Nowadays, natural disasters, warfare, violent crime, acts of terrorism, domestic violence and child abuse are circumstances that significantly impact life in modern society (Bush, 2009). These events necessitate professional counselors to effectively treat the trauma associated with these personal and societal crises. When counselor are therapeutically engaged with a child or adult who has been traumatized or encounter with the trauma survivor, he or she may be at risk to intrusive thoughts, avoidance, negative affect and impaired psychological functioning (Chrestman, 1995). Therefore, counselors are vulnerable to compassion fatigue. The concept of compassion fatigue emerged only in the last several years in the professional literature. It represents the cost of caring about and for traumatized people (Adams et al., 2006; Figley, 2002).
1.1 Definition of compassion fatigue
Some authors identified compassion fatigue as a state in which a counselor lacks of emotional strength, exhaustion, experience languor, and loss of vitality and energy (Alkema, Linton, & Davies, 2008). In other words, it may be understand as a sense of being tired of helping others and finding it difficult to act out of compassion. Additionally, some experts view compassion fatigue as a hazard associated primarily with mental health clinicians and with first responders to natural and human made disaster such as China earthquake and incident of 9/11 (Boscarino, Figley, & Adams, 2004). Among the helping professions, genetic counselors clearly do witness much pain and suffering, and may fall prey to compassion fatigue (Udipi, Veach, Kao, & LeRoy, 2008).
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According to Fidley (1993) as cited in Figley (2002), compassion fatigue or secondary traumatic stress (STS) can be define as the natural consequence behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other-the stress resulting from helping or wanting to help a traumatized or suffering person. As Figley (2002) pointed out, compassion fatigue is identical to secondary traumatic stress disorder (STSD) and is the equivalent of post traumatic stress disorder (PTSD) (Figley, 2002). Moreover, compassion fatigue is also recognized as secondary traumatization, secondary traumatic stress disorder, or vicarious traumatization within professional literature (Figley, 2002; Hofmann, 2009).
1.2 Historical Background of Compassion Fatigue
The study of traumatic events and their subsequent impact on human beings has grown considerably over the past two decades. Since the early 1980’s, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (APPENDIX A) has recognized both acute and Post Traumatic Stress Disorders (PTSD) as identifiable mental health concerns (Alkema et al., 2002). Besides that, according to the notion stated in criterion A1 of the PTSD diagnosis, it clearly indicates that people can develop the symptoms of PTSD without actually being physically harmed or threatened with harm (Alkema et al., 2008; Figley, 2002). That is, people can be traumatized simply by learning about the traumatic event. However, according to a review of the traumatology literature, it come to a conclusion that nearly all of the hundreds of reports focusing on traumatized people exclude those who were traumatized indirectly or secondarily and only focus on those who were directly traumatized, that is, the victims (Craig & Sprang, 2010; Figley, 2002). As a result, after more than a decade of negligence of the indirect traumatized people, it is important to consider the least studied aspect of traumatized stress, which is secondary traumatic stress (STS) or later, compassion fatigue.
The term compassion fatigue was used as far back as 1990, the news media in the United States used compassion fatigue to describe the public’s lack of patience, or perhaps simply the editors’ lack of patience, with “the homeless problem,” which had previously been presented as an anomaly or even a “crisis” which had only existed for a short time and could presumably be solved somehow. Later on in 1992, Joinson first used the term in print, in discussing burnout among nurses who deal with hospital emergencies, counselor, emergency workers and other professionals who experience STS in the line of duty (Dominguez-Gomez & Rutledge, 2009). That same year Jeffrey Kottler (1992), in his book, Compassionate Therapy, emphasize the importance of compassion in dealing with extremely difficult and resistant patients. Additionally, compassion fatigue has been studied by the field of traumatology, where it has been called the “cost of caring” for people facing emotional pain (Boscarino et al., 2004; Hofmann, 2009).
Furthermore, one of the first earliest references in the scientific literature regarding this cost of caring comes from Carl G. Jung in “The Psychology of Dementia Praecox”. In this text, Jung discusses the challenges of countertransference – the therapist’s conscious and unconscious reactions to the patient in the therapeutic situation. In his text, he pointed out that therapist can treat their patients with schizophrenia by participates in the delusional fantasies and hallucinations with the patient. Nevertheless, he warns that this participation in the patient’s darkly painful fantasy world of traumatic images has significant deleterious effects for the therapist; especially when the therapist has not resolved his/her own developmental and traumatic issues (Craig & Sprang, 2010; Figley, 2002).
