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Compassion Fatigue & Secondary Traumatic

Presentation by: MHN Training & Development

©2018 Managed Health Network, LLC. All Rights Reserved.

Participant Handbook

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Learning Objectives

• Understand the causes and components of compassion fatigue and secondary traumatic stress • Discuss similarities and differences between compassion fatigue, secondary traumatic stress, stress and work burnout • Identify the major symptoms of secondary traumatic stress • Present different prevention and treatment approaches to alleviate the impact of secondary traumatic stress • Discuss different strategies that can enhance individual resilience in stressful work environments

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What is Compassion Fatigue?

• Indirect exposure to traumatic events • Stress responses due to repeated exposure • Severe levels have symptoms similar to Post-Traumatic Stress Disorder – Secondary Traumatic Stress

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Related Terms & Conditions

• Compassion Fatigue • Vicarious Trauma • Secondary Traumatic Stress • Stress and Burnout • Compassion Satisfaction

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Compassion Fatigue versus Work Burnout

• Work Burnout – Stress and hassles with work – Cumulative and relatively predictable – Reduced through a respite or life change

• Compassion Fatigue – State of tension/preoccupation with cumulative trauma of clients – Symptoms that are disturbing or disabling – Symptoms may need higher level of professional intervention – Severe levels indicate Secondary Traumatic Stress

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Symptoms of Stress Build-Up

Stress symptoms may manifest themselves in many ways: • Physical • Emotional • Mental/Cognitive • Behavioral • Delayed reactions

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Assessing Stress Levels

• Be Aware of Effects of Stress – Individual/Unique Reactions to Stress

• Use Stress Inventories

• Acknowledge When Stress is Having an Impact – Awareness is the first step in

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Work Burnout • Burnout – Characterized by long-term exhaustion and diminished interest in work. • Often results from chronic occupational stress (e.g., work overload)

• Symptoms of Burnout – – Physical exhaustion – Feelings of being overwhelmed – Loss of interest or motivation – Lack of productivity – Feeling hopeless, powerless, cynical, and resentful • Burnout is “Too Much” Stress – Prolonged – Unrelenting – Leads to the “Exhaustion” phase of the General Adaptation Syndrome – Depletion of energy and resources

©2018 Managed Health Network, LLC. All Rights Reserved. 8

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Stress versus Burnout

Stress Burnout • Characterized by over- • Characterized by engagement disengagement • Emotions are over-reactive • Emotions are blunted • Produces urgency and • Produces helplessness and hyperactivity hopelessness • Loss of energy • Loss of motivation, ideals, and • Leads to anxiety disorders hope • Primary damage is physical • Leads to detachment and • May kill you prematurely depression • Primary damage is emotional • May make life seem not worth living

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Symptoms of Secondary Traumatic Stress

Secondary Traumatic Stress is comprised of four major symptoms: • Intrusion • Hyperarousal • Avoidance • Dissociation

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Secondary Traumatic Stress: Intrusion

• Recurring thoughts, flashbacks or nightmares

• Psychological distress when experiencing something reminiscent of the trauma

• Physiological response when experiencing something reminiscent of the trauma

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Secondary Traumatic Stress : Hyperarousal

• Difficulty falling or staying asleep • Increased or exaggerated startle response • Hypervigilance • Irritability or outbursts of anger • Difficulty concentrating

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Secondary Traumatic Stress : Avoidance

• Avoiding thoughts or feelings • Avoiding people, places, or things • Inability to recall important aspects of the trauma • Disinterest in significant activities • Feeling withdrawn or disconnected • Pessimistic about the future • Restricted range of feelings

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Secondary Traumatic Stress : Dissociation

• Feelings of depersonalization or de-realization • Indicators of memory disturbance • Mental absorption into situations/events • Increased or exaggerated distractibility

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Impact of Compassion Fatigue/ Secondary Traumatic Stress

• Reduction in job performance • Increase in on-the-job mistakes • Decrease in morale • Deterioration of personal relationships • Increase in psychological issues • Increase in health problems/somatic complaints

