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!