Empathy Fatigue: Healing the Mind, Body, and Spirit of Professional Counselors

1. Empathy Fatigue: Healing the Mind, Body, and Spirit of Professional Counselors Mark A. Stebnicki, Ph.D., LPC, CRC, CCM Professor, Dept. of Rehab Studies East Carolina University

2. The More We Stress Together… • There are discrete, basic, and universal emotions that persons react to on a Mind, Body, & Spiritual level. • Emotions involve different body systems which arouse our parasympathetic and sympathetic system. • Chronic activation of the nervous system (stress response) has both a physiological and emotional cost. • Cumulative effects of multiple client problems lead to a deterioration of the professional’s coping skills and resiliency skills- esp. if symptoms go unrecognized.

3. A Paradigm Shift in Mental Health and the Allied Helping Professions • Horrific terrorist attack Sept. 11th (2,996 deaths) • War in Afghanistan & Iraq (3,860 Am; 84K Iraqi Civilian deaths +) • Tsunami December 26th 2004 (275,000 deaths+) • Hurricane Katrina 2005 (70 deaths +) • Child Deaths (intentional-unintentional) by gun violence (3,024 deaths/yr) • School shooting deaths (171 deaths ‘92-’98) • Cumulative AIDS-related deaths in U.S (through 2002 501,669d); Ethiopia (1.8 mil predicted by ’08)

4. Fire Flood Hurricanes/Tornados Ice storms Plane crashes Volcanoes Earthquakes Epidemics Workplace violence Traumatic injury in the workplace School shootings Bioterrorism Transportation Accidents Civil Unrest Types of Disaster

5. Different Models & Philosophy inCrisis Response • American Red Cross (ARC) • Critical Incident Stress Debriefing (CISD) • Critical Incident Stress Management (CISM) • National Organization for Victim Assistance (NOVA) • Acute Traumatic Stress Mgt (ATSM) • NC Disaster Task Force (eclectic model)

6. ARC EMS/IC-EM Law/Fire Public Health DSS School Counselors CISM Teams MH/LME EAPs Baptist Men Salvation Army United Way FEMA National Guard/Military Insurance Adjustors Media Airline Industry Banks/Financial Institutions In a Constant State of Disaster Preparedness: Crisis Response Teams

7. Hurricane Katrina • FW Katrinia Slide Show.ppt

8. Who Takes Care of the Healer’s Wounded Soul? “What kind of God could allow such pain, suffering, or horrific acts to take place …” The search for personal meaning in extraordinary stressful and traumatic events due to natural disasters, chronic mental/physical conditions, life-threatening disease, or addictions requires constant attention to self-care practices.

9. Purpose and Intent • A growing interest among educators, practitioners, and clinical supervisors in the identification of risk factors for professional impairment professional fatigue syndromes. • A critical need among the helping professions to address early intervention for coping with the mental, emotional, spiritual, and occupational exhaustion that occurs as a natural artifact of providing services to others. • Cultivate healthy coping and resiliency strategies.

10. Top Ten Signs You Had a Bad Thanksgiving 10. You ran out of booze by 11am. 9. Most frequently used phrase at dinner: “Excuse me, I need to use the bathroom.” 8. Your meal was frozen left-overs from Thanksgiving 2006. 7. Severed your thumb on the new electric knife because the cousins were fighting over the turkey wishbone. 6. Only thing on TV:Miami (0-9) at NY Jets (1-7).

11. 5. Your turkey is wearing a dog collar. 4. When your dinner came out, so did your Aunt Ginny. 3. You woke up from a tryptophan-induced sleep and found yourself naked in the neighbors backyard. 2. Your turkey dinner came from a box labeled “Bojangles.” 1. You had to show-up to work Monday and you still had relatives at your house 

12. Empathy Fatigue: A Concern for the Helping Professions • APA - Advisory Committee on Colleague Assistance Impaired Professionals. • AMA- Physician Impairment: “physical, mental, and behavioral disorder that hinders the physician’s ability to safely treat patients safely.” • American Nurses Association- “Compassion Fatigue”. • ACA Task Force on Counselor Wellness and Impairment: • Educate counselors on prevention strategies • ID resources counselors • Intervention and treatment recommendations • Advocate for professional counseling associations to establish programs on counselor impairment

13. Empathy Fatigue: A Combination of other Professional Fatigue Syndromes • Countertransference: the unconscious absorption of the patient’s issues, involves a type of symbolic or parallel experience of emotional button-pushing. It results in a sense of anxiety, stress, sense of loss, grief, and over-identification w/pt. (Jung et al.) • Burnout: a negative shift in the way professionals view people they serve. A cumulative emotional exhaustion, depersonalizaiton, feelings of a lack of personal accomplishment resulting in a loss of compassion, genuineness, and concern for the patient. (Maslach; MBI) • Compassion Fatigue: An acute stress reaction unhealthy form of countertransference results from emotional, mental, and physical exhaustion. (Figley; Stamm, et al.)