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Co-Occurrence of Other Disorders

• Depression • Bi-Polar Mood Disorder • Generalized Anxiety Disorder • Panic Disorder • Phobias

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Tips to Counteract Compassion Fatigue/Secondary Traumatic Stress

• Recognize it as an outcome of trauma work • Limit exposure to trauma when possible • Be aware of when reenactments (flashbacks) occur • Maintain healthy professional boundaries with clients • Establish and maintain professional connections • Redesign workload to provide balance in exposures to trauma • Focus on larger purpose of your work

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Clinical Treatment

• – Cognitive-Behavioral Therapy – Mindfulness Training • Medications – Antidepressants – Anti-anxiety medications

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Organizational Approaches to Prevention

• Clear purpose and goals • Employee and management training • Functionally defined roles • Effective management structure and leadership • Administrative considerations • Team support • Plan for stress management

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Positive Stress Management Strategies

• Proactive Stress Management Behaviors • Healthy Lifestyle Habits for Stress Reduction • Positive Thinking Patterns to Reduce Stress • Increases Stress Resilience

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Proactive Stress Management Behaviors

• Be assertive about your needs

• Get organized (and stay that way…)

• Vent in emotionally healthy ways

• Use humor appropriately

• Look to reduce or redefine stress in your life

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Healthy Lifestyle Habits for Stress Reduction

• Enhance your healthy diet

• Stop smoking

• Reduce alcohol consumption

• Increase your amount of exercise

• Protect your sleep

• Pursue leisure activities

• Engage in active relaxation

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Positive Thinking Patterns to Reduce Stress

“Cognitive Reframing” • Challenge the “Shoulds” • Avoid “All or Nothing” thinking • Re-frame failures as new opportunities • Be compassionate with yourself • Focus on the present • Embrace optimism

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Social Support Increases Stress Resilience

• Identify your social support needs

• Identify helpful/non-helpful behavior

• Communicate your needs respectfully and specifically to those in your support network

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Enhancing Resilience to Compassion Fatigue

• Having a strong Commitment • Having a sense of Control • Seeing change as a Challenge • Participating in Creative activities • Having a strong Support network

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Resources

• MHN Online www.MHN.com • U.S. Department of Health and Human Services; and Mental Health Administration, Center for Mental Health Services www.samhsa.gov • America's Continuing Education Network www.ace- network.com • The Green Cross Foundation www.greencross.org • Gift from Within www.giftfromwithin.org • Figley, C. (2002).Treating Compassion Fatigue. Routledge Publishing.

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Managed Health Network, LLC (MHN) is a subsidiary of Health Net, LLC. The MHN family of companies includes Managed Health Network (CA) and MHN Services, LLC. Managed Health Network is a registered service mark of Managed Health Network, LLC. All rights reserved.

©2018 Managed Health Network, LLC. All Rights Reserved.

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Handout A. Symptoms of Compassion Fatigue/Secondary Traumatic Stress

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Handout B. Compassion Fatigue, Secondary Traumatic Stress and Related Issues: Some Definitions

 Compassion fatigue, a label proposed by C. Figley as a less stigmatizing way to describe secondary traumatic stress, has been used interchangeably with that term.

 Secondary traumatic stress refers to the presence of PTSD symptoms caused by at least one indirect exposure to traumatic material. Several other terms capture elements of this definition but are not all interchangeable with it.

 Vicarious trauma refers to changes in the inner experience of the therapist resulting from empathic engagement with a traumatized client.13 It is a theoretical term that focuses less on trauma symptoms and more on the covert cognitive changes that occur following cumulative exposure to another person’s traumatic material. The primary symptoms of vicarious trauma are disturbances in the professional’s cognitive frame of reference in the areas of trust, safety, control, esteem, and intimacy.

 Stress is is a physical, mental, or emotional factor that causes bodily or mental tension. Stresses can be external (from the environment, psychological, or social situations) or internal (illness, or from a medical procedure). Stress can initiate the "fight or flight" response, a complex reaction of neurologic and endocrinologic systems.

