For Care-Giving Professionals

COMPASSION

Fatigue

An Introductory Handbook of self-care for those who may be affected by other peoples trauma

TABLE OF CONTENTS Common Questions ........................................................................... Self-Test for Helpers .......................................................................... Preface ................................................................................................ Introductory vignette ........................................................................ 4 5 7 9

Introduction and definitions ........................................................... 10 Burnout vs. Compassion Fatigue.. ................................... 10

Redistribution of Compassion Fatigue: The Stress of Caring Too Much video and booklet made possible in part by HIPPOCRATES Magazine

........................................................................ 12 Why should we care? Early warning signs ......................................................... 12 Universal vulnerability .................................................... 13

Critical Incident Stress vs. Compassion Fatigue .......................... 14 Differences and similarities ............................................. 14 Impacting events on emergency personnel [chart] .......... 15 Vulnerability ..................................................................................... 15 Warning signs .................................................................. 17 Overcoming denial .......................................................... 19 a Model of Compassion Fatigue [chart] .......................... 22 Effects on spouses & families of veterans.. .................................... 23 Case study/Interview ....................................................................... 24 What can you do about it? .............................................................. 28 Eye Movement Desensitization & Reprocessing ............ 30 Support networks ............................................................. 31 Role of employers ............................................................ 36 Therapist hygiene & treatment ...................................................... 37 Prevention ......................................................................................... 44 Education and training ..................................................... 47 Resources.. ........................................................................ 48 Closing vignette.. .............................................................................. Sponsors ............................................................................................ Panel biographies.. ........................................................................... Index ................................................................................................. 50 52 53 58

Copyright 1994, Visionary Productions, Inc. All rights reserved. 2809 West 15th Street, suite 202, Panama City, Florida 32401 Printed in the United States of America

Compassion Fatigue Self-Test for Helpers*

Some principal questions addressed in this videoconference...

What is Compassion Fatigue? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
How is CF different from burnout? ........ ................................................. 8

Please describe yourself

Male or

Female; number of years helping is.

Consider each of the following characteristics about you and your current situation. Write in the number for the best response. Use one of the following answers:
1 = Rarely/Never

2 = At Times

3 = Not Sure

4 = Often

5 = Very Often

What are the warning signs?. ........................................................... 10, 15 Who is vulnerable to CF? ........................................................... 11, 13, 35
How is CF different from critical incident stress ................................ 12

Answer all items, even if not applicable. Then read the instructions to get your score.
Items about you:
I_ _ 2_ _ 3_ _ 4_ _ 5_ _ 6_ _ 7_ _ 8_ _ 9 _____ 10.____ 11.____ 12.____
13.____ 14.____ 15.____ 16.____

What about denial of CF? ................................................................. 17, 33 Is all this just psyche stuff?. ................................................................ 27
What can I d o about CF? ........................................................................ 29 What is the role of humor in treating CF?. ........................................... 32 Are families vulnerable to CF? .............................................................. 33 What can employers do? ........................................................................ 34 Are physicians less vulnerable to CF? .................................................. 37 Do personality types play a role? .......................................................... 39 Is CF in the DSM-IV? .............................................................................. 41

I force myself to avoid certain thoughts or feelings that remind me of a frightening experience. I find myself avoiding certain activities or situations because they remind me of a frightening experience. I have gaps in my memory about frightening events. I feel estranged from others. I have difficulty falling or staying asleep. I have outbursts of anger or irritability with little provocation. I startle easily. While working with a victim I thought about violence against the person or persons who victimized. I am a sensitive person. I have had flashbacks connected to my clients and families. I have had first-hand experience with traumatic events in my adult life. I have had first-hand experience with traumatic events in my childhood. I have thought that I need to work-through a traumatic experience in my life. I have thought that I need more close friends. I have thought that there is no one to talk with about highly stressful experiences. _ have concluded that I work too hard for my own good. I

How is CF different from countertransference? . . . . . . . . . . . . . . .. . . . . . . . . . . . 44 What are some methods of prevention? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 What are some methods of treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 45

Items about your clients and their families:

What about the vulnerability of clergy, foster parents, and other . caretakers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7
4

