Compassion Fatigue Healing the HeartRenewing the Soul by

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Compassion Fatigue: Healing the Heart-Renewing the Soul by Donna M. White RN, Ph. D,

Compassion Fatigue: Healing the Heart-Renewing the Soul by Donna M. White RN, Ph. D, CS, CADAC Fellow-Board Certified Expert in Traumatic Stress Lemuel Shattuck Hospital, Boston, MA Public Health Nursing Webinar August 3, 2010 Copyright, D. White 2010

Acknowledgements • New England Alliance for Public Health Workforce Development • Boston University School

Acknowledgements • New England Alliance for Public Health Workforce Development • Boston University School of Public Health • Massachusetts Association of Public Health Nurses (MAPHN) Copyright, D. White 2010

Overview The purpose of this workshop is to present the profile of a Health

Overview The purpose of this workshop is to present the profile of a Health Care Professional suffering from Compassion Fatigue. The interactive seminar will identify common stressors that impact performance of professionals working in Health Care. The learner will be given methodologies to identify patterns of Compassion Fatigue and strategies to promote Wellness, Recovery and a renewed sense of identity as a caring professional. Copyright, D. White 2010

Learning Objectives Upon completion of this session you will be able to: • Identify

Learning Objectives Upon completion of this session you will be able to: • Identify three symptoms of Secondary Traumatic Stress Disorder (STSD) • Describe how Secondary Traumatic Stress Disorder (STSD) and the sequelae Compassion Fatigue, is a risk to Health Care Professionals (HCP) • List two Occupational Supports for Health Care Professionals experiencing STSD. Copyright, D. White 2010

Lemuel Shattuck Hospital Copyright, D. White 2010

Lemuel Shattuck Hospital Copyright, D. White 2010

A dedication… St. Francis of Assisi—Patron Saint of Compassion He relinquished a life of

A dedication… St. Francis of Assisi—Patron Saint of Compassion He relinquished a life of wealth & chose a humble life to care for the sick, the disenfranchised, the poor, prisoners, and believed no one should ever die alone at the end of their earthly life. Copyright, D. White 2010

Ever wonder… • • • Why you chose your profession? Ever think about the

Ever wonder… • • • Why you chose your profession? Ever think about the rewards of it? Why you continue even when exhausted? Do you regret anything? Name it… How often do you think about what you do and the impact it has on who you are? • How can you learn to “live softly”? Copyright, D. White 2010

Health Care Professional Prone to Compassion Fatigue • • • Heroic treaters Intensely caring

Health Care Professional Prone to Compassion Fatigue • • • Heroic treaters Intensely caring and concerned for others High achievers Strong academics - top ½ of their class Dysfunctional home/early life Highly competent Excellent employee Driven to succeed Finds failure difficult Copyright, D. White 2010 Cerney, 1995

Positions available • Long hours with required overtime • Must be available off-shifts, weekends,

Positions available • Long hours with required overtime • Must be available off-shifts, weekends, and holidays • Must be tolerant of aberrant behavior • Must be willing to handle daily crises • Emotionally draining and physically difficult work • Sadness and tragedy seen often • High degree of paperwork and responsibility • Low salary that will increase after 20+ years Copyright, D. White 2010

Occupational Signs of Stress Biological: • Bodily functions • Physical symptoms • Adverse physiological

Occupational Signs of Stress Biological: • Bodily functions • Physical symptoms • Adverse physiological changes Copyright, D. White 2010

Occupational Signs of Stress Psychological: • Decreased tolerance of others • Low frustration ability

Occupational Signs of Stress Psychological: • Decreased tolerance of others • Low frustration ability • Loss of humor and joy Copyright, D. White 2010

Occupational Signs of Stress Social: • Withdrawal • Isolation • Loneliness • Unable to

Occupational Signs of Stress Social: • Withdrawal • Isolation • Loneliness • Unable to complete tasks • Poor utilization of social networks • Negative patterns in supervision Copyright, D. White 2010