 Burnout is characterized by emotional exhaustion, depersonalization, and a reduced feeling of personal accomplishment. While it is also work-related, burnout develops as a result of general occupational stress; the term is not used to describe the effects of indirect trauma exposure specifically.

 Compassion satisfaction refers to the positive feelings derived from competent performance as a trauma professional. It is characterized by positive relationships with colleagues, and the conviction that one’s work makes a meaningful contribution to clients and society.

Source: Adapted from Secondary Traumatic Stress: A Fact Sheet for Child-Serving Professionals. The National Child Traumatic Stress Network. www.NCTSN.org (2011)

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Handout C. ProQOL R-IV: PROFESSIONAL QUALITY OF LIFE SCALE Compassion Satisfaction and Fatigue Subscales—Revision IV

[Helping] people puts you in direct contact with their lives. As you probably have experienced, your compassion for those you [help] has both positive and negative aspects. We would like to ask you questions about your experiences, both positive and negative, as a [helper]. Consider each of the following questions about you and your current situation.

Select the number that honestly reflects how frequently you experienced these characteristics in the last 30 days.

0=Never 1=Rarely 2=A Few Times 3=Somewhat Often 4=Often 5=Very Often

______1. I am happy.

______2. I am preoccupied with more than one person I [help].

______3. I get satisfaction from being able to [help] people.

______4. I feel connected to others.

______5. I jump or am startled by unexpected sounds.

______6. I feel invigorated after working with those I [help].

______7. I find it difficult to separate my personal life from my life as a [helper].

______8. I am losing sleep over traumatic experiences of a person I [help].

______9. I think that I might have been “infected” by the traumatic stress of those I [help].

______10. I feel trapped by my work as a [helper].

______11. Because of my [helping], I have felt “on edge” about various things.

______12. I like my work as a [helper].

______13. I feel depressed as a result of my work as a [helper].

______14. I feel as though I am experiencing the trauma of someone I have [helped].

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______15. I have beliefs that sustain me.

______16. I am pleased with how I am able to keep up with [helping] techniques and protocols.

______17. I am the person I always wanted to be.

______18. My work makes me feel satisfied.

______19. Because of my work as a [helper], I feel exhausted.

______20. I have happy thoughts and feelings about those I [help] and how I could help them.

______21. I feel overwhelmed by the amount of work or the size of my case[work]load I have to deal with.

______22. I believe I can make a difference through my work.

______23. I avoid certain activities or situations because they remind me of frightening experiences of the people I [help].

______24. I am proud of what I can do to [help].

______25. As a result of my [helping], I have intrusive, frightening thoughts.

______26. I feel “bogged down” by the system.

______27. I have thoughts that I am a “success” as a [helper].

______28. I can't recall important parts of my work with trauma victims.

______29. I am a very sensitive person.

______30. I am happy that I chose to do this work.

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Copyright Information © B. Hudnall Stamm, 1997-2005. Professional Quality of Life: Compassion Satisfaction and Fatigue Subscales, R-IV (ProQOL). http://www.isu.edu/~bhstamm. This test may be freely copied as long as (a) author is credited, (b) no changes are made other than those authorized below, and (c) it is not sold. You may substitute the appropriate target group for [helper] if that is not the best term. For example, if you are working with teachers, replace [helper] with teacher. Word changes may be made to any word in italicized square brackets to make the measure read more smoothly for a particular target group.

Disclaimer This information is presented for educational purposes only. It is not a substitute for informed medical advice or training. Do not use this information to diagnose or treat a health problem without consulting a qualified health or mental provider. If you have concerns, contact your health care provider, mental health professional, or your community health center.

Self-scoring directions, if used as self-test

1. Be certain you respond to all items.

2. On some items the scores need to be reversed. Next to your response write the reverse of that score (i.e. 0=0, 1=5, 2=4, 3=3). Reverse the scores on these 5 items: 1, 4, 15, 17 and 29. Please note that the value 0 is not reversed, as its value is always null.

