLipsky,L.&Burk,C.(2009).Trauma stewardship: An every-day guide to caring for self while caring for others.SanFrancisco:Berrett-Koehler.

4.vanDernootLipsky,L.&Burk,C.(2009).Trauma stewardship: An everyday guide to caring for self while caring for others.SanFrancisco:Berrett-Koehler,p.81.

5.Maté,G.(2003).When the body says no. Toronto:VintageCanada,p.6. 6.vanDernootLipsky,L.(2009).p.111. 7.vanDernootLipsky,L.(2009).p.111. 8.FormoreinformationoncomplexPTSD,see:Courtois,C.A.,&Ford,J.D.(2009),

Treating complex traumatic stress disorders. NewYork:GuilfordPress. 9.Gentry,J.E.,Baranowsky,A.,&Dunning,K.(1997).http://www.tir.org/research_

pub/research/compassion_fatigue.html 10.Baranowsky,A.B.(2002).Thesilencingresponseinclinicalpractice.InC.R.Figley

(Ed.),Treating compassion fatigue.NewYork:Brunner-Routledge. 11.vanDernootLipsky,L.(2009).pp.103–104. 12.vanDernootLipsky,L.(2009).p.65.

RECOMMENDED READING

Toreadmoreonsignsandsymptoms:

Figley,C.R.(Ed.).(1995).Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized.NewYork:Routledge.

Pearlman,L.A.,&Saakvitne,K.W.(1995).Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors.NewYork:W.W.Norton.

vanDernootLipsky,L.&Burk,C.(2009).Trauma stewardship: An everyday guide to caring for self while caring for others.SanFrancisco:Berrett-Koehler.

InherbookTrauma Stewardship,LauravanDernootLipskyhasanexcel-lentconceptualizationofsymptoms,whichshecalls,“The16warningsignsoftraumaexposureresponse.”(p.47)


http://www.compassionfatigue.ca

http://compassionfatigue.ca/moving-out-of-the-red-zone-of-compassion-fatigue-getting-feeling-back-in-our-toes/

http://compassionfatigue.ca/moving-out-of-the-red-zone-of-compassion-fatigue-getting-feeling-back-in-our-toes/

http://www.tir.org/research_pub/research/compassion_fatigue.html

http://www.tir.org/research_pub/research/compassion_fatigue.html


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