1.3 Statistic of compassion fatigue on counselors
Throughout the years, the number of natural and technological disasters was on the rise, therefore, studies of the effects of disaster events on both the victims and the disaster responders increased (Boscarino, Adams, & Figley, 2006; Bush, 2009). Many researchers focus on those professionals who provide therapy to victims of trauma such as trauma counselors, crisis workers, nurses and other caregivers who become victims themselves of secondary traumatic stress (STS) or compassion fatigue (Bourassa, 2009; Coetzee & Klopper, 2010; Figley, 2002).
Studies which focus on examine the psychological impacts of providing mental health counseling to the disasters’ victims had found out that counselors were psychologically affected by their work, whether or not they personally experienced the disaster (Martin et al., 2010). For instance, as Myers and Wee (2005) pointed out, nearly three-quarters (73.5%) of counselors were rated as being at risk of compassion fatigue, which include moderate risk (23.5%), high risk (29.4%), and extremely high risk (20.6%) in their study of the psychological impact on counselors who work with the trauma survivors of the Oklahoma City Bombing (Myers & Wee, 2005) Furthermore, Meldrum et al. (2002) found that 27% of a sample of Australian mental health professions who worked with traumatized individuals reported extreme stress from this type of work (Meldrum, King, & Spooner, 2002).
In a research article that have been done by Arvay and Uhlemann (1996) using a sample of 161 trauma counselors in British Columbia, they found out that 24% of the counselors interviewed perceived life as stressful. Sixteen percent reported high levels of emotional exhaustion, 4% reported levels of depersonalization and 26% reported feeling ineffective at work in terms of professional accomplishment (Arvay & Uhlemann, 1996). Fourteen percent of the sample reported traumatic stress levels similar to PTSD. In their article, Arvay and Uhlemann (1996) also pointed out that the impaired counselor was in his or her early 40’s, held less than a master’s degree and was more likely to work for an agency than in a private setting. Additionally, Sprang et al. (2007) also found out that young female with higher educational degree and less experience in clinical settings predicted elevated levels compassion fatigue in the study’s sample of 1,121 mental health providers (Sprang, Clark, & Whitt-Woosley, 2007).
1.4 Causes of compassion fatigue
According to Figley (2002), compassion fatigue occurs when one is exposed to extreme events directly experienced by another and becomes overwhelmed by this secondary exposure to trauma. Thus, counselors who always listen to reports of trauma, horror, human cruelty and extreme loss of their clients are at high risk of experience compassion fatigue.
In effective counseling, controlled reactivation of the traumatic memories is promoted by many interventions or forms of psychotherapy due to in the prevailing opinion among psychotherapists; working through the traumatic events is beneficial to the client (Craig & Sprang, 2010; Kinzel & Nanson, 2000). For instance, in behavior therapy, clients are asked to confront with stimuli relating to the traumatic events through returning to a crime scene (in vivo) or imagining the events of the crime (in sensu) (Craig & Sprang, 2010). However, psychotherapy work with torture victims is potentially harmful to the therapist and can lead to compassion fatigue although working through the traumatic events experienced by a sufferer of PTSD seems to be beneficial to the client.
Undeniably, empathy allows counselors to relate to others in their care and to have a sense of what their clients are feeling. Moreover, it also helps the counselors to put the clients’ experiences into perspective and understanding how the clients are being affected by the incidents which the counselors are trying to mediate (Meadors et al., 2009). In brief, in an effective counseling, empathy understanding is necessary. Besides that, counselors, by the very nature of their work, are called on to be compassionate toward their clients on a daily basis (Meadors et al., 2009; Pickett, Brennan, Greenberg, Licht, & Worrell, 1994). However, the more compassionate and empathetic a counselor is toward the suffering of the traumatized person, the more vulnerable that counselor is to compassion fatigue. It is due to compassion fatigue is based on the idea of a syndrome resulting specifically from empathizing with people who are experiencing pain and suffering; counselor can become overwhelmed and may begin to experience feelings of fear, pain and suffering similar to that of their clients (Figley, 2002; Meadors et al., 2009).