14. Empathy Fatigue (EF) “ A dynamic state of psychological, emotional, social, physical, occupational, and spiritual exhaustion that occurs on a continuum, resulting from the helpers’ own wounds that are continually revisited by their client’s life-stories of stress, chronic illness, mental/physical disability, trauma, grief, and loss.”

15. Theory of Empathy Fatigue • Persons who work in “high touch” professions are more vulnerable than those that don’t… • A natural artifact of working with patients that have intense acute and chronic physical conditions, mental health conditions, and behavioral health issues. • Many times an unconscious process where the professional and those around them may not recognize. • EF is cumulative and ranges on a continuum of low, moderate, and high levels of physical-emotional-mental spiritual, and occupational exhaustion.

16. The Nature of the Helping Profession • Requires facilitating empathic approaches, cultivating client connections and relationships where we must attend, listen, act empathically to help our clients unfold the multiple layers of their stress, grief, loss, or traumatic experiences by searching through their emotional scrapbook. • The search for personal meaning and purpose of our client’s pain and suffering may contribute to the helper’s spiritual fatigue experience. • If professional helpers are mindful of this experience, and view this as an opportunity for nurturing personal growth and development, then they will learn resiliency strategies that can help to replenish their wounded spirit.

17. The Wounded Healer Experience: Healing the Spirit • Traditional Native American teachings “each time you heal someone you give away a piece of yourself until at some point you require healing.” • The phenomenon that takes place between client and therapist when the therapists own psychological and emotional wounds are opened by listening to their client’s story. (Jung)

18. Healing the Spirit • Wounded healer experience (Nouwen, 1972) “When our souls are restless, driven by other conflicting stimuli and worries…withdrawn into ourselves…how can we possibly create the room and space where someone else can enter freely without feeling himself an unlawful intruder?” • (Miller, 2003) suggests client stories of addictions, physical or sexual abuse and psychological trauma can adversely affect the mind, body, & spirit of the healer. Wounded therapists have vulnerabilities too- we have responsibility for disclosing our wounds along side our clients…

19. The Nature of Empathy Fatigue • Dalai Lama (1999) suggests counselors can become exhausted by their duties because of the constant exposure to the suffering of others and can induce feelings of helplessness and despair. “Empathy is really what we are describing when we talk about compassion fatigue and that it is the simple compassion a person experiences when they want to see another person free from suffering.”

20. Share Your Experiences as a Professional Helper • Ichose the profession/career I am in because… • I am encouraged by my clients’/patients’ success when I see that they… • My mind, body, and spirit is most affected by clients’/patients’ who are… • I work best and my needs are met when I have… • I do not work well under conditions that involve… • If I could make any change(s) in my career/job I would like to…

21. EF Risk Factor Functional Assessment • Personality Traits • History of MH Problems • Maladaptive Coping Behaviors • Age and Experience-Related Factors • Organizational Factors • Job Duties within the Organization • Socio-Cultural Factors • Person’s Response to Past Events • Level of Support

22. Empathy Fatigue: Critical Pathways • Impairment in professional helpers who uses empathy-focus therapeutic interactions. • Communication (verbal/non-verbal) between clients and professionals during therapeutic interactions that are integrated in the professional’s thoughts and feelings and becomes associated as a physical-emotional reaction. • Multiple interaction of personality traits, coping resources, developmental level of helper, and opportunity (or lack of) to build resiliency organizational-environmental supports. • Experienced by helpers as an acute, chronic, delayed onset reaction ranges on a continuum. • Experienced by helpers dealing with a variety of issues- daily hassles to addictions, trauma... • Cumulative effects that lead to deterioration of counselor’s coping abilities and resiliency.

23. Case Illustration of Nurse Ratchette While we were in nurses training, we were always told to “be professional.” No one ever said exactly what that meant, or how to be a professional. I guess we thought it meant being cool and calm under pressure, objective with our patients, and not to get easily rattled by things. But I did get rattled and upset at times- like the first time a patient died. I would be feeling panicky, angry, and sad but I would be fighting any expression of those feelings because I knew they were not “professional.”

