Ethical Considerations in Field with Compassion Fatigue and

Ethical Considerations in Field with Compassion Fatigue and Trauma Jon Hudson, MSW, Ph. D University of Wisconsin, Oshkosh Department of Social Work 22 nd of September 2016

• Concerns over Secondary Traumatic Stress Among Social Workers Study of direct practice social workers in 2007 found that it was highly likely SW would be exposed to secondary trauma and experience symptoms of STS, while 15% developed PTSD • STS and compassion fatigue are becoming increasingly viewed as an occupational hazard of providing direct services to traumatized populations (Bride, 2007) • Social workers who experience compassion fatigue and STS are believed be at higher risk to make poor professional judgments in comparison to those not demonstrating STS and compassion fatigue but there is not absolute scale used in the measurement of these two issues (Bride, Radey, & Figley, 2007) • Not generally addressed to a high degree in most BSW programs and many MSW programs but there is a growing body of literature on the ethics of doing so.

Primary Traumatic Response v. Secondary Traumatic Response • A primary traumatic response is when the worker is exposed to the event • Secondary traumatic response is the proximity of the worker to the event, in most cases this is exposure to a traumatic event through contact with the client (Badger, 2001)

Critical Incident Stress • The psychological consequence of a critical event that is perceived by the individual as being outside the normal range of his/her daily experience and the results of which can be psychological, physical, and emotional distress (Beaton, 2003)

Vicarious Trauma or Traumatization • Taken from constructivist self-developmental theory • Changes to therapist cognitive beliefs related to self, other, and the world are cumulative and permanent • VT is associated with disruptions to either one’s: • • • Safety Trust Esteem Intimacy Control (Pearlman & Saakvitne, 1995)

Vicarious Trauma or Traumatization • Factors contributing to VT taken from a research synthesis 1994 -2003 • Personal history of trauma (persuasive) • Amount of exposure to traumatic material of clients (hours with client, % of caseload, cumulative exposure (some) while NOT contributing (reasonable) • Perceived coping ability as a protective factor (reasonable) • Having supervision (some) (Baird & Kracen, 2006)

Secondary Trauma or Secondary Traumatic Stress • Associated with those (either professional, caregivers, family members) who experience symptoms, which are brought on by helping persons suffering from PTSD • The precipitating experience(s) of the individual can be of short duration such as with an EMS team • Has been referenced and is similar to compassion fatigue by some • A disorder that is characterized by: • • Exhaustion Hypervigilance Avoidance Numbing (Figley, 1995)

Secondary Trauma or Secondary Traumatic Stress • Factors contributing to ST taken from a research synthesis 1994 -2003 • Personal history of trauma (reasonable) but also NOT linked (reasonable) • Amount of exposure to traumatic material of clients (hours with client, % of caseload, cumulative exposure (persuasive) while NOT contributing (some) • Perceived coping ability as a protective factor (some) (Baird & Kracen, 2006)

Indirect Trauma • Any indirect exposure to a traumatic event(s) can lead to the development of distressing and potentially enduring responses. Factors increasing risk include empathy and organizational stress. Most often occurs in the healthcare profession, but also with psychotherapists, shelter care staff, journalists, trauma researchers, and first responders, both paid and volunteer. • Indirect trauma can sometimes occur when repeated viewing images of disastrous events

Trauma Countertransference • In response to the client’s trauma, the social worker may start to assume the role of rescuer or identifying with the trauma, causing boundary issues and/or attempts to control the client. The results of trauma-countertransference include doubting or minimizing the client’s denial, professional distancing, or in extreme cases, client abandonment (Herman, 1998)

Compassion Fatigue • A reduced capacity or interest in being empathetic and results from knowing about a traumatizing event experienced or suffered by a person or an ongoing crisis. • A state of biological, psychological, and social exhaustion brought on by extended exposure to compassion stress and potentiated due to poor social support network both in the person’s personal and professional lives. • Compassion fatigue can occur without experiencing secondary traumatic stress such as with mental illness (Newell & Nelson-Newell, 2014). • Found to be related to both secondary trauma and job burnout in a study among SW in NYC after 9/11 (Badger, 2001; Adams, Boscarino, & Figley,

