Recently we completed a survey of CeDAR employees, asking them to identify the causes of burnout and secondary trauma that they experience on a daily basis. While different employees identified different specific examples, the items listed on this slide are all categories of problem areas that were identified by our employees. They were also the same issues that were identified in our employee satisfaction surveys.I assume that concerns about communication, change and growth, alterations in policies and procedures, interactions with difficult patients, peer conflict and staffing issues could be a list of possible causes of burnout in any healthcare environment!
In the healthcare industry it is important to discuss two specific ways that this trauma transmission can take place.Vicarious Trauma is a term that was identified by McCann and Pearlman in the early 1990’s. Vicarious trauma is a process in which one healthcare worker becomes traumatized from their consistent interactions with one patient or one family, that is especially symptomatic or that has a significantly profound trauma narrative. It is said to be an infectious process where the professional either suddenly or slowly begins to experience similar symptoms as those experienced by the patient. Often the professional is aware of subtle shifts, but struggles to put their finger on what is different. I had this experience several years ago while working with a very violent and paranoid Vietnam Veteran. I found myself experiencing significant intrusive thoughts about his well-being and I was confronted by my wife on new behaviors like locking doors and rechecking the locks consistently throughout the evening. I was not consciously aware of the behavior change or my growing anxiety until I was asked about it. Once identified, I was able to work through it quickly and the symptoms went away.A chiasm is defined as the crossing of two tracks. So Chiasmal Trauma occurs when an entire work group, department, or organization experiences trauma after “crossing paths” with the trauma experience of one particularly difficult patient or family, a co-worker, or beloved leader. The best example of Chiasmal Trauma that I can think of comes from an oncology unit of a hospital where I worked. A woman came into the unit and was visited by her husband and three small girls. The nurses got to know that family. The mother went into remission and left the hospital. A few years later the mother came back in. The family visited and the nurses became reaquanited with the young girls, now a few years older. The mother again went into remission and left the hospital. A few years later the mother returned and passed away. I was called in to debrief the nursing staff and the primary image for most nurses were the children and husband that they had some to know.
Now that we have reviewed the common symptoms of compassion fatigue, it is time to look at factors that can assist us in dealing more effectively with work related stress and trauma and that can actually prevent work related compassion fatigue. The first factor is personal resilience. There is a quote from Robert Louis Stevenson’s Mody Dick that I think is a wonderful metaphor to describe individuals who have a high degree of resilience. “Life is not a matter of having good cards, but of playing a poor hand well! More specifically, the American Psychological Association defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats, and even significant sources of stress. . . “ Resilient individuals overcome adversity by maintaining a connection to supportive people, healthy activities, and to life itself. They also maintain a sense of hope. Across cultures, researchers have found that individuals with the most resilience consistently maintain a solution focus and a belief that focusing on a successful future is more important than focusing on a painful or stressful past. It hasn’t been that long ago that we believed that resilience was something that we were born with. We now know that we are all born with the capacity to develop the traits that are commonly found in resilient individuals.
Barnes understanding compassion fatigue phoenix ms
Understanding Compassion Fatigue
The Role of Resiliency and Self-Care in Organizational
and Employee Wellness
Michael F. Barnes, Ph.D., LPC
Clinical Program Manager
We will review each of the six questions below:
o What is Compassion Fatigue?
o How does one get Compassion Fatigue?
• Factors that influence burnout and secondary trauma
o What are the symptoms of Compassion Fatigue?
o How do you develop a resilient workforce?
o What is the influence of self care activities in resilient
Reasons to be Aware of Compassion Fatigue
According to Carla Joinson (Nursing92), there are four reasons
why you need to be aware of compassion fatigue and respond
appropriately to it:
Compassion Fatigue is emotionally devastating.
May experience great sadness, grief, depression, exhaustion
2. Caregivers’ personalities lead them toward it.
You can’t get compassion fatigue if you are not compassionate,
3. The outside sources that cause it are unavoidable.
Working with death, trauma, grief, anger, conflict have a cost!
4. Compassion Fatigue is almost impossible to recognize without a
heightened awareness of it.
Employees must understand what to look for in themselves
and their co-workers.
The person with it is usually the last one to know.
Continuum of Traumatic Stress
(Primary Trauma Victim)
(Trauma Experienced by Family Members,
Friends, First-Responders, Helping
(Trauma Experienced by Care-Givers and
• Burnout is a state of physical, emotional, and mental exhaustion.
• Generally caused by long-term involvement in emotionally
• “Rustout” is a much better term, because it better represents
the slow, gradual process that eats away at a caregiver’s spirit
• On a personal level burnout is a leading cause of reduced
compassion satisfaction (job satisfaction).
