Compassion Fatigue and Trauma Work

On Tuesday 29 November my students and I watched a DVD about secondary trauma, compassion fatigue and burn out; all conditions that can effect individuals working with clients who have suffered psychological trauma. Those of us who work with children are particularly at risk of developing a reaction - the vulnerability of children and an inbuilt need to protect them from harm can leave us feeling powerless and helpless when faced with a child's distress and suffering.

Secondary Trauma

Secondary trauma is a term used to describe a range of symptoms effecting individuals who attend traumatic incidents where people are killed or seriously injured. Fire fighters, police officers and paramedics are particularly at risk; but individuals working as nurses, doctors, therapists and support workers, caring for traumatised individuals, can also develop the symptoms of secondary trauma. Our ability to empathise with others leaves us vulnerable to traumatic reactions when we are helping individuals who have experienced overwhelming amounts of distress. Individuals exposed to secondary trauma may experience symptoms that are similar to Post Traumatic Stress Disorder (PTSD), a condition that effects individuals directly involved in the traumatic incident: flashbacks, intrusive thoughts, nightmares, depression, anxiety, avoidance, anger, hyper-vigilance, alcohol and drug misuse.

Compassion Fatigue

Individuals regularly working with the victims of trauma and abuse may develop or be at risk of developing compassion fatigue. Overwhelmed by the amount of traumatic information he or she is seeing, feeling and hearing, the individual's mind reacts to protect the individual. This involves closing down emotionally so the person is no longer emotionally available to their clients (and family); the individual may become tired, impatient, cynical and dissociated from their work. Stress builds and individuals react by becoming frustrated and angry. Losing our sense of humour is one of the first signs of compassion fatigue. An individual my also lose their common sense and become angry - passion replaces compassion. In these circumstances the individual needs to take a break. Once he or she has recharged his or her batteries the zest for work usually returns.

Burn Out

If the individual continues to work with trauma, despite experiencing compassion fatigue, then he or she may go on to experience burn out. In these circumstances the individual loses their desire and ability to do their job, a state of total exhaustion takes over, often accompanied by depression. The individual's mind and body is in revolt and will not allow them to continue being with distress and trauma. Recovery from burn out may take many months, or even years, and often results in a change of role for the individual or even a change in career.

Protecting Workers

Advice from senior professionals on the DVD centred on the need for a work-life balance: plenty of sleep, rest, exercise, sex, relationships, interests and hobbies, innoculate the trauma worker against compassion fatigue and burn out and increases resilience. At an agency level there is a need for supervision in order to help workers off load. Individuals new in post are particularly vulnerable to trauma reactions so effective training and support is essential.

Questions

How did you react to the DVD? What issues were important for you?

List some of the signs of stress in you and your colleagues?

Individuals working with children may be particularly at risk of developing compassion fatigue. What do you do to maintain a work life balance?

Further Reading

Educating Child Welfare Workers About Secondary Trauma and Stress: HERE

Book Review: The Heroic Client by Duncan, Miller and Sparks

The Heroic Client is wonderfully polemical – a fearless examination of contemporary medical approaches to mental illness and its treatment. The book targets the pharmaceutical industry and the psychoactive drugs it produces. It attacks the medical model and its tendency to define mental illness reductively in terms of ‘biochemical imbalance”. The authors are sceptical of approaches that stigmatise individuals and reify the causes of mental illness by applying biological models and questionable diagnoses - an approach that turns clients into passive recipients of behavioural treatments and tablets. The authors ask for clients to be cast in a different light - competent, resourceful, and resilient – with the agency and self-efficacy to find solutions and make positive changes.

The book begins with a chapter entitled, “Therapy at the Crossroads”, in which the authors warn of a situation developing in which counsellors and psychotherapists exclusively work for medical practitioners. In these circumstances the medical model becomes the only way of explaining mental illness, with the therapist as an adjunct to medication, a fixer of broken people. In chapter two the authors challenge the supremacy of the medical model, calling into question the evidence base on which it rests and suggesting other constructions of mental health and mental illness that include the social context and the personal history of the client.

