Part Two: Does Self Care Work?
By Françoise Mathieu, M.Ed., CCC.
Pioneers in the field of compassion fatigue and secondary traumatic stress research say that they were caught off guard by the enthusiastic response that they received when they published their initial findings in the 1990s. One colleague recently told me: “It was a bit like trying to put the toothpaste back into the tube – people were very excited about this new idea of compassion fatigue, and the notion of self-care caught on like wildfire but meanwhile, the field was still in its infancy. There wasn’t even agreement on a name for this phenomenon, let alone what really worked to prevent or reduce it.” In fact, to this day, terminology continues to be hotly disputed: is it burnout, compassion fatigue, vicarious trauma, secondary trauma, compassion stress, moral distress, empathic strain? Are they one and the same or are they clearly distinct concepts? The debate rages on. Meanwhile, back in the trenches, helping professionals of all stripes were trying to do the best they could while working within an increasingly compromised system.
In the past few years, new research has emerged which suggests that it is time for a more sophisticated understanding of the best ways to manage and reduce CF and STS – one that goes beyond healthy eating and massages.
Intrigued by the field’s growing focus on wellness practices to reduce CF and STS, Toronto-based researchers Ted Bober and Cheryl Regehr investigated whether self-care was in fact effective in reducing STS in trauma counselors. Their 2006 study found that although their subjects believed that leisure activities and self-care would reduce their secondary trauma symptoms, that was not in fact the case: therapists did not engage in these self-care practices more often when they believed in them, and when they did take better care of themselves, it unfortunately did not reduce their trauma scores. Essentially, self-care was not working in reducing STS, in spite of agencies spending tens of thousands of dollars on workplace retreats and work-life balance workshops. In fact, Bober and Regehr argued, organizations were beginning to unwittingly blame their staff for not managing their lives better – the message was now “if you had better work-life balance, you wouldn’t be so overwhelmed with the workload and the trauma stories.” Meanwhile, the workload continued to increase, and the resources to disappear. As one social worker recently told me: “They tell us that overtime is no longer allowed, and that this is for our own wellness. I suspect it’s really about budget cuts, to be honest, and that they are using the self-care excuse to encourage us to stop working at closing time. But in truth, our caseloads are so huge we can’t get all the work done in a regular workday. So, what are we supposed to do? Let children die so that we can go all home at five?”
Nine years have passed since the Bober and Regehr research was first published, and we finally have plenty of solid data that supports the findings that self-care, alone, cannot prevent STS and CF in helping professionals. We now know that the most effective solutions are linked to workload, a reduction in trauma exposure, staff feeling effective through experiencing success in their work, better social support and, finally, taking a long hard look at the systemic problems in the way service is being delivered. Yet in spite of this, the emphasis of workshops and workplace initiatives remains heavily focused on individual self-care and work-life balance. Why are we not translating the new research findings into practice? First, we need to figure out how to do this in a depressed economy.
On the brink
The Rust Belt, home of the automotive sector, was hit particularly hard by the financial collapse of 2008. In the steel town of Hamilton, Ontario just 60 miles north of Buffalo, rates of social assistance claims increased by 30% in just one year following the downturn. This was accompanied by significant layoffs in all sectors of social services, especially in child protection. For helping professionals working in homelessness, social assistance and other community services, their clients’ realities hit awfully close to home: many of the mental health staff’s spouses had also lost their jobs. A year after the financial crisis, one Hamilton-based welfare worker said to me: “I am one paycheck away from being one of my own clients.” How do you set those stresses aside, as a case worker, and remain present for your clients? How do you cope with the moral distress of having to turn away individuals in crisis because your agency no longer has the resources to help them? The truth is that the economic downturn further strained an already fragile, overtaxed system and, as a direct result, human service staff is now struggling more than ever before.
Significant demographic changes are also at our doorstep: Our workforce is ageing rapidly, and many of us are now part of the “sandwich generation” where we try to juggle our children’s needs while simultaneously caring for elderly parents. Attracting good talent – and retaining them – is also because a cause for concern. The new generation of workers, the Millennials, (also known as “Generation Y”) who were born in the 1980s-90s are not, as a whole, willing to sacrifice their health and personal lives for the job, and keeping them is becoming increasingly difficult. If working in mental health was already a challenge a decade ago, how will we sustain ourselves now that the resources are even scarcer?
Laurie Barkin is a San Francisco-based psychiatric nurse. She is the author of a poignant memoir of compassion fatigue and vicarious trauma in a hospital setting. Reading The Comfort Garden: Tales from the Trauma Unit is like watching a slow motion train wreck: At the start of the book, we are in the mid 1990s and Barkin, a highly experienced mental health professional, is trying to adjust to the arrival of Managed Care in her institution. I recently spoke to Barkin who explained: “When it was ushered into our hospital, the substance of our weekly psychiatric consult departmental meetings abruptly shifted from discussing issues related to providing excellent patient care to the business of patient care. Entire staff meetings were devoted to the minutiae of filling out billing forms. On multiple occasions we were reminded that initial consultations were reimbursed at a much higher rate than follow-up consultations. Our productivity was measured only in numbers, first as an entire group, followed by the smaller groups of which we were comprised—psych nurses, psychologists, and psychiatrists—and finally as individual clinicians. It felt like a horse race. It seemed that ‘quality of care,’ a long-held value within our department, ceased being relevant in this new world.”