• On an organizational level, the more employees experiencing
burnout the greater the employee perceptions of a toxic
Maslach (2003), Three dimensions of burnout:
Disillusionment related to a sense of ineffectiveness and lack
of accomplishment. The greater the imagined success and
power, the greater the potential for disillusionment.
Exhaustion related to great need for services, but limited
resources with which to help a client.
Cynicism resulting from unrealistic expectations and a lack of
Care givers and medical professionals must
understand their motives for getting into this field and
how they influence the three dimensions above!
Aspects of work at CeDAR that increases
experience of burnout
To much change
Rules not being well articulated and not followed consistently
Working with Difficult patients
Incidence of Traumatic Events
Worldwide, it is estimated that two-thirds of the population is exposed
to a traumatic events that meet the DSM stressor criteria for PTSD.
According to the National Center for PTSD:
• 61% of men and 51% of women report having experienced at least
one traumatic event (lifetime)
• 10% of men and 6% of women report having experienced four or
more traumatic events (lifetime)
• Of these trauma victims, 8% receive diagnosis of PTSD
• 1% of American population (New England Journal of Med)
• Unresolved trauma symptoms interfere with treatment and
can lead to relapse.
PTSD & Substance Abuse Disorders
• Prevalence of PTSD and Substance Use Disorders
• Among persons who develop PTSD, 52% of men and 28% of
women are estimated to develop an alcohol use disorder.
• 35% of men and 27% of women develop a drug use disorder.
• The numbers are even higher for veterans, prisoners, victims of
domestic violence, first responders, etc.
(Najavits, 2004a, 2004b, 2007)
• Individuals with PTSD are 3 to 4 times more likely to develop
SUD’s than individuals without PTSD have earlier histories with
A & D, more severe use, and poor treatment adherence.
(Khantzian & Albanese, 2008)
PTSD & Substance Abuse Disorders
• Treatment outcomes - PTSD and SUDS
• PTSD/SUDS patients are more vulnerable to poorer short- and
(Ouimette, Moos, & Brown, 2003)
• PTSD heightens the likelihood of addiction relapse and the
potential for multiple relapses.
(Norman, Tate, Anderson, & Brown, 2007)
• A trauma history and current trauma symptoms are associated with
relapse to alcohol or other substance use in alcohol dependent
(Heffner, Blom, & Anthenelli, 2011)
• PTSD/SUDS has been shown to be associated with poorer treatment
outcomes and higher relapse rates.
(Sonne, Back, Zuniga, Randall, & Brady, 2003)
How Does Someone Become Traumatized?
o Direct personal experience of an event that involves threatened
death, actual or threatened serious injury, or threat to one’s
o Witnessing an event that involves death, injury, or a threat to the
physical integrity of another person
o Learning about unexpected or violent death, serious harm, or
threat of death or injury experienced by a family member or other
o Consider each employee in each of your departments and the
multitude of unique ways in which they interact with the clients
that you come into contact with!
o What is their preparation to deal with these stories on a daily
Causes of Secondary Trauma
• Vicarious Trauma - (McCann, I.L. & Pearlman, L.A., 1990)
Single member of a system is effected due to regular contact
with traumatized individual.
o Accumulation of memories of clients’ traumatic material that
affects and is affected by the therapists perspective of the world.
• Chiasmal or Secondary Trauma (Kisher, G. R., 1984)
o Chiasm defined as the crossing of two tracks
o Entire system crosses tracks with trauma experienced by one
system member, on client, beloved leader, etc.
Burnout + Secondary Trauma = Compassion Fatigue
Freud – trauma occurs when the ego is overwhelmed “as a
consequence of an extensive breach being made in the protective
shield against stimuli.” (Freud, 1922)
Think in terms of exhaustion of one’s physical and emotional
immune systems that fights traumatic infection.
The more traumatic the trauma narrative, the greater the likelihood
the employee will experience secondary trauma response.
The greater the employee stress, burnout or exhaustion, the weaker
the psychic immune system and the greater the likelihood that the
employee will be impacted by normal daily trauma narratives.
Common Symptoms of Compassion Fatigue
Re-experiencing traumatic events
Avoidance or numbing of reminders
Recollections of the events, sudden intrusive thoughts
Dreams and or nightmares
Efforts to avoid thoughts and feelings
Diminished interest in activities
Detached estrangement from others
Irritability or outbursts of anger
Symptoms of Compassion Fatigue
(From Lombardo & Eyre, 2011: Compassion Fatigue: A Nurse’s Primer)
• Work-related symptoms
o Avoidance or dread of working with certain patients or in
o Reduced ability to feel empathy towards patients or their
o Frequent use of sick days
o Lack of joyfulness
• Physical symptoms
o Digestive problems: diarrhea, constipation, upset stomach
o Muscle tension
o Sleep disturbances: inability to sleep, insomnia, too much sleep
o Cardiac symptoms: chest pain/pressure, palpitations,
Symptoms of Compassion Fatigue
(From Lombardo & Eyre, 2011: Compassion Fatigue: A Nurse’s Primer)
• Emotional symptoms:
o Mood swings
o Excessive use of substances: nicotine, alcohol, illicit drugs
o Anger and Resentment
o Loss of Objectivity
o Memory issues
o Poor concentration, focus, and judgment.