At the heart of the book are three chapters that provide an alternative to the established diagnostic approach. In examining the client’s story for signs of pathology the medical model misses an alternative interpretation of the client’s experience, one in which the client endures or overcomes trauma and loss through the discovery and use of social networks and inner resources. The ‘heroic client’ has a different tale to tell once he or she is freed from the template imposed on them by pathologising and medicating mental health professionals.

To support the heroic client practitioners ensure their therapy is client directed (chapter three) and outcome informed (chapter four). In my favourite chapter, rich with case material, the book highlights the importance of identifying and exploring the client’s theory of change (chapter four). The authors refer to research carried out on the innovative hypnotherapist Milton Erickson in the 1980s. Nobody could quite understand how he worked out which intervention his clients needed for recovery to take place. Eventually the researchers realised that Erickson didn’t know either, but that his clients did. Erickson listened to his clients and from them he discovered what they needed in order for therapeutic change to take place.

The book contains a critical examination of psychoactive medication. The fact that so many children are being prescribed stimulants and anti-depressants ought to concern us all. The authors explain just how flimsy the evidence is supporting anti-depressants, with many proving hardly more effective than placebos. So, this book is a cri de coeur – urging therapists to stand against the drug companies and the medical model and to listen instead to clients and their heroic stories. A very good read!

A "Victim Letter" - the Start of a Process

The BBC News Website have a story here about a young burglar, under the supervision of the Youth Offending Team and required to write a remorseful letter to his victims. The young person does write a letter but instead of saying sorry, he blames the victim for leaving open the kitchen window, living in a high crime area and not closing the living room curtains. His last sentence is, "But anyways I don't feel sorry for you and I'm not going to show any sympathy or remorse".

The police released this letter to the public as a warning for householders to close their curtains. I would imagine they did this without consulting the Youth Offending Team or the Probation Service. The police often have their own agenda in these matters and don't see how their actions actually undermine public confidence in the Criminal Justice System. As a result we have a number of agencies rushing to defend the principles of restorative justice and someone from the Ministry of Justice providing a bland statement on the effectiveness of Intensive Supervision.

Of course restorative justice is only meaningful if the offender feels and expresses genuine remorse. If that happens then the results can be very positive for the victims and the offender. This type of response was never going to be sent to any victims, rather it is the beginning of a process in which the views expressed in the letter can be challenged and changed. If I was working with this young offender I would thank him for his honesty; I would then begin the process of confronting the beliefs and values that underpin the thoughts expressed in the letter. This young man (and I am assuming it is a young man) has no empathy for the victim, takes no responsibility for his actions and feels no remorse. It's the job of the Youth Offending Team to address those deficits. No need for outrage, just good probation work!

Book Review: An Anatomy of Addiction by Howard Markel

My favourite book this year turns out to be An Anatomy of Addiction: Sigmund Freud, William Halsted and the Miracle Drug Cocaine by Howard Markel. Such an enjoyable read: a good story, well written with humour and insight from a doctor and professor of the history of medicine.

Markel provides some entertaining chapters on the discovery and early use of cocaine. It was used as a pick-me-up added to soft drinks and wine, as a cure-all for the depressed and liverish and as a local anaesthetic that revolutionised surgery. By the time cocaine's addictive and destructive properties were recognised thousands were addicted to the drug.

Markel's account of Freud's cocaine use is fascinating, fair and balanced, an antidote to E.M. Thornton's tendentious Freud and Cocaine - also reviewed on my blog here. He describes Freud's early research into the drug's medicinal properties, including the disastrous treatment for morphine addiction of his friend, Ernst von Fleischl-Marxow. Despite his friend's double addiction to morphine and cocaine and resulting death, Freud became an advocate of cocaine and used the drug himself for around ten years. It is fascinating to consider how much cocaine influenced Freud's ideas in the 1890s, including his Analysis of Dreams.

William Halsted was a contemporary of Freuds. He has been called the father of modern surgery. He advocated the antiseptic approach of Lister, and at a time when surgeons operated in dress coats, insisted his staff wear surgical garb, scrubbed their hands and don rubber gloves. He developed new operations and new treatments and yet throughout his career he was addicted to morphine and cocaine. Halsted's cocaine addiction began when he started testing the drug's anaesthetic qualities, injecting himself under the skin and cutting himself to see how deep he could cut without pain. Soon he was addicted. His friends and colleagues attempted to rehabilitate Halsted whilst preserving his reputation. Thus they sent him on a sea voyage to wean him off the drug and when this failed he was sent to a mental hospital where he was prescribed morphine in order to manage the symptoms of cocaine withdrawal. Halsted was addicted to drugs for the remainder of his life but managed to control his drug use (but with frequent relapses) thanks to a huge effort of will. After some years working in the pathology lab at the new Johns Hopkins University Medical School he was appointed to a professorship and continued to advance the profession of surgery until his death in 1922.