I am frightened of things traumatized people and their family have said or done to me. 18.____ I experience troubling dreams similar to a client of mine and their family. 19.____ I have experienced intrusive thoughts of sessions with especially difficult clients and their families. 20.____ I have suddenly and involuntarily recalled a frightening experience while working with a client or their family.
17.____

21.____ I am preoccupied with more than one client and their family. 22.____ I am losing sleep over a client and their familys traumatic experiences. 23.____ I have thought that I might have been infected by the traumatic stress 24.____ 25.____ 26.____ 21.____ 28.____ 29.____ 30.____

PREFACE Dear Fellow Professional: There is a cost to caring. We professionals who are paid to listen to the stories of fear, pain, and suffering of others may feel, ourselves, similar fear, pain, and suffering because we care. Sometimes we feel we are losing our sense of self to the clients we serve. Over the past ten years, I have been studying this phenomenon. During this time, especially since coming to Florida State University, I have spoken with or received correspondence from hundreds of professionals about their struggles with this kind of work-related stressor. They describe episodes of sadness and depression, sleeplessness, general anxiety, and other symptoms that they eventually link to trauma work. The concept of Compassion Fatigue emerged only in the last several years in the professional literature. It represents the cost of caring about and for traumatized people. It is a special form of burnout and has common features with countertransference. Compassion Fatigue is the emotional residue of exposure to working with the suffering, particularly those suffering from the consequences of traumatic events. Professionals who work with people, particularly people who are suffering, must contend with not only the normal stress and dissatisfaction of work, but also with the emotional and personal feelings for the suffering: the compassion-consuming work of human services. We hope that you make good use of this transcript and the video tape from which it is drawn. As you become familiar with the signs and symptoms of Compassion Fatigue, we hope that you will be more able to recognize its presence in others, as well as yourself. And, once aware, we trust that the tape and transcript will enable you to help others as well as yourself to resist or recover from this difficulty. We hope that you will write us and let us know how you are doing and what we need to know to better identify, classify, treat, and prevent Compassion Fatigue. Sincerely,
Psychosocial Stress Research Program Florida State University Tallahassee, Florida 32306
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of my clients and their families. I remind myself to be less concerned about the well-being of my clients and their families. I have felt trapped by my work as a helper. I have felt a sense of hopelessness associated with working with clients and their families. I have felt on edge about various things and I attribute this to working with certain clients and their families. I have wished that I could avoid working with some clients and their families. I have been in danger working with some clients and their families. I have felt that some of my clients and their families dislike me personally.

Items about being a helper and your work environment:

31.____ 32.____ 33.____ 34.____ 35.____ 36.____ 37.____

I have felt weak, tired, rundown as a result of my work as a helper. I have felt depressed as a result of my work as a helper. I am unsuccessful at separating work from personal life. I feel little compassion toward most of my co-workers. I feel I am working more for the money than for personal fulfillment. I find it difficult separating my personal life from my work life. I have a sense of worthlessness/disillusionment/resentment associated with my work. 38.____ I have thoughts that I am a failure as a helper. 39.____ I have thoughts that I am not succeeding at achieving my life goals. 40.____ I have to deal with bureaucratic, unimportant tasks in my work life.
SCORING INSTRUCTIONS: (a) Be certain you responded to all items. (b) Circle the following 23 items: l-8,10-13,17-26, and 29. (c) Add the numbers you wrote next to the item. (d) Note your risk of Compassion Fatigue: 26 or less = Extremely low risk 31 to 35 = Moderate risk 27 to 30 = Low risk 36 to 40 = High risk 41 or more = Extremely high risk Then, (e) Add the numbers you wrote next to the items not circled. (f) Note your risk of burnout: 19 or less = Extremely low risk 25 to 29 = Moderate risk 20 to 24 = Low risk 30 to 42 = High risk 43 or more = Extremely high risk
*Note: This instrument is under development. Please contact Dr. Charles R. Figley, Psychosocial Stress Research Program, Florida State University, MFT Center (R86E), Tallahassee. FL 32306; phone (904) 644-1588, fax (904) 644-4804.

Charles R. Figley, Ph.D.

1994, Florida State University Psychosocial Stress Research Program.