So what is happening? Copyright, D. White 2010

So what is happening? Copyright, D. White 2010

Burnout…a patient cousin Well intended aspirations evolve into behaviors that can lay the groundwork

Burnout…a patient cousin Well intended aspirations evolve into behaviors that can lay the groundwork for burnout and possibly compassion stress and other negative patterns in the workplace Such as… Copyright, D. White 2010

Negative factors • • Decreased energy—”keeping up the speed” Feelings of inadequacy, possibly failure

Negative factors • • Decreased energy—”keeping up the speed” Feelings of inadequacy, possibly failure Reduced recognition for good work High propensity towards feelings of guilt Feelings of helplessness/powerlessness Pressure to succeed-overachieve Vulnerability to criticism Copyright, D. White 2010

Negative factors…cont’d. • • Inner-directed rage Under-assertiveness Feeling victimized Inflexibility*—in professions that do not

Negative factors…cont’d. • • Inner-directed rage Under-assertiveness Feeling victimized Inflexibility*—in professions that do not reward flexibility • Personality influences—perfectionism, rigidity and an enormous capacity for an extreme workload* Red Cape Syndrome— “super-martyr” Copyright, D. White 2010

Negative factors • A strong work ethic, self-direction and idealism in the workplace can

Negative factors • A strong work ethic, self-direction and idealism in the workplace can spiral negatively without supervision* • Subsurface anger in HCPs equates to a sense of powerlessness • Horizontal violence-misdirected anger and subtle sabotage towards others in their lives • Highly critical and fault finding Dropplemann & Thomas, 1996 Copyright, D. White 2010

Burnout… “A state of physical, emotional and mental exhaustion caused by long-term involvement in

Burnout… “A state of physical, emotional and mental exhaustion caused by long-term involvement in emotionally demanding situations”. -Pines & Arnson, 1988 Copyright, D. White 2010

Stages of Burnout… • • • The Honeymoon -- Thank you so much! The

Stages of Burnout… • • • The Honeymoon -- Thank you so much! The Awakening -- expectations are different The Brownout -- self-confidence wanes Full Scale Burnout -- open criticism The Phoenix Phenomena -- you can get well Maslach, 1985, et al Copyright, D. White 2010

Burnout The essence of the problem is not the recognition of the feelings. It

Burnout The essence of the problem is not the recognition of the feelings. It is the clash between expectations and reality. Can emerge gradually… Copyright, D. White 2010

A Conspiracy of Silence • The work of Healthcare in this century is physically

A Conspiracy of Silence • The work of Healthcare in this century is physically exhausting and emotionally daunting…caring for the seriously ill, the dying, the wounded and the diseased. • Effects on the provider are myriad • Viewed as “just doing my job” • Professional disciplines minimize their contribution… Finke, 2003 Copyright, D. White 2010

Figley’s Model of Compassion Stress and Fatigue Emotional Contagion Empathic Ability Disengagement Empathic Response

Figley’s Model of Compassion Stress and Fatigue Emotional Contagion Empathic Ability Disengagement Empathic Response Empathic Concern Sense of Achievement Copyright, D. White 2010 Compassion Stress

Blurring of roles • Compassion stress has its roots in burnout. • A sense

Blurring of roles • Compassion stress has its roots in burnout. • A sense of achievement can be known as a “helper’s high”. The reward of the task completion is greater for the professional than the fulfillment of the need in the person being cared for. • Empathic responses can fuel continued spiraling to fulfill the needs of others… leading to exhaustion. Copyright, D. White 2010

Cognitive Impact of Secondary Traumatic Stress • Diminished concentration • Confusion • Spaciness •

Cognitive Impact of Secondary Traumatic Stress • Diminished concentration • Confusion • Spaciness • Loss of meaning • Decreased self-esteem • Preoccupation with trauma • Trauma imagery • • • Apathy Rigidity Disorientation Whirling thoughts Thoughts of self-harm or harm towards others • Self-doubt • Perfectionism • Minimization Copyright, D. White 2010

