Adapted from “The Compassion Fatigue Workbook”
We also have a more detailed example of Signs and Symptoms here.
Learning to recognise one’s own warning signs of compassion fatigue (CF) and vicarious/secondary trauma (VT/STS) serves a two-fold purpose:
First, it can serve as an important check-in process for someone who has been feeling unhappy and dissatisfied, but did not have the words to explain what was happening to them. Secondly, developing a warning system allows you to track your levels of emotional and physical depletion. It also offers you tools and strategies that you can implement right away.
Let me give you an example of what a warning system may look like:
Say, for example, that you were to learn to identify your CF/STS symptoms on a scale of 1 to 10 (10 being the worst you have ever felt about your work/compassion/energy, and 1 being the best that you have ever felt).
Then, you learn to identify what an 8 or a 9 looks like for you i.e. “when I’m getting up to an 8, I notice it because I don’t return phone calls, think about calling in sick a lot and can’t watch any violence on TV” or “I know that I’m moving towards a 7 when I turn down my best friend’s invitation to go out for dinner because I’m too drained to talk to someone else, and when I stop exercising.”
Being able to recognize that your level of CF/STS is creeping up to the red zone is the most effective way to implement strategies immediately before things get worse.
But look back to what also emerges in this process: you are starting to identify the solutions to your depletion.
If I know that I am getting close to an 8, I may not take on new clients with a trauma history, I may take a day off a week, or I may return to see my own therapist.
In order for you to develop your warning scale, you need to develop an understanding and an increased awareness of your own symptoms of compassion fatigue and vicarious trauma/STS.
In their book Transforming the Pain, Saakvitne and Pearlman (1996) have suggested that we look at symptoms on three levels: physical, behavioural and psychological/emotional. As you will see, there is often overlap between these categories.
Please take a look at the list below and notice which ones are your most frequent warning signs:
Physical Warning Signs (More detail available in extra information post)
- Increased susceptibility to illness
- Sore back and neck
- Irritable bowel, GI distress
- Rashes, breakouts
- Grinding your teeth at night
- Heart palpitations
Behavioural Signs (More detail available in extra information post)
Increased use of alcohol and drugs
- Anger and Irritability at home and/or at work
- Avoidance of clients/patients
- Watching excessive amounts of TV/Netflix at night
- Consuming high trauma media as entertainment
- Not returning phone calls at work and/or at home
- Avoiding colleagues and staff gatherings
- Avoiding social events
- Impaired ability to make decisions
- Feeling helpless when hearing a difficult client story
- Impostor syndrome – feeling unskilled in your job
- Problems in personal relationships
- Difficulty with sex and intimacy due to trauma exposure at work
- Thinking about quitting your job (not always a bad idea by the way!)
- Compromised care for clients/patients
- Engaging in frequent negative gossip/venting at work
- Impaired appetite or binge eating
Emotional/Psychological Signs (More detail available in extra information post)
- Emotional exhaustion
- Increased anxiety
- Impaired appetite or binge eating
- Feelings of hopelessness
- Suicidal thoughts*
- Reduced ability to feel sympathy and empathy towards clients or family/friends
•Cynicism at work
- Anger at work
•Resentment of demands being put on you at work and/or at home
•Dread of working with certain clients/patients/certain case files
•Diminished sense of enjoyment/career(i.e., low compassion satisfaction)
- Depersonalization – spacing out during work or the drive home
- Disruption of world view/heightened anxiety or irrational fears
•Intrusive imagery (You can read an excellent description of this in Eric Gentry’s Crucible of Transformation article).
- Hypersensitivity to emotionally charged stimuli
•Insensitivity to emotional material/numbing
•Difficulty separating personal and professional lives
•Failure to nurture and develop non-work related aspects of life
Once you have read through and circled your most frequent warning signs, try and identify your top three most frequent warning signs. I call them the “big three”. Are they all physical, emotional or behavioural or do you see a mixture of signs from each category? Would you say that you are currently in the Green (healthy), Yellow (warning sign) or Red zone with your overall functioning?
Now, ask a loved one or close colleague to share with you what they think your “Big Three” warning signs are, at home and at work.