This booklet contains, among other things, a transcript of the national PBS satellite videoconference on 23 June 1994 entitled

[Opening prerecorded vignette featuring professionals in the caring fields sharing some of their feelings on Compassion Fatigue...] GLORIA (mental health counselor): Ive always been able to enjoy hearing and listening to other people. JOYCE (hospice nurse): Ive always been like that. Ive always been the person who put the band-aids on. LARRY (highway patrolman): If I've got something I need to do, I go in and I put 110% into everything that Im doing. GLORIA: The people that I work with on a daily basis are usually so cognitively impaired that it is difficult for them to even make the decision to get out of bed in the mornings. LARRY: In law enforcement in general you have quite a bit of stress as far as what is generated as far as what you come in contact with, also the job itself. JOYCE: Telling someone that youre going to die is the ultimate bad news. KEN (mental health counselor): One of the things that was so devastating for me as I moved into the mental health field was that people wanted to kill themselves, you know, the suicidal ideations and the homicidal ideations, and it was so draining for me. LARRY: The hardest thing for troopers, I believe, would be youre there, you see it when it happens. You have the initial impact. You get to see it from the start. GLORIA: Yes, I do take the agonizing helplessness and hopelessness home with me sometimes. KEN: A lot of times I didnt have the right answers and I couldnt heal those folks. JOYCE: When your mind plagues you that you could have or should have done something else to the point that you cannot lay down and sleep, then you know that you are stressed.

Compassion Fatigue: The Stress of Caring Too Much. Certain visual aids have been added for the
reader, as well as Dr. Figley's self-test for helpers and brief, one-page biography sheets on each of the five distinguished panelists. Additionally, an index will help you look up specific topics. The opening and closing vignettes featured professionals in the caring fields sharing some of their feelings on Compassion Fatigue, and these prerecorded remarks are set off in italics at the beginning (pp 9-10) and at the end (pp 50-51) of the transcript.

Note: Compassion Fatigue is the same as what is

sometimes called Secondary Traumatic Stress Disorder, and Compassion Stress is the same as what is sometimes called Secondary Traumatic Stress. Compassion Fatigue and Compassion Stress are used by our experts because they wish to remove the stigma of disorder from what is essentially a normal consequence of working in an abnormal situation.

This material is educational and is intended to focus attention on the issue of Compassion Fatigue. It is not intended as specific diagnosis in individual cases. The opinions expressed by the experts are their own. The producer and publisher of the material assume no liability in connection with its use. Please consult with a professional regarding your specific situation.

G L O R I A : One day particularly that I am thinking of I had three patients return from the hospital in one day that I had worked with and they were all in crises and it was just overwhelming. JOYCE: I cant remember the exact day but I can remember the time that for 14 days running, one of my patients died. I didnt have time to get used to one of them before another one went.

LARRY: One day, August 18, it was a Thursday, my partner was shot and killed on the side of the road. He had been shot in the face one time with his own revolver. When I got down there, its like, I do remember this. Its something I will never forget. G L O R I A : The red flag sign for me is when I feel myself totally disengaged with interacting with people. It's almost a sense of being numbed out. LARRY: My personality had changed 360. I mean, I was the total opposite. I was withdrawn, found it hard to talk to people. J O Y C E : When it becomes something that stays with you even in your sleep... GLORIA: There is no hope. Its hopelessness to the depth and degree and obliqueness. The hole is deep and dark. Theyre feeling that way. They dont need my presence there when theyre already in that deep, dark pit.