As Alkema et al. (2008) pointed out, the common situations of counselor that can lead to compassion fatigue include 1) listening to stories of child abuse; 2) working with suicidal ideation, 3) interacting with the terminally ill; 4) responding with humanitarian aid in situations like disaster, poverty, or war; 5) caring for families with an injured or dying child; 6) providing support for survivors of rape; and 7) providing services for bereaved families.
It is important to note that the sense of being overwhelmed or vulnerability to compassion fatigue is subjective, meaning that what overwhelms one counselor, may not necessarily overwhelm another. Additionally, even one story that overwhelms the counselor’s ability to make sense of the event, can lead to compassion fatigue symptoms (Alkema et al., 2008; Bush, 2009). Therefore, it is essential for the counselor to recognize compassion fatigue symptoms in themselves and their coworkers in turn to provide any emergency aid if needed.
1.5 Symptoms of compassion fatigue
The symptoms of compassion fatigue vary in intensity depending on counselor characteristics and the characteristics of the client population. The resulting symptoms of compassion fatigue typically have an acute onset and are usually associated with a particular event (Stamm, 2005). Symptoms may include: being afraid, having intrusive images enter the person’s attention, having trouble sleeping, or avoiding situations that remind the individual of the event (Tehrani, 2010).
Moreover, compassion fatigue can have negative impact on spiritual development of counselor due to in some cases, counselor are psychologically bombarded by the traumatic recollections, emotional suffering, and psychological pain brought by their clients into session. A counselor might begin doubting his/her values, might express anger or bitterness toward God, and begin withdrawing from fellowship (Udipi et al., 2008). Furthermore, the range of counselor behaviors indicating compassion fatigue can include spending less time with clients, being late and absent from work, making professional errors, being hypercritical of others, making sarcastic and cynical comments about clients and the organization, abusing chemicals, and keeping poor records (Stewart, 2009; Tehrani, 2010). In addition, compassion fatigue also can manifest as physical symptoms such as rapid pulse, sleep disturbance, fatigue, reduced resistance to infection, weakness and dizziness, memory problems, weight change, gastrointestinal complaints, hypertension, and head-aches, backaches, or muscle aches (Meadors et al., 2009)
According to Stewart (2009), for people exposed to primary stressors (i.e., client) and for those exposed to secondary stressors, there is a fundamental difference between the pattern of response during and following the traumatic event. Researches indicate the symptoms of secondary traumatic stress disorder (STSD) or compassion fatigue is nearly identical to post-traumatic stress disorder (PTSD), except that PTSD symptoms are directly connected to the sufferer (e.g., client), yet STSD symptoms is associated with a exposure to knowledge about traumatizing event experienced by the people who care (e.g., counselor). Moreover, as Fidley (2002) pointed out, symptoms of compassion fatigue can be divided into categories of intrusive, avoidance, and arousal symptoms.
Table 1: Compassion fatigue symptoms
Thoughts and images associated with client’s traumatic experiences
Obsessive and compulsive desire to help certain clients
Client/work issues encroaching upon personal time
Inability to “let go” of work-related matters
Perception of survivors as fragile and needing the assistance of the caregiver
Thoughts and feelings of inadequacy as a caregiver
Sense of entitlement or specialness
Perception of the world in terms of victims and perpetrators
Personal activities interrupted by work-related issues
Silencing Response (avoiding hearing/witnessing client’s traumatic material)
Loss of enjoyment in activities/cessation of self-care activities
Loss of energy
Loss of hope/sense of dread working with certain clients
Loss of sense of competence/potency
Secretive self-medication/addiction (alcohol, drugs, work, sex, food, spending, etc.)
