Resisting Vicarious Trauma: Understanding, Preventing, and Healing from Compassion Fatigue

1. OCEACT Annual Statewide Conference 2016 Resisting Vicarious Trauma Fumiyo Nishimoto, MSW, CSWA Peer Bridgers Program Coordinator Oregon State Hospital

2. “The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, a sensitivity and an understanding of life that fills them with compassions, gentleness, and a deep loving concern. Beautiful people do not just happen.” ~Elisabeth Kubler-Ross

3. Overview of Topics: • Define trauma, secondary traumatic stress, vicarious trauma, compassion stress, compassion fatigue, and burnout • Explore the prevalence of vicarious trauma • Discuss the implications of, and contributing factors to, vicarious trauma • Discuss signs and symptoms of vicarious trauma • Explore caring practices • Understanding and applying collective care

4. Looking at Trauma

5. What is Trauma: • NASMHPD: The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters. • APA: An emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives. Psychologists can help these individuals find constructive ways of managing their emotions.

6. What is Trauma: continued • SAMHSA: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social emotional , or spiritual well-being • The general psychiatric definition of “trauma” is “an event outside normal human experience.” • Trauma has also been defined as, “any sudden and potentially life-threatening event.” This refers to one-time traumatic events, but most of it applies to prolonged, repeated trauma as well.

7. Definitions: Secondary traumatic stress • Secondary traumatic stress: the natural, consequent behaviour and emotions that result from knowledge about a traumatizing event experienced by another and the stress resulting from helping or wanting to help a traumatized or suffering person.  • The term is often used to describe the sub-clinical impacts; however the criteria and identified symptoms are almost identical to the updated post-traumatic stress disorder. Secondary traumatic stress includes symptoms produced in response to exposure to details of traumatic event/s experienced by a significant other (i.e. not necessarily as a result of acting in the role of therapist or helper)

8. Definitions: Vicarious trauma • Vicarious trauma (VT): the cumulative transformative effect on the supporter / helper working with people who have experienced traumatic life events, both positive and negative. • The transformation in the self of a trauma worker that results from controlled empathic engagement with traumatized clients and their reports of traumatic experiences. • The process of change in your neurological, cognitive, physical, psychological, emotional and spiritual health that occurs when you listen to trauma-content narratives day after day or respond to traumatic situations whilehaving to control your reactions. • Over time this process can lead to changes in your well-being because of your responsibility to your clients.

9. Definitions: Compassion stress • Compassion stress. Charles Figley coined this term as a non-clinical, non-pathological way to characterize the stress of helping or wanting to help a trauma survivor. Compassion stress is seen as a natural outcome of knowing about trauma experienced by a client, friend, or family member, rather than a pathological process. It can be of sudden onset, and is often experienced as helplessness, confusion, increased isolation, as well as secondary traumatic stress symptoms.

10. Definitions: Compassion fatigue. • Compassion fatigue, also coined by Figley, is considered a more severe example of cumulative compassion stress. It is defined as “a state of exhaustion and dysfunction, biologically, physiologically, and emotionally, as a result of prolonged exposure to compassion stress.” Charles Figley uses it more or less interchangeably with secondary traumatic stress; compassion fatigue is simply more ‘user friendly’ as a term.

11. Definitions:Burnout • Burnout is defined as a state of prolonged physical and psychological exhaustion, which is perceived as related to the person’s work. • Burnout doesn’t necessarily include a traumatic element or PTSD-like symptoms: accountants, for example, can experience burnout from their work. • Christine Maslach defines burnout in terms of three key elements: “Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do ‘people work’ of some kind.”

12. Who is Affected by Vicarious Trauma? • Teachers • Lawyers • Doctors • Mental Health Professionals • Rescue Workers • Peer Support Specialists • Job Placement Professionals • Police Officers • Nurses • Journalists • Hospice Workers • Therapists • Occupational Therapists • Physical Therapists • Paralegals • Volunteers • Social Workers • Therapists

13. Reflect on: • What are some ways that you have changed over time because of your peer support / clinical work? • What sort of problems or people do you find it especially easy to empathize with? • What sort of problems or people do you find it especially difficult to empathize with? • What are some ways that caring about people who have been hurt affects you?

14. Contributing factors • Personal history (including prior traumatic experiences) • Coping mechanisms / skills • Support network • Resiliency /individual nature of responses or adaptations to VT • Cultural traditions of expressing distress and extending and receiving assistance / support • Professional role, work setting, and exposure • Agency support • Affected population’s responses and reactions

15. Reflect on: • What are three “individual risk factors” that may be placing you at risk of experiencing vicarious trauma at present? • What are three things in your life related to you as an individual that you feel help protect you from vicarious trauma? We can call these latter “individual protective factors.”