Burnout: A state of extreme dissatisfaction with ones work characterized by: Excessive distancing from clients Impaired competence Low energy Increased irritability with supporters Other signs of impairment and depression resulting from individual, social, work environmental, and society factors.
chart 1 DR. FlGLEY: Thats a good question because I think a lot of people that see the videotape beforehand tend to think, Oh, well thats burnout. Well, it really isnt, because burnout is associated with lots of sources of stress and hassles involved in your work, it is very cumulative, it is relatively predictable, and frequently a vacation or change of job helps a great deal. Compassion Fatigue is very different than that. In many ways it is a form of burnout, but the precise definition really clarifies it. If we could go to the definition of burnout and put that up (see chart 1), youll see that it is essentially a notion that it is a state of extreme dissatisfaction with ones work and it is characterized by a number of things. It depends upon whom you read with regard to burnout literature. But it is excessive distancing from clients that was mentioned already, impaired competence, low energy. There also are sources of increased irritability with ones supporters. There are other signs of impairment, but a lot of that is really connected with a gradual buildup in dissatisfaction with your job and it could be connected to not liking your supervisors, not enjoying your view out your window. Compassion Fatigue is something much more narrow. Compassion Fatigue is really the notion of being burned out, if you will, by the kind of work that we do, the kind of clients that we have, and the residue from working with those clients. Now if we can put that definition up you can clearly see the difference (see chart 2). Were suggesting that Compassion Fatigue is a state of tension and preoccupation with the individual or cumulative trauma of the clients--so not about supervisors, not about the hassles, but the clients as manifested in one of several ways. Now for those of you who are familiar with PTSD you will recognize these symptoms. It is

The Stress of Caring Too Much

MS. SWlTZER: Until recently, the study of traumatic stress has focused on PostTraumatic Stress Disorder, afflicting those directly affected by a shocking event. But what of individuals who have experienced extreme stress or trauma indirectly, such as those working in the helping professions. How are professionals affected by working with traumatized and troubled clients? What skills or resources do professionals or caretakers need to effectively cope with secondary traumatic stress? During this program we will answer these questions and provide you with a clear understanding of the concept of Compassion Fatigue. Hello, Im Beth Switzer. Ill be your moderator for the program. Joining me for this discussion are Dr. Charles Figley, Director of the Psychosocial Stress Research Program and Professor of Family Therapy at Florida State University; Dr. Ann Burgess, Professor of Psychiatric Mental Health Nursing at the University of Pennsylvania; and Dr. Jeffrey Mitchell, President of the International Critical Incident Stress Foundation and Professor of Emergency Medical Services at the University of Maryland. Welcome to each of you. Dr. Figley, we are going to begin with you. We hear a great deal about burnout and today we are going to hear about Compassion Fatigue. What is the difference and the relationship between the two?

Compassion Fatigue:

Compassion Fatigue: A state of tension and preoccupation with individual or cumulative trauma of clients as manifested in one or more ways: l Reexperiencing the traumatic events l Avoidance/numbing or reminders of the event l Persistent arousal
chart

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1O

reexperiencing of the traumatic event, so reexperiencing of the sorts of things that our clients tell us; of seeing our clients tell us these things and remembering that; avoidance or numbing of reminders of the traumatic event; persistent arousal. We just cant let go that personal information that we gathered as a result of doing our job. MS. SWITZER: Weve got a lot that we are going to discuss. Weve got a lot of folks that are going to be able to actively participate in our discussion that are joining us in well over 30 states by satellite, so they will be asking questions in just a little bit. I would like to move to Dr. Ann Burgess. Ann, what I want to talk about to begin with is, from your perspective, why should we care about Compassion Fatigue? DR. BURGESS: I think there are many reasons we should be concerned about it but the most important is because the health of the professional is at stake--not only the mental health, but the physical health. Once you begin to increase the Compassion Fatigue level, you stand the chance of losing that worker from the field. They may leave, they may change, whatever. They just cannot tolerate the intensity that they feel. MS. SWITZER: Any particular examples of that? DR. BURGESS: Well one of the bases for this that I like to use is to understand some of the biology that underrides this. I think if we can think of the brain, which is really what governs our being, and in fact is the largest organ in our body and probably the least understood--I think it is between 4 and 5 pounds that we carry around in our heads--in the brain there is this limbic system that really is our alarm and protection site. The minute that we feel any danger or any threat to it, that sounds for us. I think all of the things that Dr. Figley has just said, the reexperiencing and everything that sounds the alarm that something is going to happen. From there you move into--when theres threat--fight or flight. That is something people may remember from high school when they learned about fight or flight. Most people will flee. Not a lot will stay in the situation and necessarily fight it, but if they can do neither, they move into the next position which is the freeze and they cannot get out of it and they feel trapped and I think this is part of what seems to be operating when people feel this enormous stress from the work that they do with people that are going through life-threatening crises. MS. SWITZER: You mentioned that this sounds the alarm. What are some of the early warning signs that we should look for? DR. BURGESS: Certainly what we call the repeated thoughts coming into the head and not being able to put them out. You may get just the opposite, feeling bored, feeling irritable. Those are more of the behavioral signs. But probably 12