Each warning sign has specific tools that can help reduce your levels of stress. For example, if you are experiencing a lot of secondary exposure-related symptoms, you may wish to examine your caseload, the availability of debriefing and grounding strategies and you may need to assess the level of extraneous trauma images and stories that you are exposing yourself to in your personal life. If you have a lot of emotional symptoms, you may want to consider a consultation with a well-trained mental health professional who is familiar with vicarious trauma and the nature of the work that you do.
In our post on Tools and Resources (link here) we will provide some more suggestions.
*Suicidal or hopeless thoughts? Get Help Now Please remember that no matter how stressful/traumatic our work is, it is not a normal consequence of VT/STS to experience suicidal thoughts or prolonged bouts of depression or hopelessness. Please seek help as soon as you notice these symptoms in yourself. If you are worried about confidentiality, or unsure where to turn, please consult online sources of support. There are urgent suicide support hotlines available 24/7 which you can find with a click of the web. Don’t suffer alone. Get help. You deserve it and so do the people who love you.
Figley, C.R. (Ed). (1995) Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.
Figley, C.R. (Ed.). (2002) Treating Compassion Fatigue, New York: Brunner/Routledge.
Gentry, E. J., (2002) Compassion Fatigue: A Crucible of Transformation in Journal of Trauma Practice, Vol 1. No. 3/4. pp.37-61.
Killian, K. (2008). Helping till it hurts? A multimethod study of compassion fatigue, burnout, and self care in clinicians working with trauma survivors in Traumatology, (14, 2) 32-44.
Mathieu, F (2012) The Compassion Fatigue Workbook – New Revised and Expanded Edition
Van Dernoot Lipsky, L. (2009) Trauma Stewardship: A guide to caring for self while caring for others. BK Publishers.
Saakvitne, K.W.; Pearlman, L. A., & the Staff of the Traumatic Stress Institute (1996): Transforming the pain: A workbook on vicarious traumatization. New York: W.W. Norton.
© Françoise Mathieu 2017
In a previous post (links here) we discussed some of the warning signs of VT/STS and Compassion Fatigue. We are often asked “what can I do personally and professionally to reduce the negative stress-related effects of my work?” We have many resources to recommend.
First, please have a look at the extensive list of TEND resources further down in the post, or also the wealth of articles we have posted in our resources section from other authors who are specialists in the field. If you are struggling with significant frustration with your workplace and feel that you do not have much control over the system or your job, and don’t feel that you can move to a better employment situation, please start by reading this article: Beyond Kale and Pedicures
Where to start?
For starters, hopefully you will have read through our other posts to assist you in identifying the main challenges that you are facing: Is it related to too much exposure to difficult stories or a lack of referral resources? Is it work overload or an unsupportive supervisor/toxic team? Are you struggling with difficult personal circumstances that are affecting your ability to manage your stress? Do you feel overwhelmed with your complex case load and feel that you lack training in managing the most difficult and challenging situations? The answers will likely be as varied as there are professions and individuals reading these lines. So where can we start?
I will be honest, we often disappoint people who come to us for sound bites and “quick fixes” to these complex issues because, well, the solutions are complicated, just like the work that we do is multi-faceted and challenging. But here are some places to start:
Recent research in the field of STS and Compassion fatigue suggests that there are particular vulnerability factors that can increase your likelihood of being negatively impacted by the work. Take a look at this Venn Diagram
Which of these factors are true for you?
Prior Trauma history/vulnerability factors
Do you have your own history of trauma? Are you currently struggling with a difficult family/personal circumstance? Do you have a history of mental illness or addiction that is currently re-emerging? All of these factors can contribute to increased vulnerability when doing high-stress, trauma-exposed work
Traumatic grief/loss in the workplace
Have you experienced losses at work? The death(s) of clients or patients, someone that you worked with who disappeared and never returned, providing you with no closure? A beloved colleague who died unexpectedly or retired or was laid off? The loss of a well-respected supportive supervisor or mentor? Significant changes to your workplace?
Are you exposed to dangerous situations in your work? Have you ever been threatened, assaulted physically or verbally on the job? Is your work high-risk?
Are you regularly exposed to indirect trauma at work? Hearing/viewing difficult case files, traumatic images and stories?