Emotional Impact of Secondary Traumatic Stress • • Powerlessness Anxiety Guilt Anger-rage Survivor guilt

Emotional Impact of Secondary Traumatic Stress • • Powerlessness Anxiety Guilt Anger-rage Survivor guilt Shutdown Numbness Fear • • • Helplessness Sadness Depression Hypersensitivity Emotional roller coaster • Overwhelmed • Depleted Copyright, D. White 2010

Spiritual Impact of Secondary Traumatic Stress • Questioning the meaning of life • Lack

Spiritual Impact of Secondary Traumatic Stress • Questioning the meaning of life • Lack of selfsatisfaction • Pervasive hopelessness • • Loss of purpose Ennui Anger at God Questioning of prior religious beliefs Copyright, D. White 2010

Interpersonal Impact of Secondary Traumatic Stress • Withdrawn • Decreased interest in intimacy or

Interpersonal Impact of Secondary Traumatic Stress • Withdrawn • Decreased interest in intimacy or sex • Mistrust • Impact on parenting (protectiveness, concern about aggression) • Projection of anger or blame • Intolerance • Loneliness • Isolation from friends Copyright, D. White 2010

Physical Impact of Secondary Traumatic Stress • • Shock Sweating Rapid heartbeat Breathing difficulties

Physical Impact of Secondary Traumatic Stress • • Shock Sweating Rapid heartbeat Breathing difficulties • Aches and pains • Dizziness • Impaired immune system • Somatic reactions Copyright, D. White 2010

Behavioral Impact of Secondary Traumatic Stress • • • Clingy Impatient Irritable Withdrawn Moody

Behavioral Impact of Secondary Traumatic Stress • • • Clingy Impatient Irritable Withdrawn Moody Regression Sleep disturbances Appetite changes Nightmares • Hypervigilance • Elevated startle response • Use of negative coping (smoking, alcohol or other substance misuse) • Accident proneness • Losing things • Self-harm behaviors Copyright, D. White 2010

Crimean War… “Their moans would pierce the heart” -Irish Nurse 1864 Copyright, D. White

Crimean War… “Their moans would pierce the heart” -Irish Nurse 1864 Copyright, D. White 2010

PTSD Experiences What Constitutes a Sufficiently Traumatic Experience: The person has experiences an event

PTSD Experiences What Constitutes a Sufficiently Traumatic Experience: The person has experiences an event outside the range of usual human experience that would be markedly distressing to almost anyone: a serious threat to his or her life or physical integrity; serious threat or harm to their children, spouse or other close relatives, or friends; sudden destruction of his home or community: or seeing another person seriously injured or killed in an accident or by physical violence. (APA, 1994) Copyright, D. White 2010

Secondary Traumatic Stress • STS is the natural consequent behaviors and emotions resulting from

Secondary Traumatic Stress • STS is the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by another human being. It is the stress resulting from helping or wanting to help a traumatized or suffering person. (Figley, 1993 a) Copyright, D. White 2010

Vicarious Traumatization… • Vicarious traumatization refers to a transformation in the person’s inner experience

Vicarious Traumatization… • Vicarious traumatization refers to a transformation in the person’s inner experience resulting from empathic engagement with trauma material. • Graphic accounts of abuse & pain • Effects are cumulative & permanent Mc. Cann & Pearlman, 1998 Copyright, D. White 2010

Vicarious Traumatization… • Effects may be intrusive and painful • Emotional residue may remain

Vicarious Traumatization… • Effects may be intrusive and painful • Emotional residue may remain after direct exposure • Contamination of personal life • Disruption of schema or beliefs about the self and the world. • Also called Transformational World View Copyright, D. White 2010

Posttraumatic Embitterment Disorder • A distinct state of mood • Differs from depression, hopelessness,

Posttraumatic Embitterment Disorder • A distinct state of mood • Differs from depression, hopelessness, and anger… but can share common emotional features or exist in parallel with them • In contrast to anger…has additional quality of selfblame and a feeling of injustice • A feeling of being let down and is nagging and self-increasing • Person may feel vengeful but helpless. Linden, Rotter, et al (2007) Copyright, D. White 2010

I am not what happened to me. I am what I choose to become.