also not feeling the satisfaction in ones work that one needs to and that is not in balance--the energy put out and the rewards coming in just dont seem to be there. MS. SWITZER: I want to move to Dr. Jeff Mitchell. I would imagine that there is a great deal of training that goes to these professionals to do what they do. I mean there is a wide variety of professionals and a lot of training. Is there any particular training, though, that can combat or that can prevent Compassion Fatigue? DR. MITCHELL: I think there is some training that can mitigate it and perhaps prevent it in some cases, but I think what we have to look at is a broader perspective than that. We have this illusion that training in and of itself arms people so that they are just simply not going to be overwhelmed by an experience or by a set of experiences. Compassion Fatigue is generally a string of these things going on for a period of time, although it can be one single event. There is no amount of training or type of training that can completely eliminate the potential for someone to have a reaction of Compassion Fatigue. In fact, there is a concept which I would like to call universal vulnerability; that everyone who does work with people, especially people who are in need, who are hurting, who have special problems going on in their own lives, who have health issues, everyone who does that work becomes basically vulnerable, so there is universal vulnerability. I think people would be quite shocked to find the numbers of people who 86.9% of emergency response are reporting they have had some reactions to personnel reported symptoms this. In 1982 I did a study looking at 360 after exposure to highly emergency personnel and asked them how distressing events with many of them had reactions to an event. It traumatized people. was a staggering number (see chart 3). It was 86.9% of those personnel reported that they (from a 1982 study by Jeffrey T. Mitchell) had significant symptoms of the stress within a roughly 24-hour period of time after they chart 3 went through one tragic event, having what I would call a critical incident. This is sort of like an industrial strength version of Compassion Fatigue. It could be one single event that does people in. There are a lot of costs. We are asked why we would be concerned with this whole issue. There are a lot of costs. There are financial costs. It costs a tremendous amount of money to replace a paramedic. We are looking in the state of Maryland at something like $26,000 a paramedic just to train them. Police officers are even higher because you have to train them and supervise them and pay them for three years to get them up to a level where they can function at their best benefit and they are estimating $100,000 to get a police officer in place. So there are great financial costs. Now we look at other costs. There is the human cost. Job performance goes down, mistakes go up. We find morale drops and when morale drops, lies go up, stealing goes up, 13

sabotage of the organization goes up. We also find relationships drop and peoples home lives start to deteriorate, personality deteriorates, and eventually we find declining overall general health. So there are lots and lots of problems that can come along from this and it is really worth saving human beings. MS. SWITZER: We are going to be hearing from members of our audience in just a moment. But Jeff, Charles and Ann were both nodding emphatically as you spoke. I want to give you a chance to follow up on what Jeff has said or add to your own comments before we take some of our questions. DR. FIGLEY: The bottom line is that this is very hard work and the very people--as we are--that put our own lives and our emotions on the line to help other people, we dont even provide the same kind of attention to ourselves. Our families say this to us in different ways that we need to attend to ourselves in this work. I think the bottom line if anything can be taken away is that it is very hard work and you are doing no one a favor unless you focus on your own issues. DR. BURGESS: To be able to not only focus on your own issues but to monitor yourself, even day-to-day, in terms of your thoughts and feelings about your work and kind of do your own mini debriefing if you will, a personal debriefing, as a way to kind of process the information that you have had to deal with all day. MS. SWITZER: A little bit later in the program we will talk about prevention and we have a checklist that folks can go along with in their packets, those that are participating in this forum today. So we will follow up on that. I am going to follow up, Jeff, on something that you said a little bit earlier. You brought up the concept of critical incident stress. What is the difference between Compassion Fatigue and critical incident stress? DR. MITCHELL: Critical incident stress is really one version of overall Compassion Fatigue. Generally when we look at Compassion Fatigue, it is a longer, slower process. But when you see a critical incident stress it is very traumatic. There is usually one single event or perhaps a series over very terrible events that really can overwhelm a persons resources. The single event can be so powerful that it can actually set somebody up to develop, eventually, Post-Traumatic Stress Disorder, which is sort of the worst-case scenario. It can cause all of the dysfunctions that we see in the longer range, the things that usually take people 2 to 3 years to develop, may actually come up within that one incident. In fact, in that same study that I mentioned earlier, I had asked people what kinds of events were likely to affect them. There were a number of things that seemed to have this universal impact (see chart 4). One of the things that we found was death to children is one of those just really awful, catastrophic events that seems to crash through every defense mechanism that we have. 14