Have you experienced a shift in your ability to feel empathy for individuals you work with and/or colleagues or loved ones? Some situations can be very depleting – chronically desperate clients who don’t follow through on your recommendations and keep coming back in distress, a very large homogenous case load where all of the stories start sounding the same, years of exposure to traumatic stories that no longer generate any reaction in you.
Many professionals describe experiencing moral distress around failures of the system: rules, laws and policies that you disagree with but are still mandated to comply with and that you feel are causing further harm, lack of referral resources and other injustices. All of these can lead to a pervasive feeling of anger and contribute to burnout and workplace toxicity and a decrease in the quality of care provided.
Burnout can result from a negative overall workplace experience: your hours, your salary, your workload, the health of your work climate, rewards and recognition, who you immediately report to, the quality of your work relationships with colleagues and a perception of fairness and adequate support to do your job in the best way possible. A negative combination of these factors can lead to burnout.
First, take a look at which elements of the Venn Diagram are most salient for you and begin by addressing those that feel most manageable. As the saying goes “Dig where the ground is soft”. Seek support, formally with a good mental health practitioner or a coach, informally with colleagues and friends, look at ways to reduce trauma exposure in your personal/leisure time. Learn some stress-reduction techniques; get more training in trauma-informed practices which can be highly protective in retaining compassion when working with difficult cases and finally, please be open to the possibility of changing jobs if things are just too challenging where you are now. As Cheryl Richardson says in her book “Take time for your life” (1999) “Do not confuse difficult choices with no choice.” There is too much at stake to ignore compassion fatigue and secondary trauma.
WANT MORE? Here are some TEND resources to explore:
Live Training – bring one of our TEND associates to your organization for specialized training in resilience, compassion fatigue, etc.
Books – we carry 3 wonderful books (and e-books of each) written by our wonderful co-executives Françoise Mathieu and Dr.Patricia Fisher
Building Resilient Teams – a workbook designed as a practical, realistic and effective approach to building team resiliency and cohesion through a sequence of safe and respectful guided discussions.
Resilience Balance and Meaning Workbook – designed to provide you with practical help in addressing the effects of workplace stress, burnout and trauma. You will see that it is designed as a highly interactive tool and you are encouraged to make the book your own by responding to the frequent questions, reflections and self-assessments.
The Compassion Fatigue Workbook – a lifeline for any helping professional facing the physical and emotional exhaustion that can shadow work in the helping professions
Online Courses – TEND also offers online courses at a very affordable price, we do bulk discounts as well for larger groups. These courses are led by Dr.Patricia Fisher and Françoise Mathieu
Organizational Health in Trauma-Exposed Environments: Essentials – an intensive online course designed for managers and supervisors of teams working in high stress, trauma-exposed environments such as healthcare, the criminal justice sector, social and human services, emergency response, armed forces, education, child welfare, community mental health, non-profit organizations and related services
Compassion Fatigue 101 Online Course -Three-part webinar series that aims to help participants identify compassion fatigue, vicarious trauma and burnout, and participants will develop self-care strategies.
Resilience in Trauma-Exposed Work – This workshop will provide a solid framework to understand the mechanisms of stress and resilience within trauma-exposed environments, and will introduce practical, best-practices approaches to increasing resilience and enhancing individual wellness and organizational health.
Other Suggested Resources:
Compassion Fatigue/Vicarious Trauma/STS:
The Compassion Fatigue Workbook by Françoise Mathieu
Trauma Stewardship by Laura Van Dernoot Lipsky
Building Resilient Teams by Dr. Patricia Fisher, R.Psych., L.Psych.
Is work Killing You? A Doctor’s Prescription for Treating Workplace Stress by David Posen
Resilience, Balance & Meaning Workbook by Dr. Patricia Fisher, R.Psych., L.Psych.
Graham, L. (2013) Bouncing back: rewiring your brain for maximum happiness. New World Library.
Tools for Managing Trauma:
Nakazawa, D.J. (2015) Childhood Disrupted: How your Biography Becomes your Biology. Atria.
Van Der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind and Body in the Healingof Trauma. Penguin Books.
Scaer, R. (2014) The Body Bears the Burden: Trauma, Dissociation and Disease. Routledge.
Maté, G. (2003) When the Body Says No: Exploring the Stress/Disease Connection. Wiley & Sons.