I am not what happened to me. I am what I choose to become. Carl Jung Copyright, D. White 2010

Figley’s Model of Compassion Stress and Fatigue Degree of Life Disruption Prolonged Exposure Secondary

Figley’s Model of Compassion Stress and Fatigue Degree of Life Disruption Prolonged Exposure Secondary Traumatic Stress Compassion Fatigue Traumatic Recollections Copyright, D. White 2010

Emotional and Spiritual Effects Through exposure to graphic accounts of abuse experiences, and the

Emotional and Spiritual Effects Through exposure to graphic accounts of abuse experiences, and the realities of people’s intentional cruelty to one another, a caring person is vulnerable to the emotional and spiritual effects of vicarious traumatization. Copyright, D. White 2010

PTSD and STSD PTSD Stressor • Outside of usual human experiences Serious threat to

PTSD and STSD PTSD Stressor • Outside of usual human experiences Serious threat to self Sudden destruction of one’s environment • Re-experience of Trauma event • Avoidance/numbing of reminders • Persistent arousal Copyright, D. White 2010

PTSD and STSD Stressor • Outside of usual human experiences Serious threat to Traumatized

PTSD and STSD Stressor • Outside of usual human experiences Serious threat to Traumatized Person Sudden destruction of TP’s environment • Re-experiencing Trauma Event of TP • Avoidance/numbing of reminders • Persistent arousal Copyright, D. White 2010

Compassion Fatigue Defined • Identical to Secondary Traumatic Stress Disorder (STSD) • Is the

Compassion Fatigue Defined • Identical to Secondary Traumatic Stress Disorder (STSD) • Is the equivalent of PTSD • Potential for chemical use Figley, 1995 Copyright, D. White 2010

Clinical Practice Issues • Loss of therapeutic realism • Negative or non-existent supervision •

Clinical Practice Issues • Loss of therapeutic realism • Negative or non-existent supervision • Personal health changes • Self-neglect • Transference/Countertransference • Compassion Stress and Compassion Fatigue Copyright, D. White 2010

Clinical Practice Issues, continued • Diminished interaction with colleagues and team discipline • Black/White-all

Clinical Practice Issues, continued • Diminished interaction with colleagues and team discipline • Black/White-all or nothing thinking • Emotionalism • Judgmental behavior • Use of chemicals for stress reduction (use, abuse, dependence) • Impaired Practice Copyright, D. White 2010

Culture of the Workplace Key marker for identifying issues for employee performance and health

Culture of the Workplace Key marker for identifying issues for employee performance and health maintenance • Professional: established roles, clear policies and protocols, supervision sessions, reasonable expectations • Negative and Punitive…. “the bureaucratic response” • Harried and rushed…. . . “a ticking clock” • Fragmented and productivity driven… “just get it done” • Team oriented vs. discipline specific…“that’s not my job” • Poor reflection of specific cultures • Chronic role strain Copyright, D. White 2010

“You have brains in your head…You have feet in your shoes. You can steer

“You have brains in your head…You have feet in your shoes. You can steer yourself in any direction you choose!” -Dr. Seuss Copyright, D. White 2010

Key points for clinical practice • • • Supervision* Boundary adherence Self-awareness Processing of

Key points for clinical practice • • • Supervision* Boundary adherence Self-awareness Processing of events and emotions Horizontal violence De-obligate yourself Copyright, D. White 2010