3. Mark the items for scoring:

a. Put an X by the 10 items that form the Compassion Satisfaction Scale: 3, 6, 12, 16, 18, 20, 22, 24, 27, 30.

b. Put a check by the 10 items on the Burnout Scale: 1, 4, 8, 10, 15, 17, 19, 21, 26, 29.

c. Circle the 10 items on the Trauma/Compassion Fatigue Scale: 2, 5, 7, 9, 11, 13, 14, 23, 25, 28.

4. Add the numbers you wrote next to the items for each set of items and compare with the theoretical scores.

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Your Scores On The ProQOL: Professional Quality of Life Screening For more information on the ProQOL, go to http://www.isu.edu/~bhstamm Based on your responses, your personal scores are below. If you have any concerns, you should discuss them with a physical or mental health care professional.

Compassion Satisfaction ______Compassion satisfaction is about the pleasure you derive from being able to do your work well. For example, you may feel like it is a pleasure to help others through your work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society. Higher scores on this scale represent a greater satisfaction related to your ability to be an effective in your job. The average score is 37 (SD 7; alpha scale reliability .87). About 25% of people score higher than 42 and about 25% of people score below 33. If you are in the higher range, you probably derive a good deal of professional satisfaction from your position. If your scores are below 33, you may either find problems with your job, or there may be some other reason—for example, you might derive your satisfaction from activities other than your job.

Burnout______Most people have an intuitive idea of what burnout is. From the research perspective, burnout is associated with feelings of hopelessness and difficulties in dealing with work or in doing your job effectively. These negative feelings usually have a gradual onset. They can reflect the feeling that your efforts make no difference, or they can be associated with a very high workload or a non-supportive work environment. Higher scores on this scale mean that you are at higher risk for burnout. The average score on the burnout scale is 22 (SD 6.0; alpha scale reliability .72). About 25% of people score above 27 and about 25% of people score below 18. If your score is below 18, this probably reflects positive feelings about your ability to be effective in your work. If you score above 27 you may wish to think about what at work makes you feel like you are not effective in your position. Your score may reflect your mood; perhaps you were having a “bad day” or are in need of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern.

Compassion Fatigue/Secondary Trauma______Compassion fatigue (CF), also called (STS) and related to Vicarious Trauma (VT), is about your work-related, secondary exposure to extremely stressful events. For example, you may repeatedly hear stories about the traumatic things that happen to other people, commonly called VT. If your work puts you directly in the path of danger, such as being a soldier or humanitarian aide worker, this is not secondary exposure; your exposure is primary. However, if you are exposed to others’ traumatic events as a result of your work, such as in an emergency room or working with child protective services, this is secondary exposure. The symptoms of CF/STS are usually rapid in onset and associated with a particular event. They may include being afraid, having difficulty sleeping, having images of the upsetting event pop into your mind, or avoiding things that remind you of the event. The average score on this scale is 13 (SD 6; alpha scale reliability .80). About 25% of people score below 8 and about 25% of people score above 17. If your score is above 17, you may want to take some time to think about what at work may be frightening to you or if there is some other reason for the elevated score. While higher scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your work and your work environment. You may wish to discuss this with your supervisor, a colleague, or a health care professional.

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Handout D. Is Your Stress Adding Up?

Emotional stress can affect you physically, emotionally, spiritually, mentally and socially. Check the symptoms you’ve experienced lately.

PHYSICAL  appetite changes  nightmares SOCIAL  headaches  crying spells  isolation  tension  irritability  intolerance  fatigue  “no one cares”  loneliness  insomnia  depression  lashing out  weight change  nervous laugh  hiding  colds  worrying  clamming up  muscle aches  easily  lowered sex drive  digestive upsets discouraged  nagging  pounding heart  little joy  distrust  accident prone  fewer contacts  teeth grinding SPIRITUAL with friends  rashes or skin  emptiness  lack of intimacy problems  loss of meaning  confusion  restlessness  doubt  lethargy  foot-tapping  unforgiving  whirling mind  finger-drumming  martyrdom  no new ideas  increased alcohol,  looking for magic  boredom drug or tobacco  loss of direction  spacing out use  needing to  negative self-talk