Most upsetting incidents by emergency response personnel: l Death of children l Injury to children l Death of any other person l Personally threatening events l Injury to operations personnel l Death to operations personnel l Knowing the victim l Grotesque sights and sounds
(from a 1982 study by Jeffrey T. Mitchell)

chart 4 Injury to children was the second one on the list. Death to any other person and then any type of event that a person who is a worker in the healthcare environment or in mental health sees as a personally threatening event can be overwhelming. We also find that people react very strongly to injury to their fellow workers, that they start wondering about their own safety and security as they work on the job. Death to emergency operations personnel is absolutely cataclysmic in its impact on the organization and on the surviving individuals. We know also that if you know the victim that will have a definite impact on you. Finally, just the mere fact that you are seeing grotesque sights and sounds that are well outside of our normal realm of human experience--those kinds of events can have just a very powerful impact on people, which again can set them up to have Post-Traumatic Stress Disorder and that is what we are trying to prevent, that is what we are trying to avoid. DR. FIGLEY: One thing I would add to that as another distinction: in the tape in the beginning, the police officer talked about losing his partner. The critical incident is really dealing with things that they see for themselves, things they experience for themselves. In Compassion Fatigue you are really absorbing the trauma through the eyes and ears of your clients. We never thought really until recently that that would have any impact. But we clearly know that is does. So that is the major difference. One is that you see it yourself, you see the catastrophe right there, and for Compassion Fatigue you see it through the eyes of your clients. DR. BURGESS: That also fits in with the limbic system because all information comes into our brains through our sensory system. So that is so powerful. MS. SWlTZER: Very quickly, before we go to these other questions with some of our viewers, how big a problem is it for professionals who have within them the professional expectation that this will not affect them and that they can deal with it? 15

A Hippocrates magazine survey of physicians reveals that: 54% restrict their emotional involvement with patients 60-75% of residents suffer from clinical depression 90% of those 30-39 years old say family life has suffered from the emotional demands of the job 75% in 1974 said they would encourage their kids to go into medicine compared to 25% in 1994
l l l l

trying to impart here. It should be part of the curriculum; there is nothing to be ashamed of. It is a normal reaction to an abnormal situation. MS. SWITZER: Dr. Burgess, this caller is asking you to go over once again some of the warning signs for caregivers, in particular, the self-auditing that they can do to keep this in check. DR. BURGESS: Again, one of the symptoms is that one kind of keeps hearing or seeing what has just been told to them. They keep focusing on a particular patients problem. So the warning signs would be that they are focusing too much on that and they are not getting their work done in other areas and they are not feeling that they are accomplishing anything. The kind of auto-diagnosing that we suggest is to really check out with a checklist to kind of see if they are managing not to continually have the thoughts, to not be avoiding things--the whole avoidance area of maybe referring out more than usual or just not having the same intensity with ones work. MS. SWITZER: Anything you would like to add? DR. MITCHELL: I think that basically we see just so much going on with people in their home life. I think that is where a lot of it shows up, they take it home. There are a lot of warning signs that people need to pay attention to and as soon as we can get them over some of these initial hesitancies to accept the problem and deal with it, we can work with them. MS. SWITZER: When you talk about the initial hesitancies to identify the problem, I am wondering if simply giving it a name, giving it an identity of its own is going to help? DR. FIGLEY: Yes, I think so. All of us think that maybe we are incompetent and not effective. But when we experience the things that are now called Compassion Fatigue, we say, Oh, we are just like other people. We are human beings. The thing I wanted to add to that, in terms of the first broadcast--and it may be rebroadcast--includes a packet, and in the packet (if anyone wants it they can write to us and we will send it to them free of charge) is a self-test for psychotherapists but there is also a form for practitioners. It is 40 items and you take it yourself. You dont have to show anyone else. Through a rating system it indicates whether you are vulnerable either for burnout, which is much more chronic and long term, or this Compassion Fatigue. You can just write us at F.S.U. MS. SWITZER: Jeffrey, I have a question for you. Is there a way to test for people who are more vulnerable to Compassion Fatigue so that we can know before they are hired? Now this is from the employers point of view and perspective.
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When physicians were asked: If you thought you were heading for compassion (fatigue), which of the following would you most likely do? 6% would seek therapy 7% would join a support group 70% would take a vacation
l l l