Markel's book provides an entertaining account of the lives of these two great Victorians, advancing the cause of medicine whilst battling their own demons and the problems of drug misuse and dependency. An excellent read!

Book Review: What is Madness by Darian Leader

I’ve just finished reading Darian Leader’s latest book, What is Madness? It’s an absorbing read – sometimes difficult – but ultimately, fascinating and humane. Leader explains the roots of psychosis using the psychoanalytic theories of Jacques Lacan and at times the explanations seem rather more complex that the phenomena being explained. The discussion of Lacan’s client, “Aimee”, for example, is labyrinthine in its use of competing psychoanalytic explanations for her psychosis and behaviour. That's why I appreciated Leader's comment that, "A psychoanalytic theory of psychosis does not imply a psychoanalysis of psychotic subjects" (294). Indeed Leader points out that individuals experiencing psychosis are suffering from too much meaning and do not benefit from the interpretations of therapists.

The book opens with a chapter entitled, “Quiet Madness” in which Leader draws our attention to a mistake commonly made in conversations about psychosis. According to Leader it is wrongly assumed that madness and the visible symptoms of madness are the same thing. For Leader the symptoms of madness - hallucinations, paranoia, delusions - are the individual’s attempt to make sense of the horror that has befallen him or her: ‘responses to madness, attempts at self-cure’ (17). This is a fascinating insight and extends my own belief that emotional disorders such as depression or anxiety are perfectly functional when seen in the context of the individual's history and current experience. This realisation ought to guide the therapists approach. Attempts to remove the symptoms of psychosis without helping the patient to explore their condition may well interfere in the process of self-healing. As Leader says, medication is useful because it tempers the intensity of psychotic symptoms but should also serve as a 'platform for dialogue'.

Leader emphasises the importance of symbolism and language when explaining madness. He sees madness as a breakdown in these structures, resulting in a terrifying loss of meaning and a disconnection from reality. In response to this the individual cobbles together what he can to make sense of his experience. This may show itself as paranoia or other delusions. The individual may believe he or she has been abducted by aliens if this restores meaning and makes sense of a catastrophic event. Psychotic individuals (and psychoanalysts?) cling to the most unlikely ideas in their attempt to make sense of the world.

In what Leader calls, “Quiet Madness”, the individual may appear balanced, keeping his delusional world under wraps and thereby achieving the semblance of normality. In an interesting chapter, Leader suggests that the serial killer, Harold Shipman, is an example of “Quiet Madness”. To his patients and colleagues he appeared to be a professional, kind and diligent doctor; but it was this role that enabled Shipman to stabilise his madness, part of which involved the murder of hundreds of patients.

Leader argues that quiet madness can erupt into full blown psychosis through various trigger events, often associated with rites of passage. Marriage, divorce or having a book published, all have the potential to trigger psychosis: moving the individual from ‘being mad’ to ‘going mad’. Events have this potential because they require from the individual a new set of symbols, and if the individual cannot symbolise this transformation they are at risk of becoming psychotic. Leader spends several chapters exploring this process so my summary here is incredibly superficial.

The final chapter of this complex book suggests ways of working with psychosis. Following his hero, Jacques Lacan, the author uses the metaphor of the secretary - to quote Lacan, the therapist ought to be, “the secretary of the alienated subject” (305). Leader likes this description, likening the therapist to a secretary who faithfully records, asks for clarifications and doesn’t intrude too much (305). The therapist as secretary helps the client to build a personal history, helps the individual to explore their own frame of reference and thereby helps in the work of self-healing. Leader is honest about the amount of time, hard work and commitment required to work with clients experiencing psychosis. He is hostile to therapies that seek to return clients to “normal” and measure success by how far their clients have adapted to social and community norms. Instead Leader suggests that an “investment in dialogue and a curiosity about the logic of that person’s world can open up new therapeutic directions and offer the possibility of change. Therapy can do no more and no less here than to help the psychotic subject do what they have been trying to do all their lives: create a safe space in which to live” (330).