“prove” self  using people MENTAL  cynicism  forgetful  Source: Well-being  dull senses Magazine Vol. 3, No.2  poor concentration  low productivity  negative attitude

EMOTIONAL  anxiety  frustration  the “blues”  mood swings  bad temper

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Handout E. Check Yourself for Burnout

Instructions: For each question, circle the number of the response that best applies to you. Use the following scale for your responses: 1 =Not at all 2 = Rarely 3 = Sometimes 4 = Often 5 = Very Often

1. I feel run down and drained of physical or emotional energy. 1 2 3 4 5

2. I have negative thoughts about my job. 1 2 3 4 5

3. I am harder and less sympathetic with people than perhaps they 1 2 3 4 5 deserve.

4. I am easily irritated by small problems, or by my co-workers 1 2 3 4 5 and team.

5. I feel misunderstood or unappreciated by my co-workers. 1 2 3 4 5

6. I feel that I have no one to talk to. 1 2 3 4 5

7. I feel that I am achieving less than I should. 1 2 3 4 5

8. I feel under an unpleasant level of pressure to succeed. 1 2 3 4 5

9. I feel that I am not getting what I want out of my job. 1 2 3 4 5

10. I feel that I am in the wrong organization or the wrong 1 2 3 4 5 profession.

11. I am frustrated with parts of my job. 1 2 3 4 5

12. I feel that organizational politics or bureaucracy frustrate my 1 2 3 4 5 ability to do a good job.

13. I feel that there is more work to do than I practically have 1 2 3 4 5 the ability to do.

14. I feel that I do not have time to do many of the things that 1 2 3 4 5 are important to doing a good quality job.

15. I find that I do not have time to plan as much as I would like to. 1 2 3 4 5

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Check Yourself for Burnout -- Score Interpretation

Add up your score across the 15 items and check your result using this scoring table.

Score Comment

15-18 No sign of burnout here.

19-32 Little sign of burnout here, unless some factors contributing to any burnout are particularly severe.

33-49 Be careful – you may be at risk of burnout, particularly if several scores are high.

50-59 You are at severe risk of burnout – do something about this urgently. In the near future, consider taking some time away from the source of burnout in your life, if at all possible.

60-75 You are at very severe risk of burnout – do something about this urgently. Consider taking some time away from the source of burnout in your life as soon as possible.

Note: This tool uses an informal approach to assessing burnout. While it may be intuitively useful, it has not been validated through controlled scientific tests and must therefore not be used as a diagnostic technique. Please, therefore, interpret the results with common sense. Also, make allowances for any recent events that may have a disproportionate influence on your mood at the time you take the quiz! If you prefer rigorously validated tests, then the Maslach Burnout Inventory may be useful. This was developed by Christina Maslach, one of the leading researchers in the field of burnout. Copies can be purchased at the following site: https://www.cpp.com/en/detailprod.aspx?pc=35.

Source: http://www.mindtools.com/pages/article/newTCS_08.htm

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Handout F. Organizational Approaches to Prevention of Compassion Fatigue

Clear purpose and goals

 Clearly defined intervention goals and strategies appropriate to different assignment settings (e.g., crisis intervention, psychological debriefing)  Community needs, focus, and scope of program defined  Periodic assessment of service targets and strategies

Employee and management training

 Training and orientation provided for all mental health workers  In-service training on current recovery topics (such as Building Resilience/Stress Hardiness; or, Critical Incidents and Trauma Response)  Staff trained and supervised to define limits, make referrals  Feedback provided to staff on program accomplishments, numbers of contacts, etc.