Burnout • “The process of physical and emotional depletion resulting from conditions at work or, more consisely, prolonged job stress. ” (Osborn, 2004) • Contributing factors- • • • Lack of supervision and support Role conflict and role ambiguity Perceived unfairness in promotion (not applicable to students, but certainly to staff Limited worker autonomy Clients’ failure to improve (Ying, 2008)

Risk Factors • Being in human service work – attributed to the emotional expectations involved and the high need for empathy , bureaucratic barriers, and balancing administrative work with other responsibilities (Newell & Nelson-Gardell, 2014) • Personal distress, which is associated with primarily a self-focused and avoidant response aimed at relieving their own distress rather than the client’s • High degree of personal stress (or a self-focused response) has been associated with a higher degree of compassion fatigue and burnout and lower compassion satisfaction (Thomas, 2013).

Positive Factors • Self-confidence and influence or effectiveness • Internal locus of control • High sense of self-esteem (Ying, 2008) • High sense of competence in coping ability • Maintaining an objective motivation v. a more immediate motivation • Resolution of personal traumas • Drawing on positive role models of coping • Buffering personal beliefs for providing positive coping abilities such as spirituality (Bell, 2003)

Positive Factors • Self-detachment – a reflective, balanced, accurate assessment of reality • Mindful self-awareness • Detachment from one’s experiences that protect against over identification with subjective emotions and cognitions • Recognition of one’s own inadequacies, failures, and suffering as part of the universal human condition • Self-kindness or forgiveness for one’s inadequacies (Neff, 2003 a, 2003 b) • High connections and support marked by a sense of positive regard (Saakvitne & Pearlman, 1996)

Implications for Social Work Education and Field • Service-learning and volunteering PRIOR to field experience is consistent with lower risk for compassion fatigue and VT and use of group supervision for support and feedback (Collins, Coffey, & Morris, 2010) • Use of strengths perspective in avoiding becoming “too close” to situations • Encourage students to focus on their own experiences of trauma in relation to the process of healing and motivation for entering the social work field (Bell, 2003) • Discuss the concepts of VT as a tool to assist students with anticipating and recognizing when/where this occurs and how to manage associated emotions, avoid stressing the pathological aftermath aspect of trauma (Courtois, 2002; Bussey, 2008) • Develop skills for self-awareness, self-care, and balance

Implications for Social Work Education and Field • Screening students’ motivations for entering the field and the internship. Gatekeeping issues influencing appropriateness of being in the profession: 1. 2. 3. low self-esteem, anxiety, self- doubt and stress increase the risk for compassion fatigue Significantly higher incidence of sexual abuse in SW students compared to business students Those with histories of trauma or mental health issues need to be screened for concerns with appropriateness (Harr & Moore, 2011; Lafrance, Gray, & Herbert, 2004; Collins, Coffey & Morris, 2008)

Implications for Social Work Education and Field • Addressing transference and countertransference. Often students have difficulty addressing both of these for fear of being viewed as incompetent, have unrealistic expectations, or simply lack selfawareness (Kanter, 2007). • Managing and maintaining appropriate boundaries to prevent and diminish potential problems with STS, VT, and potentially PTSD. • Communication with field instructors and field faculty related to concerns and problems, and observations indicating potential STS

Implications for Social Work Education and Field • Four key resiliency and protective factors (Saakvitne & Pearlman, 1996) 1. Balance • • • Developing mindfulness Developing skills related to non-reactivity Boundaries & Connections 2. Develop measures that help to disrupt memory formation post eventsome form of distraction is best 3. Boundaries • 4. Emphasize that while you, the SW, have empathy and compassion for the person or persons involved in the traumatic event, your focus is to understand but not feel the client’s pain. Self-Care • • Good supervision, both in field and in field seminar Recognition of STS situations and symptoms Self-soothing activities that foster self-protectiveness Sleep, proper diet, exercise – but is it realistic?

Implications for Social Work Education and Field • Group Model approach involving 10, single-session 2 hour groups that followed a format: • Why are you here and what to expect (getting started) • Providing a context – what is VT • Recognizing and responding to VT – how has it impacted you • Ending and Transition – lessons learned (Clemans, 2005)