Leader, D. (2011) What is Madness? London, Hamish Hamilton

The Immortals Will Not Live Long in the Memory

Last night I went to the cinema to watch The Immortals 3D. I have to say up front that I am fussy in my movie viewing and have high expectations. I want films to be intelligent and to tell a good story with rounded characters I can believe in and empathise with. I am often disappointed and in The Immortals (I now realise) I was bound to be disappointed since it isn't that kind of film.

First of all I have a beef with 3D. There are a few moments when 3D is amazing, when objects float in mid air between the viewer and the screen. But these moments are so rare that they do not justify watching a film wearing sun glasses. What the viewer gains in depth of field he or she loses in brightness and colour. I have seen two films in 3D just recently and with both I wanted to say, 'Can someone please put the light on'.

On a positive side the Immortals has some spectacular computer generated imagery and the beefcake actors are lovely to look at. But the film is a disappointment because it presents charactures rather than characters: the evil Hyperion is covered in scars and crushes people's heads when they bring him bad news. He seeks to destroy mankind because the gods failed to save the lives of his wife and child. Thus he holds a special contempt for priests, setting fire to one after dowsing him in oil. This is all we know about Hyperion, a villain with no back story and no complexity, someone we can hate with a clean conscience.

The heroic Theseus is physically perfect but incredibly boring. We know nothing about him except he loves his mum, wants to protect poor people and has been blessed by the gods. He is naive and seems like a school boy in a man's body. When he makes a speech to raise the morale and stiffen the resolve of his army it isn't convincing. One soldier shouts, 'Who are you to lead us?' A good question! The response, 'I'm an ordinary Joe like you' didn't inspire much confidence.

At the same time as this human conflict is being acted out to it's predictable conclusion, complete with references to future conflict, in case this makes money and a sequel is needed, a conflict also rages in the heavens. The Olympians led by Zeus intervene once Hyperion unleashes the Titans. Keats' poem Hyperion has a wonderful image of a Titan led on the beach, the poet is able to communicate the vast size of the Titan in just a few sentences. In this film, and with all this technology to hand, the Titans are presented as imps, moving at Benny Hill speeds, they seem an unlikely scourge. Zeus joins the battle and at this point the stylised fight scenes, with heads and bodies hacked and smashed, tip over into silliness and a memory of the Ninja Turtles came into mind.

But more disappointing than all this was the plot. The 300 was a much better film, despite it's right wing agenda and xenophobia, because it told a simple story well. Not so The Immortals; which is a shame because the Greek Myths contain eternal truths, wonderful metaphors and great events. The Immortals captures none of this. Even Troy was better!

The Lobotomists on BBC Radio Four

I have just listened to an excellent BBC radio programme on the history of the Lobotomy. Hugh Levinson, the producer and presenter, has written a BBC News article about the programme here.

The programme was about the short lived idea that patients living with mental illness could be cured if only the connections between the frontal lobes and the rest of the brain could be severed. The operation (called a Leucotomy in Britain) involved drilling holes into the patient's skull just behind the eye sockets and below the temples, and then inserting a long spike, like an overly long ice-pick, into the brain to make cuts behind the frontal lobes. One commentator observed that the procedure contradicts the standard medical view that cutting healthy tissue tends to make things worse not better.

The programme featured three famous exponents of the procedure: Egas Moniz in Portugal, Walter Freeman in the States and Sir Wylie McKissock in the UK.

The Lobotomy was popular throughout the 1940s and into the '50s. The programme estimated, for example, that within that short period Sir Wylie McKissock carried out 3000 lobotomies. He would even tour provincial hospitals at the weekends operating on patients. Freeman also was an advocate of the procedure, even making a movie to advertise the benefits of the operation.

Shockingly there was no research done into the procedure and no follow up investigations to see how patients recovered after surgery. The Lobotomists convinced themselves that about a third of patients were helped by the surgery whilst the rest were no worse for it. There was no evidence for this and in fact many patients suffered catastrophic harm as a result of the treatment. With the discovery of anti-psychotic medication in the 1950s the practice faded. The history of medicine is full of such horrors.

