Debating the Texas shooting: Where to go to read something that makes any sense on this topic

I received several emails this week from people who read this blog. It was very nice as it puts faces to my readers and I’m never sure who is “out there” actually reading these posts. So, Hello dear friends and colleagues (Hi Deb – it was lovely to have tea yesterday, we should do that more often. Go write that book, it’s going to be a fantastic resource!).

I am posting my blog post early this week as I am taking Monday off – it’s been a hectic past few weeks with a lot of travelling and presenting, and it’s time for a bit of self care for this workshop presenter.

This was an interesting week: I presented a one hour talk on PTSD to a second year Abnormal Psychology class at Queen’s University (weird timing given the Texas shooting, I’ll return to that in a minute) and offered an evening and a one day session for the Alzheimer’s Society here in Kingston. The evening session was for family caregivers and the day for helping professionals. I learned a lot during both events. I can tell you one thing: when I am elderly and in need of long term care, I hope to receive care from people such as the ones on the panel. These folks, most of whom have been looking after elderly patients with dementia for 20-30 years, radiated with compassion for their clients. When they described why they love their work, their faces started lighting up. I can’t quite capture it now, as it is 6am and I’m about to take my son to play hockey, but it was something very moving. Everyone on the panel also spoke of their self care strategies and it was clear that they have remained compassionate and resilient because, in part, they had learned to care for themselves both physically and emotionally. All of them exercise on a regular basis, try to eat well and have a strong support network.

It was also wonderful to present to family caregivers. These folks have been caring for a loved one with for years, often on their own, often in their homes until they can no longer do it. I hope I was able to offer a little bit of support to them, in my limited ways. It was certainly an honour to meet you all.

I will not wade into the massive speculation that took place in the media this week surrounding the psychiatrist who went postal and killed a dozen military personnel in Texas. If you have google alert you will have been deluged with posts discussing and speculating on whether this man suffered from vicarious trauma and whether that is what led him to kill. The problem with the internet, of course, is that there is a lot of rubbish being written by pretty much anyone who can type, and there is some good stuff in among all that. I found a good discussion on the topic, written by Drs Figley and Pearlman and other solid sources, so I invite you go read this to if you want a sensible analysis of the few facts that are known at this time.

As for me, I’m off to Hamilton this week to present to helpers who work in developmental pediatrics. I also want to rake leaves, make soup and go for a run in the crisp November air. I hope you also have a good week and can fit in some time to exercise, stretch and breathe.


Staying afloat in the eye of the flu storm: An online course for Health Care Workers

Last week, both my children came down with the flu (likely the most popular strain currently deluging the media). So my husband and I juggled: we shared the home care for the week (I was co-teaching a three day Crisis intervention course) and washed our hands like mad and tried to resist giving hugs and kisses to them (now, that was hard). They are back in school and seem to be on the mend and we are trying to catch up on missed deadlines and the lot.

It was nothing very serious, but it reminded me of the incredible stress of having younger children and getting the dreaded call from the daycare, which normally meant that not only Poopsie was sick today, but he/she was going to be banned from daycare for the following day, until they were deemed to have been fever-free for a full 24 hours. As soon as I would see the daycare number on call display, my mind would start racing, thinking about coverage for the following day, what was I going to do with the suicidal client I had just safety contracted with (the deal being that they would come back to see me on the next day), who would see the couple who had travelled 2 hours to come for a session who were already on their way to the office, and where would I fit in all the people who had been moved to the following day. Of course, it always worked out, somehow, but the stress involved was significant. And I’m talking about minor ailments here, not the catastrophic illnesses that so many people cope with.

Working as a front line worker has many rewards but the challenging reality is that you have to be “on” when you’re at work. You were up all night with a sick family member? Too bad, you have to be 100% focused right now. There are no half measures really. Of course, there are many ways to help each other out – family and friends can step in, if they live nearby, but the stress of the unkwown never really goes away when you are a front line health care worker.

Of course, with the flu outbreak this week, hospital and public health workers are facing a mounting workload and having to deal with many stressors all at once – the hours-long lineups for vaccination speak for themselves, as do the crowded flu clinics.