Richardson, C. (1999) Take Time for Your Life: a 7 Step Program for Creating the Lifeyou Want. Broadway books.
Mindfulness & Self–compassion websites
Maclean’s Magazine recently published an article stating that approximately 29% of young doctors experience symptoms of depression or receive a clinical diagnosis. Why? Part of the problem lies in the immense competition young doctors face to obtain jobs. The culture of residency, where young physicians are often required to work excessive hours to stay competitive, is cited as a major source of mental health deterioration. Perhaps most obvious are the stresses associated with making difficult, life-and-death decisions with little to no experience.
Compounded, these issues are causing a mental health crisis among young health-care providers across Canada, and particularly medical students. Lack of sleep, stress and poor self-care contribute to diminishing mental health. Zane Schwartz writes that there is hope: “Young doctors across Canada are trying to change [the] statistics, encouraging struggling peers to seek support and building programs that make it easier for them to take care of themselves…the new curriculum for the University of Toronto, rolling out this fall, which will include several weeks of resiliency training.” Resiliency training is at the forefront of efforts seeking to help future medical professionals cope with the stresses of their work. At UoT, Shayna Kulman-Lipsey, Manager of Counselling has launched a number of initiatives aimed at breaking the stigma attached to seeking help. She argues that the ability to gain resiliency is dependent, in part, on reaching out to peers for support, which can be difficult in an environment that stigmatizes asking for help as a sign of weakness. If medical students develop the skills to maintain resiliency earlier in their careers, they will be better equipped to take on high-stress workplaces and maintain high levels of patient care later.
In the United States, a similar need has been identified by the American Academy of Pediatrics (AAP). This month, the AAP released a special article in Pediatrics, the Official Journal of the AAP titled “The AAP Resilience in the Face of Grief and Loss Curriculum” authored by a group of physicians from across the United States. According to the publication, The AAP Section on Medical Students, Residents and Fellowship Trainees identified a need to address the management of grief and loss that health care professionals experience throughout their careers. The development of this new curriculum was endorsed and sponsored by the AAP Section on Hospice and Palliative Medicine.
A large portion of the new AAP curriculum focuses on the physician-patient and physician-family relationship, with modules designed to help pediatric health-care professionals learn to communicate effectively with children and their parents. The last section of the curriculum, Part D: Introduction to Personal Well-Being, has been developed specifically to address physician well-being. Like the folks at UoT, the authors here argue that teaching medical students personal strategies to cope with stressful events in the workplace will promote long-term well-being and resiliency as their careers progress. The new curriculum recommends a Wellness Learning Plan, that “might be incorporated at the beginning of medical school and reviewed with the student’s advisor or mentor quarterly.” While the AAP publication is specific to the experiences of grief and loss, the message is more broad: resiliency is critical in maintaining personal well-being in high-stress, trauma-exposed workplaces. Educating students early in their careers with these types of curricula may offer longer-term prevention of burnout, fatigue and secondary traumatic stress.
To read more about programs for medical students at the University of Toronto, please visit: http://www.md.utoronto.ca/Annual_Report/learner-experience/resilience
To learn more about the new “AAP Resilience in the Face of Grief and Loss Curriculum”, please visit: http://pediatrics.aappublications.org/content/pediatrics/early/2016/10/06/peds.2016-0791.full.pdf
Become more centered among the chaos
In the course of their work, many helping professionals are regularly exposed to difficult and sometimes traumatic material: anyone working in the criminal justice system, victim services, front line workers, those who work with forensic evidence and child exploitation, first responders, mental health crisis teams, homeless shelter staff and many others.
When there is a lot of exposure the risk for secondary trauma and compassion fatigue are high. How do we remain healthy and balanced while doing this challenging work? We need tools in our toolbox, skills that we can use before, during and after the difficult event has taken place. New research on grounding techniques and trauma reduction skills are showing promising results in helping to reduce secondary traumatic stress in trauma-exposed professionals.
This fall, we are delighted to begin bringing to you a brand new workshop designed by our very own Diana Tikasz, MSW, RSW. Diana has worked for many years in high stress, high trauma-exposed work settings and brings to this training her vast experience as a front line worker and supervisor, as well as the newest findings on the neuroscience of trauma exposure management.