More stuff to know… • The way you feel or behave is never caused

More stuff to know… • The way you feel or behave is never caused by others or the way they treat you. • The way you behave is influenced by how you feel. • The way you feel is created and controlled and maintained by interpretations in your mind. • Anything that was learned can be unlearned. * • You can change the way you think! • Getting reasonably upset instead of overly upset can give you choice and control. Managing Emotions Under Pressure, 2006 Copyright, D. White 2010

Methodologies for Biopsychosocial Role Strain • Personal Philosophy • Support Groups • Workplace Support

Methodologies for Biopsychosocial Role Strain • Personal Philosophy • Support Groups • Workplace Support (lunch time meetings, gyms, spiritual areas, supervision luncheons, away days) • Exercise programs • Educational pursuits • RTW (Return-to-Work) Contracts (when applicable, established boundaries and parameters) Copyright, D. White 2010

Healthy Strategies for Survival • Assertiveness Training - Learning how to present • •

Healthy Strategies for Survival • Assertiveness Training - Learning how to present • • • personal views without aggression Health Promotion - Learning & self - health care Adaptation - Goal surrender Learning to “Roll with the Punches” Cooperation - Affiliation “Social Glue” bonding Develop emotional resilience Copyright, D. White 2010

Healthy Strategies for Survival, continued • Recognition of competing—originates in primal drives…food, power, sex

Healthy Strategies for Survival, continued • Recognition of competing—originates in primal drives…food, power, sex • Supervision - New techniques/new perspective • Continuous critical thinking • Methodologies for role strain Copyright, D. White 2010

More Healthy Strategies • • Therapy—individual or group Employee Assistance Program (EAP) consultation Quiet/sacred

More Healthy Strategies • • Therapy—individual or group Employee Assistance Program (EAP) consultation Quiet/sacred areas “Take 5 Room” Study groups Yoga/exercise/good nutrition* Stress e-mail forums Stress reduction programs Compassionate writing Copyright, D. White 2010

Healthy Strategies… • • Mental diversions—songs, movies, stories Schedule vacations routinely Alternative Therapies Dining…not

Healthy Strategies… • • Mental diversions—songs, movies, stories Schedule vacations routinely Alternative Therapies Dining…not gulping food* Pursue and interest—hobbies Encourage recreation Private time on a daily basis Contact with family & friends Copyright, D. White 2010

Ten Worry Stopping Techniques • Set aside a special time for worrying. Concentrate only

Ten Worry Stopping Techniques • Set aside a special time for worrying. Concentrate only on worrying during selected times. • Ask yourself: “What is the absolute worst thing that may happen? ” • Ask yourself: “Will that absolute worst thing really happen? ” How many times? • Use “self-talk” and thought-stopping to short circuit “worries. ” STOP! • Learn and use Scientific Conflict Resolution Techniques for family and personal decisions. Resolve internal conflict; reduce worrying. Copyright, D. White 2010

Ten Worry Stopping Techniques, continued • Instead of imagining and re-imagining the negative, picture

Ten Worry Stopping Techniques, continued • Instead of imagining and re-imagining the negative, picture what you ideally want to have happen. Imagine it and then develop an action plan to begin to move toward that ideal. • Learn to disagreeably. To protect …use I- messages and active listening techniques, “I believe…. discussion” • Take a risk & ask questions…you can’t know everything! • Read. Books and articles are available to teach yourself. • Talk to those you trust… for their guidance Accept reality…know the limits of your control… The crisis will pass…with or without you being stressed Copyright, D. White 2010

Stress Hardiness • The concept of “stress hardiness” or resistance to stress was developed

Stress Hardiness • The concept of “stress hardiness” or resistance to stress was developed by Dr. Suzanne Kobasa at City University in New York. • Dr. Kobasa has studied many groups of people who have very stressful occupations. Those who seem to cope with their job stress, having a hardiness to it, have three specific characteristics. • How do these apply to you? Copyright, D. White 2010