This morning, I heard a very topical radio interview on CBC’s The Current on the impact of the pandemic on health care workers. On the show was Dr Robert Maunder, a psychiatrist at Mount Sinai Hospital in Toronto who is part of a team who have developed The Pandemic Influenza Stress Vaccine, an online course for health care workers to help us develop resiliency skills while facing the pandemic. He said that several studies found that health care workers who were in the thick of things during the SARS epidemic were found to have lasting psychological effects from working in the SARS environment (more fearful of contamination for long periods of time following the end of the SARS outbreak).

Let me quote from their press release: “A computerized course for health-care workers worldwide to build their resilience during a pandemic. Based on the SARS outbreak in 2003, Mount Sinai experts understand that the spike in health-care workers’ stress-related absenteeism results from fear of contagion, concern for family health, job stress, interpersonal, isolation, and perceived stigma. That’s why Mount Sinai researchers Dr. Robert Maunder and Dr. William Lancee led a pilot study of computerized training for 150 Mount Sinai health-care workers in 2009. The results suggest that the training improves health-care workers’ belief that they can handle the changes a pandemic brings, confidence in support and training, and interpersonal problems. This also suggests that the training may be able reduce stress-related absenteeism. From these findings, the researchers are launching The Pandemic Influenza Stress Vaccine course, which will be an education tool and also the basis of pandemic resilience research.

The course is available over the Internet making it widely accessible at no cost for the health-care workers. The goal is to reach 3,000 health-care workers worldwide.

The course is now live. It is part of a randomized control trial. Hospital-based health-care workers can register at The pilot study was funded by Canadian Institutes for Health Research.”

I have not yet had time to go take a look at the course, but Dr Maunder suggests that if you are a health care worker facing the onslaught right now, it may be very worth your while to take a few minutes out of your day to take the course now, rather than wait until you are not in the eye of the storm.

Book Review: The Resilient Clinician

by Robert J. Wicks, Oxford University Press

This short, reflective book was written specifically for clinicians: psychologists, mental health counsellors and social workers. It will be most useful to those with a background in clinical psychology who do face to face work with clients on a regular basis.

Dr Robert Wicks is a psychologist and a professor at Loyola College in Maryland. “A recognized expert in the prevention of secondary stress, in 1994 he was responsible for the psychological debriefing of relief workers evacuated from Rwanda during that country’s bloody civil war.” (from his book bio)

I was thrilled to see that Dr Wicks centers his approach on the use of positive psychology and mindfulness.

Robert Wicks explains his goal in writing the book as: “to introduce and highlight those areas that can help renew clinicians in today’s challenging climate. It is amazing how little it can take to change the emotional tide in favor of such a beneficial move. Small alterations can sometimes jumpstart a positive step to a healthier attitude more than disputing dysfunctional thoughts ever can.”

Chapters headings are:

Sensing the dangers: Chronic and acute secondary stress
Enhancing resiliency: strengthening one’s own self-care protocol
Replenishing the self: Solitude, silence and mindfulness
Daily debriefing; Mindfulness and positive psychology

My conclusion: A lovely erudite book on self care for clinicians who are ready to reflect on their own journey of compassion fatigue and self care.

Why are the four basic self care strategies so hard to implement in our lives?

I recently asked an audience of about 100 people how many of them practiced or had ever tried relaxation training and/or meditation. Approximately 10 people raised their hands.

This is not an anomaly, it’s the usual response I get. It’s similar to the response I get when I ask groups how many of them would say that they:

1) Get enough sleep on a regular basis
2) Eat 3 healthy meals per day, with lots of fruit and vegetables, reducing caffeine, saturated fats and salt.
3) Exercise 3-4 times a week
4) Take breaks during the day to refuel and just chill out

Last time I asked this question, one person out of 150 said yes.


For those of you who are regular readers of this blog, you know that I feel very strongly about the importance of eating healthily for many reasons (cancer prevention, keeping diabetes at bay, increasing our immunity, weight control, the list goes on) but I am also very aware of the many obstacles we face: time crunch, financial constraints, food dislikes to name a few.