16. Signs and Symptoms of Vicarious Trauma: Emotional • Prolonged grief • Prolonged anxiety • Prolonged sadness • Irritability • Labile mood • Depression • Agitation / anger • Changed sense of humor • Tuning out • Feeling less safe in the world

17. Signs and Symptoms of Vicarious Trauma: Behavioural • Isolation • Numbing • Staying at work longer • Not being able to separate work from personal life • Increased alcohol consumption • Undertaking risky behaviours • Impulsivity • Avoiding people or duties • Difficulty sleeping • Changed eating habits • Increased dependencies or addictions involving nicotine, alcohol, food, sex, shopping , internet, and/or other substances • Sexual difficulties

18. Signs and Symptoms of Vicarious Trauma: Physical & psychological • Hyperarousal symptoms (e.g., nightmares, difficulty concentrating, being easily startled, sleep difficulties) • Repeated thoughts or images regarding traumatic events, especially when you are trying not to think about it • Feeling numb • Feeling unable to tolerate strong emotions • Increased sensitivity to violence

19. Signs and Symptoms of Vicarious Trauma: Physical & psychological: continued • Cynicism • Generalized despair and hopelessness, and loss of idealism • Guilt regarding your own survival and/or pleasure • Anger • Disgust • Fear

20. Reflect on: • Write down any signs of vicarious trauma that you have experienced in the last two weeks. • Think back over the last couple of years. What are some early warning signs of vicarious trauma (i.e., the first signals that warn you that you’re struggling in this area)?

21. Caring practices: Addressing Vicarious Trauma: What can support you in doing this work? “When self-care is prescribed as the antidote for burnout, it puts the burden of working in unjust contexts onto the backs of us as individual workers.” -Vikki Reynolds Self-care is not only about individual workers, it is also about organizations and communities.

22. Caring practices: Caseload • The management of caseloads through limiting the number of clients per week and the number of “intensely traumatic” cases may minimize the potential vicarious effects of working in this field. • Have realistic expectations of caseloads. • Allow some degree of worker control of, or involvement in, the allocation process

23. Caring practices: Supervision • Regular access to individual supervision is a minimum requirement for worker, whether in an agency or in private practice. • Separation between clinical supervision and line management that focuses on operational supervision. • Supervision should provide a forum where workers feel safe to discuss the impacts of the work on themselves, without fear of stigmatisation or questioning of their competence.  • Supervision should also be a place where concerns about worker or client safety can be raised, discussed and acted upon (addressing clearly inappropriate, unethical or harmful conduct).

24. Caring practices: Peer supervision • One-to-one or group peer supervision • Sharing experiences of how the work is affecting work and personal life offers social support and normalization of the worker’s own experience. • This Sharing of experiences assists with addressing troubling thoughts such as ‘I am not cut out for this’, or ‘there must be something wrong with me for me to be feeling this way’. • Other benefits include reconnecting with others and sharing potential coping resources. • Peer supervision has also been found to decrease feelings of isolation and increase empathy and compassion.

25. Caring practices: Work environment • Ensure adequate, comfortable facilities for lunch and tea breaks, in a space that is separate from the client interaction areas. • Provide opportunities for non-counselling / non-peer support work (e.g. community education, resource development, etc.) •  Add nurturing and comforting touches to the work space (e.g. plants, framed pictures). • Take time to share success stories in the work; this can be incorporated into organizational routines such as group supervision or team meetings. • Foster a culture of care for workers.

26. Caring practices: Education and training • Ongoing professional development, education and training is essential for peer support professionals and mental health professionals who work in the trauma field.

27. Caring practices: Sprituality • The effects of vicarious trauma are often related to a loss of a sense of meaning, and can influence ways of thinking about self, others and the world. • Intentionally engaging in practices that re-connect you to your professional and personal ethics, beliefs and values is an important part of feeling sustained in the work. • This engagement could be through supervision conversations which make space for questions of ethics, purpose and intentions; connecting with colleagues who share similar hopes and values; and engaging in community activism around issues of significance.

28. Caring practices: Regular Leave: • There can be a range of reasons why workers don’t always take regular breaks from the work. This is understandable, considering the commitment to be of service to others that often motivates workers in this field. It is not uncommon for this commitment to develop into an unreasonable sense of obligation, having workers struggling with thoughts of being selfish, or fearful that they will be perceived as abandoning their clients if they take holidays and breaks.