WTF isn’t a swear word! It refers to the Window of Tolerance Framework. The WTF is our optimal zone – the place where we do our best work, when we are feeling calm yet energized, healthy and creative. Stressors and triggers can bring us out of that zone into high stress and reactivity, or into numbness and avoidance.
The techniques offered in this workshop will encompass the whole self as we can often retreat and get stuck in our heads. An emphasis will be on learning and incorporating strategies that change the way we work as opposed to using all our personal time to replenish what our work takes out of us.
This session will provide skills to help move yourself out of states of reactivity or avoidance and into the place of possibility to become more centered among the chaos. This is a crucial skill for front-line workers and others working with forensic evidence, investigations, court, witnesses and victims, and those working with individuals who have experienced difficult and traumatic experiences.
Those who would benefit are any folks in a helping profession that feel they are often overly stressed or hijacked by emotion, or those who are no longer enjoying their work and wondering whether they need to make a career change. Helpers who wish to learn specific skills that they can utilize to protect themselves in difficult situations whether it is working with those challenging clients, sitting in a difficult team meeting or interacting with a colleague who pushes your buttons. It is also for those who find that at times their personal lives are creating the WTF moments, which makes it extremely difficult to be present at work.
Diana: “I often say that helping work is even more difficult when the professional is going through their own personal stresses. We will focus on providing a framework and resources to help us navigate the storm. This workshop is especially for those who are feeling completely detached from what they are doing, feeling as though they are just “going through the motions” or counting down the days to retirement.”
Presented by Brian Miller, Ph.D.
Facing compassion fatigue, burnout and vicarious trauma is challenging. As we raise awareness about self-care techniques, we must also expand our search for strategies that help treat anxiety and trauma into the broader neuroscientific and treatment literature. Here, we find important evidence-informed strategies for influencing the way professionals experience their time with clients, how they think about it, and how to “keep the energy moving” to help professionals be more resilient.
Join Dr. Brian Miller as he presents the CE-CERT model (Components for Enhancing Clinician Experience and Reducing Trauma) model, which is comprised of specific, defined skills to help therapists thrive. Compassion satisfaction occurs when we find our job rewarding even as we are doing it, not when we have sufficiently shielded ourselves from our job. In order to make that goal attainable, we must consciously oversee our affective experience as we work with clients.
Dr Miller will be identify five key clinical practice and supervision skills, and the foundational knowledge of the relevant neuropsychological, social cognitive, anxiety and trauma treatment literature from which they are drawn. These skills include; engaging and “metabolizing” intense affect; skills for decreasing rumination; conscious oversight of narrative; reducing emotional labor, and; parasympathetic recovery. Participants will gain key strategies to positively change their working experience.
Brian Miller is the Director of Children’s Behavioral Health at Primary Children’s Wasatch Campus In Salt Lake City, Utah. Until recently, he directed the Trauma Program for Families with Young Children at The Children’s Center in Salt Lake City, a community mental health center serving preschool age children and their families. Dr. Miller has worked in a broad variety of treatment and mental health policy settings, including serving as the Salt Lake County Mental Health Director, Clinical Director of Davis Behavioral Health, Associate Director of the Utah State Division of Mental Health, and as a psychotherapist in private practice. He consults with behavioral health agencies on implementation of evidence-based practices, transforming practice to trauma informed care, and organizational supports for secondary traumatic stress in treatment providers. He holds a Ph.D. from Case Western Reserve in Cleveland, Ohio, where he was a Mandel Leadership Fellow. He currently serves as board president for the National Alliance on Mental Illness, Utah Chapter, and on the board of the Polizzi Clinic, a free clinic for behavioral health services in Salt Lake City.
Working in trauma exposed environments can easily leave us feeling unbalanced. In this workshop, Diana Tikasz will present a useful model to understand what happens to us internally as helpers throughout the course of our stressful days. The model helps us to continuously self-monitor and recognize when we are off centre. The model alerts us to the need to re-set ourselves for optimal balance and wellness. Diana will teach strategies that will help you stay grounded and re-establish equilibrium when the stress related to trauma content has knocked you off balance. She will discuss how to utilize these strategies before, during, and after exposure will be addressed.