The exercise piece is tricky. A lot of people say to me “I’m not in good enough shape to go to the gym, I feel very self-conscious” and I totally respect that. A friend of mine (who went on to lose a significant amount of weight and run a marathon) could not walk around the block with me without having to stop to catch her breath. But she persevered, walked a bit faster each week, then started alternating running with walking (10 minutes of running, one minute of walking), an approach to running that is highly recommended by coaches at running clinics. It took a long time and a lot of hard work, but she started out small and eventually the results were life-changing.

Isn’t that always the best way? To take small, realistic steps?

I invite you to reflect on the four categories above and see whether there is an area that you can celebrate. Is there something you are feeling particularly pleased with, in terms of self care? These can be very small steps (increasing my vegetable intake by one serving, taking 5 minutes off each day for the past week, etc.).

What would you commit to working on that is realistic and achievable for the week to come?


This was supposed to be a post about positive psychology and learned optimism. I normally mull over my posts all week and write them on Fridays but on Thursday night, I went to a lecture on burnout aimed at new medical students and I was uncomfortable with some of what I heard so I was forced to use my writing time for that instead. (forced by no one but myself, but you know how sometimes you feel strongly about things and so you can’t focus on anything else? That kind of forced. Compelled, I guess, is more accurate.)

Although I enjoy public speaking, writing and blogging on my own terms, I am not very comfortable in the limelight of op-ed. Some people are incredibly good at it. You know: the witty yet caustic artfully crafted letters to the editor, the inflamed yet articulate caller on the radio phone-in show. Neither of those are within my comfort zone (or talent zone). In fact, my last brush with op-ed fame was about 6 years ago. It was a slow news week in the middle of July and a local print journalist became interested in my opinions related to playground safety (a long, boring story). The day after my piece was published, my friend tried to buy all the newspapers in our neighbourhood so I wouldn’t read the incendiary letters to the editor mocking me and the position I had taken on this issue…Not a big deal, but not very comfortable either.

When it comes to public debate, I am more of a muller – when I experience something that troubles or upsets me, it often happens to me in slow motion, and I almost always need time to reflect and chew my ideas over before making a point or jumping into an argument. That does not make me a very strong debater, sadly, (although I am learning over time at the feet of a master of debate, my partner, who win arguments even on topics he knows nothing about! It’s sometimes enraging but also kind of sexy).

But here goes nothing. My op-ed piece.

Dr Patch Adams: A muddled message about burnout

On Thursday night I attended (along with hundreds of young medical students) Dr Patch Adams’ presentation “The Joy of Caring” which was held at the Biosciences complex on Queen’s Campus, organised by the Aesculapian Medical Undergraduate Society. We were invited to hear “an inspirational talk including the exploration of burnout prevention for caregivers, and the power of care, not only in the patient’s life, but also in the caregiver’s life.”

As a compassion fatigue specialist and someone who devotes nearly all of my time to providing education on burnout to health care professionals, I was very interested to hear Dr Adams’ thoughts on this topic.

I was moved and rather awed by Dr Adams’ total devotion to his life’s goal (which is to offer free medical care to all), and the love and acceptance that he conveys towards his patients across the globe, particularly the most neglected members of society.

However, as I heard Dr Adams speak, I grew increasingly uneasy about one aspect of his message.

Throughout his talk, Dr Adams described his routine of working from 7am to 3am daily and having rarely, if ever, taken a day off work in his many years as a physician and therapeutic clown. He also spoke of a twelve year period where he and other physicians lived with their children and spouses in a six bedroom house which they ran as a free hospital, co-habiting with “5 and sometimes 50 patients at one time, sharing bathrooms, living rooms and bedrooms. Having no privacy whatsoever.” Although he was not advocating that we all do the same, I wondered how his lifestyle was coming across to medical students around me – I wondered whether this was seen by some of them as something to aspire to, a gold standard of self-sacrifice – the sign of a truly dedicated doctor.

Then, I was startled by Dr Adams’ main message which was that, in his opinion, “There is no such thing as physician burnout when you offer [the kind of medical care he offers]. Burnout is not possible when you care.” I do agree with Dr Adams that it is often the system that burns us out rather than the patients themselves: the increasing volume of work, insufficient staffing, inadequate referral resources, etc.