3 Characteristics of Stress Hardiness • Commitment • Control • Challenge Kobasa, 1979, 1985

3 Characteristics of Stress Hardiness • Commitment • Control • Challenge Kobasa, 1979, 1985 Copyright, D. White 2010

Fourth “C” • The fourth “C” stands for “closeness. ” • Everyone who wants

Fourth “C” • The fourth “C” stands for “closeness. ” • Everyone who wants to be stress hardy must have someone (one person or one hundred) with whom to share the stress, a confidante who is willing to “be there” when times are tough. -Betty Morgan RN, Ph. D, CS Copyright, D. White 2010

Positive Effects? … “…a heightened sensitivity & enhanced empathy for the suffering of victims,

Positive Effects? … “…a heightened sensitivity & enhanced empathy for the suffering of victims, resulting in a deeper sense of connection with others…a deep sense of hopefulness about the capacity of human beings to endure, overcome and even transform their traumatic experience: and a more realistic view of the world, through the integration of the dark sides of humanity with healing images”. Mc. Cann & Pearlman, 1990 Copyright, D. White 2010

Small Stuff • • Choose your attitude every day Listen with your ears…and eyes

Small Stuff • • Choose your attitude every day Listen with your ears…and eyes Strive for integrity…not fame Listen to your own advice Think of the “Plane analogy” Cherish tranquility Rest without guilt Learn to relax when you are “too busy” Copyright, D. White 2010

and finally…. . “I want to know what sustains you from the inside when

and finally…. . “I want to know what sustains you from the inside when all else falls away. I want to know if you can be alone with yourself. …and if you like the company you keep in the empty moments” -Oriah Mountain Dreamer Indian Elder Copyright, D. White 2010

References • Cavaiola, A. & Colford, J. (2006) A Practical Guide to Crisis Intervention,

References • Cavaiola, A. & Colford, J. (2006) A Practical Guide to Crisis Intervention, Boston: Lahaska Press. • Echterling, L. G. , Presbury, H. H. , & Mc. Gee, J. E. (2005). Crisis intervention: Promoting resilience and resolution in troubled times. Upper Saddle River, NJ: Pearson • Ferrell B. , and Coyle, Nessa. (2007). The Nature of Suffering and the Goals of Nursing. Oxford University Press. Copyright, D. White 2010

References • Figley, C. R. Compassion Fatigue. New York, Brunner/Mazel, 1995. • Garfield, Charles.

References • Figley, C. R. Compassion Fatigue. New York, Brunner/Mazel, 1995. • Garfield, Charles. (1996). Sometimes My Heart Goes Numb. • Halpern, J. From Detached Concern to Empathy: Humanising Medical Practice. Oxford, Oxford University Press, 2001. Copyright, D. White 2010

References • James, R. K. (2008). Crisis intervention strategies (6 th ed. ). Belmont,

References • James, R. K. (2008). Crisis intervention strategies (6 th ed. ). Belmont, CA: Brooks/Cole. • Reynolds, W. J. The Measurement and Development of Empathy. Aldershot: Ashgate Publishing, 2000. Copyright, D. White 2010

Thank you to all… • To all of you here today for your interest

Thank you to all… • To all of you here today for your interest and commitment to your colleagues • To all those present for their willingness to promote this topic…discussion promotes wellness in ourselves and ultimately, those we serve. • Especially to the organizers of today for their hard work & tireless efforts to make today happen for all of us. Copyright, D. White 2010

QUESTIONS and ANSWERS Donna M. White, Ph. D, RN, CS, CADAC Contact via email:

QUESTIONS and ANSWERS Donna M. White, Ph. D, RN, CS, CADAC Contact via email: donna. [email protected] ma. us Nursing Continuing Education credits are available for 30 days following the live presentation. In order to receive your evaluation form and nursing contact hour certificate please email your: name, state, email address to: Patti White, MAPHN at pattiwhite [email protected] com Copyright, D. White 2010