29. Caring practices: Wellness: continued • Regular exercise • Sleep • Healthy eating • Drinking enough water • Humor and laughter • Limit your consumption of alcohol • Pilates or yoga • Relaxation techniques (such as progressive muscle relaxation, diaphragmatic breathing, visualization and meditation) • Massage, whirlpool, sauna • Repetitive activities (such as cross-stitching, walking, quilting, drawing and cooking)

30. Caring practices: Wellness: continued • Nurturing relationships • Contact with home/friends through email, phone, tapes • Talking • Ongoing support group • Reflection: journaling, writing, meditating, poetry • Creative activity such as drawing, sculpting, cooking, painting and photography

31. Caring practices: Wellness: continued • Knowing your values: Where do you tend to find meaning and purpose in life? • Participating in a community of meaning and purpose • Regular times of prayer, reading, meditation • Spiritually / ethically meaningful conversations • Singing or listening to meaningful music • Contact with religious leaders or inspiring individuals • Time with art, nature, or music • Solitude

32. Collective Care: • “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.” -Margaret Mead • “Fostering collective sustainability acknowledges that we are meant to do this work together.” -Vikki Reynolds • To enable a sustainable approach to peer support we must cultivate, “an ethic of doing justice which embraces clients, workers, communities, and societies.” -Vikki Reynolds • “During the last few weeks I have felt a tremendous amount of frustration and pain from colleagues and friends due to systematic fragility. Let us recognize our strengths, be gentle with each other, remember the victories we have shared in the past, recall how beautiful we are, and continue to hold on to our hope.” -Fumiyo Nishimoto

33. Collective Care: • Emphasis on supporting workers to connect with the beliefs, values and ethics which draw us to do this work and to consider and understand experiences of distress in this context. • Encourages workers to move beyond understanding vicarious trauma and burnout in terms of individual deficit, to consider broader ethical and relational dimensions of the work. • Consider individual distress (moral injury) within a relational context and to reflect on how this understanding can contribute to building a community of action and support

34. Reflective Practice Questions:Distress as an opportunity to acknowledge values, wishes and hopes • Why was this conversation or series of conversations particularly significant to me? • Is it possible that some belief, something I value or give importance to, has been transgressed or challenged? Can I name what this is? • Why are these values significant to me? • How can I find connection with others around these values in my work and in my non-professional life? • What further action might I be able to take in relation to my work that would fit with these values?

35. Reflective Practice Questions: Distress as an opportunity to consider workplace practices • What opportunities are available to talk about the many experiences of my work? • Of the many different stories of work that could be shared, what stories and whose stories are being privileged? • How are the connections people have to what is important and of value to them shared in the workplace? • What opportunities are there for celebration in relation to the achievements of the work? • What opportunities are there to share moments of sadness, moments of beauty, moments of joy?

36. Reflective Practice Questions: Distress as an Opportunity to reconnect with local knowledge and relationships • How is the work we are doing valuing the community of, and building on the contributions of, people that might support those we are meeting? • Thinking of how the people we meet have demonstrated unique skills and knowledge in responding to the effects of abuse in their lives, are we finding way to document this? Can we contribute to creating an audience for this?

37. Reflective Practice Questions: Distress as an opportunity to connect with others around the politics of the work • Who else would most likely to share this sense of distress/outrage? • How could we come together to take some form of action as an outcome of this distress? • How can the ideas and understanding gained in conversations inform organizational responses, policy, legislative systems, and education of other workers?

38. Reflective Practice Questions:Distress as an opportunity to connect with others around the politics of the work…Continued • How can what is talked about in one on one conversations connect people with each other around their common experience of life in ways that enable broader social action? • How are the politics of gender, class, race, age, ability, and heterosexual dominance being named and responded to within the conversations I have and within the organization more broadly?

39. References: • Catherall, D. (1995). Coping with secondary traumatic stress: The importance of the therapist’s professional peer group. In B. Stamm, Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (pp. 80-94). Lutherville, MD, USA: Sidran. • Figley, C. (2002). Compassion fatigue and the psychotherapist’s chronic lack of self care. Journal of Clinical Psychology, 58 (11), 1433-1441. • Herman, J. (2001). Trauma and recovery: The aftermath of violence – from domestic abuse to political terror (3rd ed.). London, UK: Pandora. • Mann, S. & Russell, S. 2002: ‘Narrative ways of working with women survivors of childhood sexual abuse.’ International Journal of Narrative Therapy and Community Work, 3:3-22. • Reynolds, V. (2009, December). Collective ethics as a path to resisting burnout. Insights: The Clinical Counsellor’s Magazine & News, 6–7. • Reynolds, V. (2010a). Doing justice as a path to sustainability in community work. http://www. taosinstitute.net/Websites/taos/Images/PhDProgramsCompletedDissertations/ReynoldsPhDDissertationFeb2210.pdf

40. Contact: Fumiyo Nishimoto, MSW, CSWAPeer Bridgers Program Coordinator, Oregon State Hospital2600 Center St NESalem, OR 97301-2682 Phone: 503-945-9736Email: fumiyo.nishimoto@state.or.us