But to state that “burnout does not occur when you care” is simply not true.

Based on very strong research (from 1995 onwards, see Figley, Stamm, Saakvitne and many others) the medical and other health care professions are recognising that there are serious problems with burnout that are intrinsic to helping others. It is in fact well established that there are serious consequences to overwork both to patients and physicians. We now know that working with patients can lead to the serious effects of compassion fatigue, vicarious trauma and burnout. Burnout is a term that has been widely used to describe the physical and emotional exhaustion that workers can experience when they have low job satisfaction and feel powerless and overwhelmed at work. Compassion Fatigue refers to the profound emotional and physical erosion that takes place when helpers are unable to refuel and regenerate due to the pace, volume or nature of the patient work they do. Vicarious Trauma has been used to describe the profound shift that workers experience in their world view when they work with patients who have experienced trauma. Helpers notice that their fundamental beliefs about the world are altered and possibly damaged by being repeatedly exposed to traumatic material. Vicarious Trauma occurs when the stories we hear from our patients transfer onto us in a way where we are secondarily traumatized and have difficulty ridding ourselves of the images and experiences they have shared with us. These problems can degenerate into clinical depression, post traumatic stress disorder, anxiety disorders and lead to alcoholism, suicidality and serious clinical errors, to name a few.

The good news is that there are simple and effective strategies that can protect us and help to mitigate these effects. We can provide care without suffering, and the answer is certainly not to deny or blame ourselves for experiencing burnout.

My concern is that Dr Adams’ take home message to medical students Thursday night was that if you do not devote every waking hour of your life to patient care, you are a failure and possibly also a shallow, selfish, materialistic human being. Dr Adams may be thriving with his own pace of life and is clearly accomplishing wonderful things in the world. But I believe that for the rest of us mere mortals the best way to provide care to others is to first and foremost start within ourselves: Dr Charles Figley, the highly respected founding father of compassion fatigue says it best: “First, do no harm to yourself in the line of duty when helping/treating others. Second, attend to your physical, social, emotional, and spiritual needs as a way of ensuring high quality services to those who look to you for support as a human being. ” (Green Cross Academy of Traumatology, Standards of Self Care Guidelines.)

This isn’t a zero sum game: you do not take away from others by caring for yourself – it is, in fact, quite the opposite. We are far more effective caregivers if we have our own emotional house in order.

Mindfulness-Based Stress Reduction: an Important Tool in Mitigating Compassion Fatigue in Helpers

Mindfulness-Based Stress Reduction (MBSR) is a holistic mind/body approach developed by Jon Kabat-Zinn at the University of Massachussets Medical Center in 1979. MBSR is “[…] based on the central concept of mindfulness, defined as being fully present to one’s experience without judgment or resistance”. (Cohen-Katz et al, 2005) The MBSR program recommends using meditation, yoga, relaxation training as well as strategies to incorporate these practices into every day life.

Research on the effectiveness of MBSR is highly conclusive: over 25 year of studies clearly demonstrate that MBSR is helpful in reducing emotional distress and managing severe physical pain. In fact, MBSR has been used successfully with patients suffering from chronic pain, depression, sleep disorders, cancer-related pain and high blood pressure. (Cohen-Katz et al, 2005) Based at Toronto’s CAMH, Zindel Segal has developed a mindfulness-based cognitive therapy program for treating depression that has shown to be highly effective.

MBSR and Compassion Fatigue

Researchers recently turned their attention to the interaction between MBSR and compassion fatigue (CF), to see whether MBSR would help reduce CF symptoms among helpers. One study of clinical nurses found that MBSR helped significantly reduce symptoms of CF, as well as helping the subjects be calmer and more grounded during their rounds and interactions with patients and colleagues. (Cohen-Katz et al, 2005) Another study investigated the effects of teaching mindfulness-based stress reduction to graduate students in counseling psychology. The study found that participants in the MBSR program “reported significant declines in stress, negative affect, rumination, state and trait anxiety, and significant increases in positive affect and self-compassion.” (Shapiro, 2007)

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Interesting speech on Compassion Fatigue

I came across this speech on the blogosphere. It was written by the Jeremy Adam Smith, senior editor of the Magazine Great Good, an online publication whose mission is described as follows on their site: “Greater Good highlights ground breaking scientific research into the roots of compassion and altruism. It fuses this science with inspiring stories of compassion in action, providing a bridge between social scientists and parents, educators, community leaders, and policy makers.”