Over time, in this busy inner city hospital, the volume of work rose and access to support and debriefing eroded. In hindsight, Barkin sees the loss of peer supervision time as a significant contributor to her stress symptoms: “Although historically, our department was never big on “processing feelings,” the advent of Managed Care decreased the frequency of these discussions from occasional to “Do it on your own time.” Day after day we clinicians witnessed the carnage caused by interpersonal violence, life-threatening accidents, chronic illness, suicide attempts, AIDS, poverty, substance abuse, lack of resources, depression, broken homes, and lives characterized by chaos and hopelessness. In my opinion, denying us time within group meetings to discuss the nature of our work and how we were coping with the stress of it, contributed to feelings of isolation, despair, compassion fatigue, and burn-out.”
Barkin says that even basic safety was a daily concern for hospital employees: “Institutional denial regarding issues of safety also compounded staff stress levels. We were acutely aware that nothing prevented weapons from being brought into the hospital. Before a parking structure was built, many staff vehicles were vandalized. After a night on-call, a medical intern was pistol-whipped on his way to his car. A new social worker was horrified to learn that perpetrators of domestic violence were seen in the same clinic as victims. A trauma nurse practitioner resigned in part because she was tired of worrying about being caught in the crossfire of gang violence in her clinic.”
Finally, after five years of trying to make things work, Barkin throws in the towel, and resigns. The hospital loses yet another highly skilled practitioner. Laurie Barkin left because she realized that working in this institution was jeopardizing her health and her family life, and that she had completely lost faith in management’s willingness to implement any real changes. By the end, she also felt very isolated from most of her co-workers.
Barkin’s memoir is a cautionary tale for the rest of us – it presents the hard truth about the price helping professionals pay when managed care has systematically stripped away the structure that allowed them to do their work safely and ethically. In her book, she writes: “Sometimes I feel like that’s what we do at the hospital. We hold up the weight of the world. And, in doing so, we hear screams and witness the suffering that sometimes becomes our screams and our suffering, only we choke it back and continue bearing the weight without complaining and without acknowledging that we too need relief.”
The Comfort Garden won the Book of the Year Award in 2011 from the American Journal of Nursing. It is one of the only memoirs of its kind that describes the process of an individual developing CF, STS and burnout and while so skillfully laying out the organizational contributing factors.
Battling the Taboos
Sadly, Laurie Barkin’s story is not unique – helping professionals often describe feeling completely alone while struggling with CF and burnout. A very real roadblock comes from our own resistance as professionals – our difficulty accepting that we may be negatively impacted by our work. Although most mental health professionals claim to be open to accessing therapy when they need it, the data doesn’t bear this out: one recent study indicated that only 60% of counselors and social workers would be willing to seek help if they needed it. Granted, it was better than the meager 15% of police officers who said the same, but shouldn’t it be close to one hundred percent? If therapists do not believe that therapy is safe or effective, isn’t that a problem? Confidentiality and fear of losing face are frequently mentioned as deterrents to seeking help, as is denial. Before exploring solutions to CF and STS, we, the helping professionals, need to acknowledge that the problem exists, something that has proven to be more difficult for many of us than one would expect.
Last year, Dr. John Bradford, one of Canada’s top forensic psychiatrists, shocked the entire country by going public about his work-induced secondary traumatic stress on national news. It was stunning and unprecedented: Bradford spoke openly of his acute emotional distress, substance use, suicidal ideation and struggles with PTSD. Dr. Bradford had worked as an expert witness in some of the most high profile sexually-motivated murder cases of the past decades in both England and Canada. Many of these crimes involved graphic video footage of rape, torture and homicide, all of which he was required to watch in order to conduct his psychiatric assessment. By going public, Bradford broke a long held taboo in our field – outing himself as a helping professional with mental illness. The psychiatrist admitted on air that, until his breakdown, he had openly doubted the existence of STS and PTSD in helping professionals: “I thought I was this tough guy, I’d done this before, this should go away [but] I’m not a skeptic anymore, […] now I know, it’s real.” It was quite a brave gamble, especially for someone who is still active in the field. However Dr. Bradford may have felt that at his age, nearing retirement, he could afford to take the risk. He also recently recused himself from an upcoming trial – a gruesome murder case, which was videotaped and broadcast on the internet by the perpetrator. The respected clinician felt that the potential triggers were too much for him. So far, Dr. Bradford has received praise from his peers for his courage and for taking a stand to normalize this occupational hazard. Perhaps it is a step in the right direction, but the audible gasps that greeted his broadcast speak volumes – mental illness in helping professionals still carries a heavy stigma.
Tomorrow: Part Three – The Climate We Create, The Culture We Feed
Françoise Mathieu is a mental health professional and a compassion fatigue specialist. She is the author of The Compassion Fatigue Workbook (2012) and co-author with Leslie McLean of a book chapter entitled: Managing Compassion Fatigue, Moral Distress and Burnout in a context of patient-centered care in Walton, M., Barnsteiner, J., & Disch, J. (eds) Patient/Family Centered Care – Patient and Care Provider Considerations, Sigma Theta Tau International, 2014. She is also the author of several magazine articles.
Françoise is chair of the annual CARE4YOU Conference on Compassion Fatigue