Functionally defined roles

 Staff oriented and trained with written role descriptions for each assignment setting as part of preparedness plan  When setting is under the jurisdiction of another agency (e.g., Mayor's Office, Medical Examiner's Office, American Red Cross), staff informed of MH role, contact people, and mutual expectations  Job descriptions and expectations for all positions  Participating crime victim services' and recovery agencies' roles defined and working relationships with key agency contacts maintained

Effective management structure and leadership

 Clear chain of command and reporting relationships  Available and accessible leaders and clinical supervisors  Full-time disaster and crime victim assistance-trained supervisors and program manager with demonstrated management and supervisory skills  Clinical supervisors and consultants experienced in content areas and trained in mental health response to community trauma  Clear and functional organizational structure  Program direction and accomplishments reviewed and modified as needed  Use of managers experienced in emergency response and community trauma

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Administrative considerations

 Shifts no longer than 12 hours, with 12 hours off  Rotation between high, mid, and low-stress tasks  Limits on working more than 40 hours/week  Two consecutive days off and vacation time required  Breaks and time away from the assignment encouraged and required when necessary  Necessary supplies available (e.g., paper, forms, pens, educational materials)  Communication tools available (e.g., cell phones, radios)  Limits on and rotation from high-exposure duties (e.g., groups with bereaved parents, trauma counseling)

Team support

 Buddy system for support and monitoring stress reactions  Positive atmosphere of support, mutual respect, and tolerance with "thank you" and "good job" said often  Team approach that avoids a program design with isolated workers from separate agencies  Informal and formal case consultation, problem-solving, and resource sharing  Regular, effective meetings with productive agendas, personal sharing, and creative program development  Clinical consultation and supervision processes built on trust, safety, and respect

Plan for stress management

 Attention to workers' functioning and stress management  Supervisors "float through" work areas to observe signs of stress  Education about signs and symptoms of worker stress and strategies  Individual and group support, defusing, and debriefing provided  Exit plan for workers leaving the operation: debriefing, re-entry information, opportunity to critique, and formal recognition for service  Ongoing education and workshops regarding long-term stresses of disaster mental health work and methods for self-monitoring and intervention  Comprehensive plan for environmental, organizational, and individual approaches and implementation timeline  Plan for regular stress interventions at work and meetings  Confidential individual counseling available for work-related issues  Extensive program phase-down plan: timelines, debriefing, critique, formal recognition, celebration, and assistance with job searches

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Handout G. Stress Hardiness Quiz: How Hardy Are You?

Write down how much you agree or disagree with the following statements using this scale: 0 = Strongly Disagree 1 = Mildly Disagree 2 = Mildly Agree 3 = Strongly Agree

___A. Trying my best at work makes a difference.

___B. Trusting to fate is sometimes all I can do in a relationship.

___C. I often wake up eager to start on the day’s projects.

___D. Thinking of myself as a free person leads to great frustration and difficulty.

___E. I would be willing to sacrifice financial security in my work if something really challenging came along.

___F. It bothers me if I have to deviate from the routine or schedule I’ve set for myself.

___G. An average citizen can have an impact on politics.

___H. Without the right breaks, it is hard to be successful in my field.

___I. I know why I am doing what I am doing.

___J. Getting close to people puts me at risk of being obliterated by them.

___K. Encountering new situations is an important priority in my life.

___L. I really don’t mind it when I have nothing to do.

To Score Yourself: The questions above measure control, commitment, and challenge. For half the questions, a high score (like “3=Strongly Agree”) indicates hardiness; for the other half, a low score (disagreement) does.

First, you will calculate your scores on control, commitment, and challenge. Then, you will add those scores together to get a score for total hardiness. See the scoring instructions on the next page.

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How Hardy Are You -- Scoring

1. To calculate your scores on control, commitment, and challenge, write in your answers above the letter of each question. Then add and subtract as indicated.

Column 1 Column 2 Column 1 minus Column 2

____ + ____ = ______+ ____= ____ A G B H = ______CONTROL ____ + ____ = ______+ ____ = ____ C I D J = ______COMMITMENT ____ + ____ = ______+ ____ = ____ E K F L = ______CHALLENGE

2. Add your scores for control, commitment, and challenge together to obtain a score for total hardiness.

______+ ______+ ______= ______Control Commitment Challenge Hardiness Score

3. Score Interpretation:

10 to 18 points: A Stress Hardy personality 0 to 9 points: Moderate hardiness Less than 0 points (a negative score): Low hardiness

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