This speech was given as a talk to nurses of UC Berkeley Health Services on surviving compassion fatigue.

Low impact disclosure: Just a warning before you read it: the first portion of the speech describes a brief but violent attack (the author was mugged which is the beginning of the story) and some of you may not want to read it for that reason.

Try this at home: The Five Key Elements of a Self Care Retreat

(Photo: Late June in Umea, Sweden)

I have just finished a busy past two weeks. I offered a full day training in Toronto, a shorter presentation at a PTSD conference and at a conference for community social services and finally the two day Compassion Fatigue Train the Trainer. I also had the opportunity to hear Babette Rothschild present grounding techniques from her very useful book “Help for the Helper”. I have also been processing orders for the new Compassion Fatigue Workbook which I am very happy to now have available for helpers who are looking for more resources to work through CF strategies on their own or as a team.

Now, thankfully, there is a bit of time to process and digest it all, (and weed the garden a bit.)

I had a widely varied group of participants at the train the trainer workshop: veterinarians, managers from homeless and women’s shelters, hospital social workers, addictions counsellors, to name a few. In our discussions, we discovered that the challenges we face are far more similar than they are different – whether you are working with pet owners or with humanoid patients, there is a strong human factor in the work: people are grieving, people are angry (often at us, for a flawed system, for a lack of resources, maybe for errors we make or errors they perceive we made). Dealing with loss, grief and anger takes its toll on us, and so does having to turn people away when we simply do not have the resources to help them.

Having a two day retreat with a small group of helping professionals is a rare opportunity to talk and reflect (in a very lovely environment – the centre where I hold these workshops is beautiful) and that alone is worth its weight in gold, in giving us all the opportunity to replenish ourselves.

I think that we need to look at small ways to create retreats for ourselves even if we do not have the time or money to go to a train the trainer workshop or an actual retreat. Here are some suggested steps:

A Retreat plan for yourself

1) Get your daytimer and book a day off (two is even better). Make sure that the entire day is free. If you have more financial resources, consider booking yourself into a local B&B and make this retreat an overnight event. You can also buddy up and plan the retreat with a colleague or two, but make sure they are committed to making this a replenishing experience and not talk shop.

2) Plan your day, making sure that you will include three key components: Stress Reduction, Relaxation and Resilience. What does this mean?

Eric Gentry, compassion fatigue scholar and co-developer of the Accelerated Recovery Program (ARP) for helpers with compassion fatigue, wrote a powerful article in 2002 called The Crucible of Transformation. I highly recommend that you read it. To obtain a pdf of the article, simply Google: Gentry crucible of transformation and then download the article from his website: (Make sure you do not download the one from the website Gift from Within as it is incomplete. For some reason, visiting his website directly does not work but googling does.)

In this article, Gentry offers two important principles that are critical to remaining healthy in the face of the challenges of our work:

“These two important principles, which have become the underlying goals for our work in the area of compassion fatigue, are: (1) the development and maintenance of intentionality, through a non-anxious presence, in both personal and professional spheres of life, and (2) the development and maintenance of self-validation, especially self-validated caregiving. We have found, in our own practices and with the caregivers that we have treated, that when these principles are followed not only do negative symptoms diminish, but also quality of life is significantly enhanced and refreshed as new perspectives and horizons begin to open.” (Gentry, 2002)

Let us highlight the two key concepts from that paragraph:

“(1) the development and maintenance of intentionality, through a non-anxious presence, in both personal and professional spheres of life, and

(2) the development and maintenance of self-validation, especially self-validated

What does this mean exactly?

A non-anxious presence refers to the ability of being in the room with the client’s pain and suffering and being able to express empathy and compassion without taking on the other person’s suffering. In both the personal and the professional realm, it is about mindfulness, the ability to notice and control your physical symptoms of stress and anxiety, and your breathing. It is a concept that is explored in depth by Babette Rothschild, author of Help for the Helper: the psychophysiology of compassion fatigue and vicarious trauma (2006).