Increased perception of demand/threat (in both job and environment)
Change in weight/appetite
1.6 Measuring compassion fatigue
It is essential to assess for compassion fatigue symptoms in the caregiver especially for counselors who work with those traumatized clients (Hofmann, 2009; Stamm, 2005) Thus, certain reliable instrument is needed to use to measure the degree of compassion fatigue in counselors. It is mainly due to through the scoring of the instrument, it can give the counselor valuable feedback or insight of their vulnerability level to compassion fatigue (Adams et al., 2008; Stamm, 2005). Besides that, an examination of the history of the counselor is also a critical step in treating compassion fatigue as researchers have found that a personal history of a traumatic experience can contribute to the experience of compassion fatigue (Adams, Figley, & Boscarino, 2008). Thus, compassion fatigue counselors can assist their co-workers to examine the role that their previous traumatic material has on making them vulnerable to the experience of compassion fatigue. For instance, the Professional Quality of Life Scale: Compassion Satisfaction and Subscales (ProQOL) have been widely used in assessing secondary/vicarious trauma (Bride, Radey, & Figley, 2007).
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Professional Quality of Life Scale (ProQOL) ProQOL is a 30 item self-report measure to assess the dimensions compassion satisfaction, burn-out and compassion fatigue (APPENDIX A). The compassion satisfaction dimension (CS) measures pleasure derived from being able to do the daily work well where higher scores on this scale represent a greater satisfaction related to one’s ability to be an effective caregiver. Besides that, the burnout dimension (BO) in this scale is associated with feelings of hopelessness and difficulties in dealing with work. Higher scores are related to higher risk for burnout. Moreover, the compassion fatigue dimension (CF) relates to work-related secondary exposure to extremely stressful events. High scores indicate that one’s are exposed to frightening experiences at work. The alpha reliabilities for the scales are 1) Compassion Satisfaction alpha = .87, 2) Burnout alpha = .72 and 3) Compassion Fatigue alpha = .80. Additionally, the construct validity upon which the test is based is well established with over 200 articles noted in the peer-review literature. Using the multi-trait multi-method mode for convergent and discriminant validity the scales on the ProQOL do, in fact, measure different constructs (Adams et al., 2008; Bride et al., 2007).
1.7 Consequences of compassion fatigue
Researches have indicated for those counselors who have the greatest capacity for feeling and expressing empathy are at the greatest risk from experiencing secondary traumatic stress or compassion fatigue (Alkema et al., 2008). Furthermore, it has been recognized that counselors suffering from compassion fatigue may be engaged in impaired or unethical practice. Those counselors may become worried with their patients/clients and exhibit signs and symptoms that are not beneficial to optimal patient/client care. It can negatively affect the ability to provide services and maintain personal and professional relationships (Craig & Sprang, 2010).
When a counselor is suffering from compassion fatigue, he or she’s ability to listen with empathy becomes compromised, the counselor may unconsciously avoid the traumatic material brought by the client in an effort to maintain the integrity of the counselor’s world view (Alkema et al., 2008; Bride et al., 2007). For instance, the counselor will tend to remain silent when he or she is unable to attend to the client’s traumatic material. Instead, the counselor will redirects the conversation to less disturbing material that is more pleasant to them (Alkema et al., 2008).
Moreover, as Adam et al. (2006) pointed out, counselors who are suffering from compassion fatigue may hurt their clients by placing their own needs above the needs of the clients. They may tend to avoid the discussion of the traumatic content as a means of protecting themselves from further exposure. According to Bride et al. (2006), avoidance of client’s traumatic issue in counseling comprise a degree of unethical practice as it further isolates the client in his or her psychological pain and suffering. As a result, the counseling alliance may be damage and will lead to further suffering for the client and puts the counselor itself at risk for injuring other clients. Besides that, it is important to note that counselor with compassion fatigue is more likely to develop a sense of isolation, exhaustion and professional dissatisfaction. Therefore, compassion fatigue has the potential to rob the professional of his or her sense of well-being if left unaddressed (Alkema et al., 2008; Craig & Sprang, 2010; Figley, 2002).
PREVENTIONS AND INTERVENTIONS
After years of clinical practice, counselors are being confronted with tragedies of life and depression (Hofmann, 2009). Therefore, they are at high risk of accumulated pain and sadness. Thus, if without an appropriate way or the time to have positive experiences, it will increase the risk of compassion fatigue and distancing (Kinzel & Nanson, 2000; Newsom, 2010). For that reason, the need for some kind of structured prevention, support, and strengthening processes is necessary in order to help the counselor to deal with indirect traumatization.