Symptoms of Compassion Fatigue at the
Excessive amount of Worker’s Comp claims
Changes in co-workers relationships (conflicts)
Inability for teams to work well together
Staff challenges organization rules & regulations
Aggressive behavior between staff/clients
Inability of staff to complete assigned tasks
Staff displays lack of flexibility
Constant changes in organizational policies
Rampant rumors & gossip
Unhealthy competition between staff members.
Compassion Fatigue Awareness Project, 2008/2009
Life is not a matter of having good cards,
but of playing a poor hand well.
Robert Louis Stevenson (1907)
• Resilience . . . Is the ability to spring back from and successfully adapt
• Those who have overcome adversity tell us loud and clear that
ultimately resilience is a process of connectedness, of linking to people,
to interests, and ultimately to life itself.
• Researchers have found that across all cultures, hope and a belief that a
successful future matters more than a stressful past, is at the heart of
• We are all born with the capacity to develop the traits commonly found
in resilient survivors.
Common traits of Resiliency
• Self Awareness
o Fearlessly look within and face
the truth regarding distress
• Internal Locus of Control
o Freedom to make decisions
based on their own beliefs
o Functionally dependent
• Engaged in Social Activities
o Social support
o Friends outside of work
• Self-Care – Work/Life Balance
o Able to maintain outside
o Exercise programs
• Flexibility/Solution Orientation
o Expressive individuals who
can think “outside the box”
o Maintain light-hearted
perspective with the ability to
laugh at oneself.
• Clear Sense of Personal Ethic
Related to Fairness,
o Other aware (issues, problems,
etc. impacting those around
o Give support to others.
Resilience (A Working Model)
Charney, ISTSS Keynote Presentation, 2013
Recommendations for Family Physicians who
experience Compassion Fatigue
American Academy of Family Physicians (Family Practice Management , April, 2000)
• Find someone to talk to.
• Understand that the pain you
feel is normal.
• Get enough sleep.
• Take some time off.
• Develop interests outside of
• Identify what’s important to
• Blame others.
• Look for a new job, buy a new car,
get a divorce, or have an affair.
• Fall into the habit of complaining
with your colleagues.
• Hire a lawyer.
• Work harder and longer.
• Self medicate.
• Neglect your own needs and
Examples of Healthy Self-Care Activities
From Saakvitne and Pealrman (1996) Transforming the Pain: A workbook on Vicarious Traumatization
Get a massage
Get medical care when sick
Take time to be sexual
Get enough sleep
Take a vacation
Take time to reflect
Write in a journal
Get personal therapy
Decrease life stress
Try in things
• Find a spiritual connection or
• Be open to inspiration
• Be open to not knowing
• Stay in contact with important
people in your life.
• Seek out comforting activities with
the important people in your life
• Allow the important people in your
life to really get to know you.
Preventing Burnout and Compassion Fatigue in
Identify the challenges that you face in your day-to-day work
environment. These challenges can be associated with your actual work
responsibilities, relationships with co-workers and others, management
or organizational issues, etc.
Identify the resources that are available in your work environment that
may be able to assist you in dealing more effectively with the challenges
Identify five things that you will do differently in your work life
to overcome challenges and prevent Burnout/CF. These may be
unique ideas or utilization of resources.
Discuss your findings/insights with someone around you.
Self-Care Assessment (Part 1)
1. Physical Self-Care
o What do you already do to take care of yourself physically?
o What do you wish you did more of to take care of yourself physically?
2. Emotional Self-Care
o What do you already do to take care of yourself emotionally?
o What do you wish you did more often to take care of yourself emotionally?
3. Spiritual Self-Care
o What do you already do to take care of yourself spiritually?
o What do you wish you did more often to take care of yourself spiritually?
4. Relationship Care
o What do you already do to insure the health of your important
o What do you which you did more often to take care of your important
Self-Care Assessment (Part II)
Given your answers to the questions above, start to develop a personal self-care
plan. (Compassion Fatigue Awareness Project, 2009/2009)
List 5 things that you MUST do on any given day to insure appropriate self-care.
List 5 things that would energize you and that you would like to fit into every