Book Review: Integration in Counselling and Psychotherapy by Lapworth and Sills

I teach on a counselling course that requires students to make sense of a number of different approaches to therapy; so I've been giving a lot of thought to integration and how it can be successfully achieved. After reviewing Cooper and McLeod on my blog here I have turned my attention to Lapworth and Sills and the second edition of their Integration in Counselling and Psychotherapy. The two books are similar because both are concerned with giving the reader an over-arching framework to help make integration possible; but whilst Cooper and McLeod provide one approach to integration - pluralistic counselling and psychotherapy - Lapworth and Sills provide an overview of what is needed if integration is to be achieved, their own model of integration - the Multi-dimensional Integrative Framework - and brief chapters on four other approaches, including a chapter on the therapeutic relationship and an outline of Multi-modal Therapy.

I am trying to work out why I disliked the first part of Lapworth and Sills. I found it too theoretical. I was left wondering how I had managed the task myself of integrating different counselling approaches. I was reminded of the cartoon strip in which Garfield the cat is stuck on the stairs after wondering how on earth he was able to co-ordinate the movement of his four legs. I could be at fault because I'm more of an activist when it comes to learning, which may also explain why my favourite chapter in the book is a case study of the Multi-dimensional Integrative Framework in action. But I don't think it's the theoretical nature of the material in these early chapters that's the problem, rather it's the lack of time taken to explain and illustrate what is being said. I was left with the sense of skating across the subject because of the authors' preference for summaries, outlines and bullet points. This tendency can also be seen at the end of the book when the authors give a brief outline of four competing theories of integration. It can also be seen in the first chapter where the authors give a potted history of integration in counselling whilst apologising because they don't have room to explore the topic further.

So for me the life saver, the thing that enabled me to go on reading, is the diagram on p89 and the case history that forms chapter six. Here the authors apply their Multi-dimensional Integrative Framework and the reader gets to see how useful it is as a model for explaining the problems experienced by the client, how these might be addressed (a formulation) and how therapy is progressing over time.

The authors argue in this book that in order for integration to happen successfully the therapist must have an over-arching framework that gives the therapist an understanding of human beings and of therapy and informs the choices the therapist makes about the strategies and techniques to borrow from different schools of therapy. It is the over-arching framework that gives those choices coherence and therapeutic power. I am reminded yet again of Yalom's point about creating a therapy for each client and I'm happy that ultimately Lapworth and Sills provide a way of doing that - and summaries of alternative frameworks that the reader can investigate further.

Lapworth, P. and Sills, C. (2010) Integration in Counselling and Psychotherapy, 2nd Edition, London, Sage.

Marg Simpson Sees a Therapist for Her Flying Phobia

First click of play gives you a pop up, which you close, second click gets you the movie at which you can laugh!

Today @Shrink_at_Large Tweeted the link to a funny Simpsons video in which Marg sees a therapist to cure her flying phobia. In true Freudian style Marg lies on the couch and free associates. With the “help” of her therapist she’s able to trace her anxiety to a time when she caught her father working as a stewardess on a passenger jet. I say in true Freudian style because one of Freud’s most famous cases, The Wolf Man, was neurotic, according to Freud, chiefly because he’d intruded on his parents having sex. In fact Freud himself wrote about seeing his mother naked on a train, an image the young Freud found both disturbing and memorable. As with a great deal of Freud, what begins as theory turns out to be autobiography.

So the scene in which Marg intrudes on her father serving drinks has a pedigree. Interestingly Marg also remembers other train related trauma, such as the engines of her toy plane bursting into flames or being machine gunned by a crop duster whilst walking past a field of corn. These are discounted by her therapist in favour of the more significant trauma of seeing her father working his way along the aisle. Marg’s phobia only becomes apparent to us when the Simpsons are given free air tickets. These are to buy Homer’s silence after he crashes a plane whilst pretending to be a pilot (which he does to get a drink in a pilots only bar). Maybe it’s this parallel that leads to Marg’s crisis: all her life the phobia had served as a defence, enabling Marg to avoid planes and airports - and ultimately the memory of seeing her father serving cocktails on an economy airline.