(Hippocrates, April 1994) chart 5 DR. FIGLEY: That is a good question. We have another visual of a recent survey of physicians and this was by a magazine, Hippocrates, whose readers are almost exclusively physicians. Sometimes the physicians are a little more candid with this because they are talking with each other (see chart 5). In that article it is clear that the physicians, even though they perhaps have never heard the term Compassion Fatigue very much, they clearly indicated that they were affected. For example, 54% restrict their emotional involvement with patients, 60-75% of the residents suffer from clinical depression. As a family therapist the thing that worries me so much is that 90% of those 30 to 39, the new physicians, say that their family life has suffered as a result of their work. And 75% in 1974, some time ago, said they would encourage their kids to go into medicine. Because of Compassion Fatigue, at least partly that, today only 25% are recommending their kids to go in. We have to do something about this. MS. SWITZER: One of our callers is asking, Dr. Figley, what could we do to prepare people in masters school to help them avoid Compassion Fatigue? DR. FIGLEY: Just an excellent question and it is something that all of us have to worry about. Clearly we need to indicate that it is unethical if we dont tell these young professionals that are going into fields in which they will be vulnerable to Compassion Fatigue; we have to tell them what happens. We have to tell them what the signs are. We have to give them the information that we are 16

DR. MITCHELL: The problem that you have with that is that you would be eliminating practically everybody who would be useful in the job because with the concept of universal vulnerability everybody is vulnerable. There is no real effective test and there are no real predictors because basically the people who are most prone to this are those who are most deeply sensitive. those who care the most, those who are willing to work the extra time, those who are willing to put more into their job than they put into almost any aspect of their life so they are very much more vulnerable; however, that is the kind of employee you want is somebody who is a go-getter. So it is real hard to say, Gee, we are going to screen out all of our best people, because you will screen out all of the most dedicated, the most caring, the most productive, and the most involved. So it is just not an effective thing to do to try to test people out. MS. SWITZER: You know, from this perspective and listening to this question then it kind of flip-flops what I just asked you about, which was, by labeling it for the person who is experiencing some of those symptoms that may be helpful. But for those watching that label may also be something that is quite derogatory or something they are watching out for. DR. MITCHELL: Absolutely, In fact. in emergency personnel they may be even more vulnerable because they have the use of certain defense mechanisms which really can be helpful for the job, but it is the two-edged sword where the other side of that is that it can tear them down (see chart 6). Emergency p e r s o n n e l For instance, they overuse denial, Im okay, Im okay, Im okay. The second thing that they overuse is may be at more of a disadvantage because emotional suppression, which is, I have to keep my they utilize emotional emotions under control in order to be able to do my job, which makes sense. However, when they overdo suppression as a that, they shut off emotions. They dont use their defense mechanism. emotions appropriately and when you dont use chart 6