24. Nurse Ratchette {continued} Everyone else seemed to be handling things okay, which made me feel even worse- like a real failure- like someone who wasn’t cut-out for this kind of work. I didn’t dare say anything for fear people would find out how weak I really was. It wasn’t until much later in my career that I discovered that most everyone else was just as scared and lonely as I was when it came to death and dealing with trauma cases.

25. Summative Philosophy of EF It is not necessarily the nature of the client’s/patient’s stress, trauma, loss, grief, daily hassles, coping, or disability adjustment issues that creates a sense of EF; rather it is the professional’s perception towards that particular patient’s personality traits/states and behavioral characteristics that determines the professional’s response to it; and it is determined by multiple factors that lead to a diminished capacity to listen, respond empathically, provide competent professional services…

26. Empathy Fatigue: The Mind-Body Connection within the Emotional Brain * Neuro-scientist, Dr. Joseph LeDoux’s revolutionized our understanding of the neural pathways of the brain. * Pre-determined chemical and electrical impulses {Amygdale} are triggered when we perceive emotions {fear, stress, and anxiety}. *Amygdala {our home security system} and hippocampus {seat of emotions} sends out an emergency call to our sympathetic nervous system and involves an all-out body system response. * A fight-flight response triggers increase blood flow to muscles, activates our cardiovascular system, and secretes stress hormones-epinephrine and norephinephrine heightens reactivity to stress. * End result – hypothalamus region of the brain, acting through the pituitary gland stimulates the neuro stress hormone Cortisol, which depresses overall brain functioning, can be toxic to tissue at high levels, depresses memory, learning, and are markers for depression and anxiety.

27. Peripheral/ANS: Sympathetic-Parasympathetic Nervous

28. The Neuroscience of Empathy Fatigue: Our Emotional Brain • There are discrete, basic, and universal emotions that persons react to on a M-B-S level; • Emotions involve different body systems which arouse our parasympathetic and sympathetic system; • Chronic activation of the nervous system (stress response) has both a physiological and emotional cost; • 80% of all physical illness is cause by stress (Kabit-Zinn, 1990; Sapolsky, 1998; Selye, 1976; Weil, 1995)

29. Why Zebras Don’t Get UlcersA Video Presentation of Stress

30. Zebras

31. Q. Why Zebras Don’t Get Ulcers Answer: Zebras don’t have cumulative stress “If you constantly mobilize energy, You never store it; Your muscles waste away; Your vascular system is under constant pressure; and constant Cortisol production turns off growth factors and can harm every system in the body…”

32. The Problem with Too Many Unhealthy Thoughts, Perception & Feelings: Stress !!! • Excessive, recurrent, and intense emotional arousal; • Repeated reactivation of our perceptual-cognitive-affective response; • Stored unhealthy thoughts, perceptions, and emotions, become a worn neural pathway which leaves an imprint on our cognitive unconscious and causes a mind-body interaction.

33. The Critical Stress Factor in Disease: Optimizing the Healing System {Dr. Weil} Lack of Energy Poor Circulation Restricted Breathing Impaired Defenses Toxic Overload Age Thoughts, Perceptions, Cognitions Spiritual Problems

34. Solution-Focus Prevention • What would this problem situation look like if you were managing it better? • What changes in your present situation/life would make sense right now? • What would you be doing differently with your problem situation if you were to make the changes you wanted to make? • What things have you thought about that would make life better for you right now? • What things/feelings in your life would you like to eliminate right now? • If you eliminated certain things in your life what would that feel like? • When do you plan on making these changes?

35. Changing the Stress Response: Protective Factors & Resiliency • Feeling some degree of internal control; • Exerting some control over your environment; • Increasing your level of information and awareness; • Changing your thoughts and perceptions; • Shifting from mindless (unconscious) reaction to mindful recognition; • Creative solution-focused problem-solving; • Support from others in our socio-familial environment; • High-ranking Baboon; Not living alone !!

36. Locus of Control http://www.dushkin.com/connectext/psy/ch11/survey11.mhtml

37. Empathy Fatigue Resiliency Quiz1= not true of me….5=exceptionally true of me As a professional counselor I perceive myself to be… • Resilient, adapt quickly to new client issues as they arise, and good at bouncing back after listening, attending, and responding empathically to my clients’ stories all day. • Optimistic, perceive that my client can increase their level of adaptive functioning regardless of how difficult their issues are, and I anticipate that things will turn out well for them. • Calm and focused while my client’s life is in crisis. • A good problem-solver by facilitating appropriate interventions by empowering my client with good resources. • Able to trust my clinical intuition and facilitate creative solutions to my client’s stressful life-challenges.