“Self-validated caregiving” refers to self-care that is guilt-free, self-care that is prioritised as a means of remaining healthy in this line of work.

So, reflect on this for yourself:

What stress relief strategies do you enjoy? Examples of stress relief are taking a bath, sleeping well or going for a massage.

What stress reduction strategies work for you? Stress reduction means cutting back on things in our lives that are stressful (switching to part time work, changing jobs, rejigging your caseload, etc.)

What stress resiliency strategies can you use? Resiliency strategies are relaxation methods that we develop and practice regularly, such as meditation, yoga or breathing exercises.

Ok, now let’s return to our Retreat plan:

Step one (a discussed above): Carve out some protected time for yourself, either on your own or with a good friend/colleague.

Step two: Make sure that your day has the five following elements:

1- Plenty of unstructured time to rest, nap, read (something unrelated to work), sit, swing in a hammock, lie on your bed…

2- A physical component: sign up for a fitness class, go swimming, stretch, run, go for a long walk around your neighbourhood or if you need a change of scenery, take public transit or drive to a completely different part of your community. If you can afford it, book a massage for your retreat day.

3- A relaxation component: Consider downloading a relaxation tape from itunes, or purchase a relaxation cd from your local bookstore (I recommend Mark Berber’s Creating Inner Calm, which is available at Chapters/Indigo) and trying out one or two relaxation or deep breathing activities.

4 -A stress resiliency activity: Consider taking a yoga class or trying out a brief meditation tape from itunes.

5-During this day, eat healthy, simple food, try to avoid caffeine and any other stimulants. If not drinking caffeine is a problem for you in terms of withdrawal, try and have just one cup in the morning and redu
ce the rest of your day’s caffeine intake.

What may happen during this day: You may feel wonderful at the end of your mini retreat, or you may find that it was a very dificult day for you. This is important information. First of all, slowing down and letting go of our daily concerns takes time and practice. Secondly, working in this field, and having to live with compassion fatigue and vicarious trauma within us, sometimes stopping and slowing down means that we are letting our guard down. This guardedness is actually something we use as a protection mechanism during our daily working lives. So you may find that your day off is filled with images, thoughts about work or about certain clients etc..

If you find that this is very strong, and difficult to deal wtih, I strongly recommend that you consider seeking the support of a trained counsellor or psychotherapist who understands compassion fatigue.

You may also find that you need to practice being in a retreat mode and that it takes a few times to get it right. I recall the first time I ever tried mindfulness meditation was at an all day mindfulness retreat (no half measures for this gal…) and it was a very uncomfortable day for me. I felt twitchy, bored, restless and eager for the day to end. As we were walking out of the retreat day, my colleague who had come with me looked totally relaxed and blissed out. I said “so, how was it for you?” She replied “oh, wonderful, refreshing, so relaxing. I feel fabulous.” I was lucky enough to experience the replenishing qualities of mindfulness meditation a few years later, but I learned that meditation takes practice and a lot of kindness towards ourselves: we can’t necessarily speed our way through it.

Your retreat will be whatever it is – easy, hard, challenging, replenishing – set the bar low. The main step is to actually carve out time away from work and other family and life commitments. From there on, it’s all gravy.

Let me know how it goes.

Chronic Crises: Working with the toenail of the elephant

I just finished co-presenting a three day crisis intervention workshop ( with my colleague Dr Mike Condra. This is a workshop we offer every October in Kingston and we meet dozens of crisis intervention workers from across the country who come to retool and hone their skills.

During this workshop, I am often asked questions related to working with clients who are chronically in crisis.

Most helpers say that they find clients in chronic crisis to be the most draining clients to work with: their seemingly endless demands, high needs, difficulty self-soothing and sometimes poor problem solving skills. The fact that we will work incredibly hard to set up a referral link for them and then the clients will sometimes sabotage the help they are being offered. The self-destructiveness, the splitting…

I have spent a lot of time pondering this challenge and seeking training on working with high need clients, and have the following suggestions for anyone wishing to continue helping such clients and retaining a respectful, helpful stance while not burning out. Read More