Diana Tikasz has been committed to trauma-focused work in the health care sector for the past 20 years. She has coordinated hospital based sexual assault/domestic violence treatment programs, which involved counselling those who have been traumatized by violence, teaching other professionals how to do this work effectively while staying healthy themselves. Diana has also worked in the area of Employee Assistance Program counselling where she has specialized in working with individuals who are feeling stressed by their personal and/or work life. Her passion is to assist people in creating personal changes that promote health. Participation on numerous community and provincial committees, research projects and educational endeavors rounds out her professional interests.
By Meaghan Welfare, BA
Do you experience conflict at work? Are you a leader? Did you know that leaders spend up to 25% of their time dealing with conflict that could be addressed and solved at the source? Unmanaged conflict is costly. It affects the mental health of your people, which results in absenteeism, employee retention issues and a negative institutional reputation. To attract and retain great employees, organizations must focus on their wellness, beginning with positive and productive relationship management. Meaghan Welfare is an expert in managing conflict within organizations while creating “conflict competence”. Her workshop will equip participants with organizational competencies designed to foster strong working relationships as well as detect and address inevitable workplace conflict.
Meaghan Welfare is a conflict management practitioner with the Department of National Defence at CFB Kingston. She is also a Certified Compassion Fatigue Educator with the Green Cross Academy of Traumatology. She holds a degree in criminology and criminal justice with a minor in law, a graduate certificate in dispute resolution from York University and a certificate in family mediation from University of Waterloo.
Working with clients in trauma can impact lawyers who represent children in the child welfare system, both personally and professionally. Prolonged or repeated exposure to the abuse and neglect suffered by child victims can result in an acute form of burnout called compassion fatigue. However, child lawyers, unlike other helping professionals, rarely have language for this loss of capacity nor support systems in place to combat it. Large caseloads, inadequate resources and systems that sometimes re-victimize instead of rehabilitate, leave practitioners feeling ineffective, incompetent and lacking compassion. These conditions compromise the child lawyer’s ethical duty to provide competent representation. Speakers focus on preventative and responsive strategies for solo practitioners, agency lawyers and leaders who manage child lawyers, as well as the ethical implications of compassion fatigue on child representation.
Listen to the Audio Link – http://apps.americanbar.org/litigation/committees/childrights/materials.html#winter2016-01
Read the Article – Here
Trenny Stovall, Esq., DeKalb County Child Advocacy Center, Decatur, GA (moderator)
Alexandra Dolan, MSS, LSW, Support Center for Child Advocates, Philadelphia, PA
Josh Spitalnick, PhD, ABPP, Adjunct Asst. Professor in Psychiatry and Behavioral Sciences, Emory University SOM, Atlanta, GA
Françoise Mathieu, M.Ed., CCC., Co-Executive Director, TEND, Kingston, Ontario, Canada
Danielle Lynch, Esq., Supervising Attorney. DeKalb Child Advocacy Center, Decatur, GA
This week on White Coat, Black Art with Dr. Brian Goldstein, Teresa Coulter shares her unique project “Sock Drawer Stories”, inspired by the traumatic stress effects on first responders. Teresa has over 14 years of experience on the front-lines and “learned to cram away” her traumatic experiences, like many of her colleagues. When she reached her breaking point, Teresa turned to her artistic nature to express her feelings and process her traumatic experiences. She has since helped other first reponders to tell their stories through her painting.
“Over the years, Teresa has had many calls to respond and function in a brutal and horrific setting. Like many of her colleagues, she learned to cram these experiences away. Her friend, Calgary paramedic Rob Gladney told her he did the same thing — he called it stuffing the bad socks into the back of the sock drawer. Both of them experienced an incident caused the entire sock drawer to spill out, forcing them to confront long-buried feelings.
For Teresa, it triggered a period of introspection and also kindled in her a desire to paint her feelings. It was then that she got the idea to recruit and paint the portraits of fellow first responders with PTSD. And Rob’s image of that over-stuffed sock drawer gave the project it’s name. The 12 portraits she painted – men and women from the front lines of health care – form the backbone of an art exhibit entitled Sock Drawer Stories. It garnered rave reviews when it was shown at the University of Calgary in June and has since been shown in Edmonton.” – Dr. Goldstein
Click here to check out this amazing project, listen to the podcast and read Teresa’s story.