38. Resiliency Quiz (continued) 6.Self-confident, optimistic, enjoy healthy self-esteem, and have an attitude of professionalism about my work. 7. Playful, humorous, have the ability to laugh at myself. 8. Curious, facilitate good interviewing skills, have a desire to understand how things work in my client’s life, and consult with others when I need help. 9. Constantly learning from my past mistakes during therapy and from the mistakes that I see other therapists make. 10. Flexible, and feel comfortable with things that are somewhat complex in my client’s life, and can adapt to various client behaviors and personalities in my counseling practice.

39. Resiliency Quiz (continued) 11. Able to anticipate when my client will develop specific problems and I have confidence that I will know how to deal with the unexpected. 12. Able to personally deal with my client’s negative or dysfunction life patterns and the ambiguity or challenge this presents in my own life. 13. Non-judgmental, a good listener, possess good empathy with my clients, express my feelings and be able to “read” other people well. 14. Able to recover emotionally from my client’s losses and setbacks, and let-go of negative feelings that I may have and how to ask others for help.

40. Resiliency Quiz (continued) 15. Durable, keep on ticking after tough client sessions and possess an balanced and healthy fighting spirit. 16. Stronger and better after facilitating interventions with difficult clients issues. 17. Able to discover some meaning in my own life at the end of the day, even after hearing multiple client stories of stress, trauma, addiction, anxiety, and depression.

41. Empathy Fatigue Resiliency Quiz Scoring 75 + = Very Resilient!! 65-75 = Resilient more than most counselors. 55-65 = Slow to rebound- but adequate. 45-55 = Whoa- I’m struggling as a counselor. 45 or less = I should leave now and seek help!

42. Resilient Professionals • Convey a sense of genuine commitment and confidence to help with their client’s stress levels and critical issues; • Communicate competence and have a good sense of mastery with handling challenging and difficult clients; • Feel optimistic, positive, and energetic about the good work they do and have good coping resources; • Have a purpose-driven life, find meaning with their profession and practice good self-care techniques; • Maintain excellent interpersonal insight and still have the capacity for warmth, caring, and empathy.

43. The Resiliency AdvantageDr. Al Siebert 1. Making conscious choices in life. 2. Power of Positive Thinking. 3. Take responsibility. 4. Internal locus of control. 5. Self motivate yourself. 6. Don’t fear trying-out new things. 7. Take control of your life. 8. Practice positive approaches to life.

44. A Paradigm Shift in Conventional - Traditional Self-Care Practices Historically: • 1960s: Human Potential and Personal Growth Movements began in Big Sur CA- Eslen- strategies for empowerment, creative problem solving, happiness, self-actualizing. • 1970s: Birth of New Age movement & the Self-help book. • New Age movement both Western paradigm cognitive-behavioral and humanistic based, and Eastern philosophies – Goal of achieving M-B wellness- but criticized as a pseudoscience, overuse of psychobabble, and too New Aggie • During 1970s: collaborative interdisciplinary approach with psychology, neuro- biological, immunology (psychoneuroimmunology) gave-way to biopsychosocial models of health and healing - CAM/IM (600+ healing txs). • Late 1970s significant growth in transpersonal psychology-the esoteric, developing psychic-intuitive abilities, secular mysticism, Native American traditions.

45. Native American Teaching “Every time you heal someone, you give a piece of yourself away, until at one point you will need healing yourself” * Shaman or Medicine Man/Woman in many indigenous cultures understood that in healing practices the healer sometimes must takes-on the pain and suffering of others while planting the seeds for transformation. * Each personal transformation should bring about the necessary experiences for handling the next crisis so the mind, body, and spirit can be transformed.

46. Old World vs. New World Shaman • Old world shaman live in a world different from their people, so they may have a clear vision of what to do – what direction to take with their people. • All activities are spent in developing faith, spiritual awareness, rituals to protect and heal M-B-S. • Shaman carry-on traditional teachings: storytelling, talk circles, pipe ceremonies, prayers, dancing, singing. • Shaman specialize in finding meaning and purpose for tribal members.

47. Post-modern Self-Help • New (Old) Age has ignored or neglected the ancient and collective wisdom of indigenous cultures. • A Calling for getting back to the roots of community, family, ext family, connections. • Professional helpers live in a much more intense world today post- Sept. 11th • More is required in preparing for handling critical incidents (natural person-made disaster response)

48. Show-up Pay Attention Be Open to the Outcomes

49. Wellness Assessment Breathing Meditation Visualization

50. Adaptive Coping & Healing Strategies: Organizational • Skilled & Competent clinical supervision • Mentoring approaches • Peer-supervision • Shift focus of treatment team meetings • Re-structure organizational philosophy to a healthy person-centered {M-B-S}