Among the intervention methods, debriefing sessions are a good way to help a counselor with compassion fatigue decompress and normalize what they are experiencing (Kinzel & Nanson, 2000; Pickett et al., 1994). During debriefing session, traumatic incident is discussed in a structured group meeting. Through debriefing, it can help the counselor to address the immediate psychological impact that he or she experienced from the client. Thus, through discussing and seeking assistance from other colleagues and caregivers who have had experience with trauma and have remained healthy and hopeful, it can assist the counselor to alleviate the traumatic symptoms (Pickett et al., 1994).
In addition, the importance of regular professional supervision, before and after traumatic events, has been identified as essential, as is continuing education and training (Kinzel & Nanson, 2000; Meadors et al., 2009). It is due to for the purpose to promote long-term coping with the consequences of the traumatic events, continuity of the supervision and training program is necessary. Moreover, the aim of supervision is to explore and reduce the impact of the painful client material on the counselors’ thinking and emotions. In the United Kingdom, personal supervision is a professional requirement for counselors and it may be provided by a clinical supervisor, manager, or peer (Kinzel & Nanson, 2000).
According to pre-existing studies, it had been recognized that self-hypnosis have beneficial effects on immune control, enhanced mood and well-being (Martin et al., 2010; Mottern, 2010; Ruysschaert, 2003). Besides that, clinical experience with clients and therapist’s reports also indicated that one’s can recovering and lowering their overall level of stress through self-hypnosis (Martin et al., 2010). Therefore, self-hypnosis is an effective tool to help counselor in preventing compassion fatigue or in promoting compassion satisfaction. In stress management, counselor’s ability to let go do play a very important role in stress-resistance or resilience. Figley (1995) also sees ‘let-it-go’ as an important aspect in the reduction of compassionate stress. Therefore, in effective counseling, it is important for the counselor to find ways to create some distance from the emotional pain that they experienced from their clients. According to Morttern (2010), practicing self-hypnosis in a regular basis is important step in promoting self-awareness and temporarily distancing oneself from the outside world. For instance, it is possible for the counselor who suffered from compassion fatigue letting go of intrusions and thoughts indirectly by imagining thoughts as clouds, coming and going, and just noticing what happens (Mottern, 2010).
Furthermore, counselors have to increase their own self awareness and live a healthy, balanced lifestyle in order decreases their vulnerability from compassion fatigue (Figley, 2002; Prati & Pietrantoni, 2009). For instance, counselors can increase their self awareness by knowing their own “triggers” and vulnerable areas and learn to defuse them or avoid them (Bride et al., 2007). Besides that, counselors have to realize that “normal responses to abnormal situations” is true for helpers as well as victims. Thus, they should allow themselves to grieve when bad things happen to others (Figley, 2002). Moreover, it is essential for the counselors to set boundaries for themselves by develop realistic expectations about the rewards as well as the limitations of helping (Prati & Pietrantoni, 2009). In brief, they have to become aware of any irrational beliefs that impair their well being throughout the helping process.
Last but not least, diversions and recreation that allow the counselor to take mini-escapes from the intensity of their work is absolutely essential to avoid from compassion fatigue (Alkema et al., 2008). Researches indicate that those that have the ability to “turn their thoughts about work off” are more resilient throughout their career (Alkema et al., 2008; Figley, 2002). For instance, counselors can express their feelings through writing in a journal, music or art.
Counselors enroll themselves in the helping profession because they want to assist other in need. Yet, counselors can become so overwhelmed by the exposure to the feelings and experiences of their clients and leave them vulnerable for compassion fatigue. Compassion fatigue, if left untreated, can spark a deterioration of personality and generate a decline in general health of the counselors. Thus, it is of vital importance to treat the helpers or counselors with compassion fatigue so that it do not reach a absurd situation where clients/victims are treated and helped, but those who help them experience such burnout that they can no longer function as mental health care providers or even continue their own life patterns as usual. Therefore, counselors and every mental health professionals must note and address the prevention steps in order to prevent compassion fatigue. In brief, compassion fatigue is a serious problem among members of the helping professions, but counselors will be able to get through it by acknowledging it, and staying connected to the good in their own life.
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