that it is soon, we will be able to establish a standard of practice that provides in this standard of practice when we go over that line, when we believe as a supervisor or as a colleague that our supervisee or our colleague is not functioning up to their capacity because of Compassion Fatigue. The message here is not that they should be fired or even necessarily that they need therapy. It is that we, as a system, need to change in order for us to be talking together about our issues and not just our clients issues. So hopefully there will be a systemic change. But if it doesnt happen then we have to hold practitioners accountable. MS. SWITZER: In just a moment we are going to take a call from Milwaukee but I want to follow up with this viewers question because it rides on the tail of the one that we just asked. You say what an employer must do, what we as colleagues must do to support and help this person. This caller is wondering and concerned that once someone gets Compassion Fatigue, do they have to resign, are they washed up? DR. BURGESS: Absolutely not. I think that the sign is there to take action, tell someone and move in that positive direction. DR. MITCHELL: It is a warning. It says, You can fix it. You can do everything from taking a vacation to talking to your loved ones to getting therapy if necessary. So there is a whole gamete of things that can be done to repair some of the damage that has already occurred. MS. SWITZER: And just as that professional and caregiver has provided a support network to those others, they indeed need their own support network to help with this as well. Jack in Milwaukee, thank you so much for holding. Go ahead, you are on the air. Jack: Hi. I just have a question about how would you overcome the denial mechanism that is built in with all health care workers in relation to Compassion Fatigue or critical incident stress situations? MS. SWITZER: That is a really good question. I am wondering that one myself. Jeff? DR. MITCHELL: It is a very difficult thing because it is not only personal. People have individual denial, you have organizational denial, you have system denial, you have society denial. In fact, the average citizen doesnt want to know that there are vulnerable human beings in those hospitals and in those emergency centers and who are in the police cars, that they are vulnerable too, because the fear is if they start having reactions of Compassion Fatigue, who will be there to take care of me? But the mechanisms that can be most used to try to limit the denial is by having very effective education programs, by having people who have been through the experience of Compassion Fatigue, who 19

emotions, they can actually turn into harmful events later on that kind of blow out like an explosion, like a volcano.

DR. BURGESS: The other is the going by the book that you find as people start pulling back. They become very rigid and rigidity is not a positive attribute in the helping field. So then I think that is something we would want to avoid. MS. SWITZER: Charles, this question is addressed to you. How do we establish ethical standards of practice to recognize when our colleagues are out of control? DR. FIGLEY: That is just an excellent question and this is another reason why this kind of medium is so important. They know where the real issues are. It is very important. First of all we just dont know enough. The term has just evolved. We are now differentiating from burnout but eventually, and I hope 18

have very strong records of professionalism behind them, that they would be able to come in and say, Look, I went through that so let me tell you what its like before you get there because we are trying to keep you from getting there. So good education programs, getting this kind of stuff out. I think that is one of the things that has happened over the last ten years when we started doing critical incident stress work: we were getting so few people who would admit that there was a problem, it took lots of education and we spent a long time educating. The very first program I did we invited 10,000 and 4 showed up. It was a little discouraging. But now, with lots of education and ten years behind us we are seeing our usual groups of 100 and every once in a while you get one in the thousands. MS. SWITZER: With this being, if not the first, one of the first programs of its type to get the information out, are you expecting to see more, not only of this, but of this kind of education and information being available across the country no matter where you are? DR. MITCHELL: Yes. I think there are going to be many more publications on it and I think there is more research going on in the field and there is a slow learning curve that will take a couple of years to catch up. But I think there are going to be more resources available. Plus we are learning new techniques that can do fairly rapid intervention and can reduce the impact of Compassion Fatigue fairly early on in the ball game. MS. SWITZER: We are going to Morgantown, West Virginia. Faye is on the line. Thank you so much, go ahead Faye.

A Model of Compassion Stress

Faye: I had to leave the room to ask this question so I may have missed something which is relevant and if so, I ask you to forgive me for that. My question is: I suggest that it is unethical not to include in the training of professionals equal content of self-awareness and looking after ourselves training together with the necessary didactic information. Do you have experience of training which includes this sort of balance?
MS. SWITZER: Faye, I dont know if you could see us from where you are, but you were getting nods of approval for the content of your question from all of our panelists. Charles, you first. DR. FIGLEY: Everyone up here has included as part of their lecture on methods, at least somewhere, and often the last part, in which you have to focus on yourself (see charts 7.8). We are going to be hearing from Matt Friedman a little bit later in which he talks about therapist hygiene. Right now, across the country and including people who are listening to this program, there are people that are probably more effective in treating Compassion Fatigue than we are. When those professionals recognize what the symptoms are and recognize it is 20

Charles
chart 7

Figley

|
happening around them, not only will they be able to take care of themselves, but they will take care of their colleagues and friends. So our purpose is really to send a wake-up call to our colleagues that this is very hard work. Once our colleagues recognize that, the innovation will flow, I am certain of that.

DR. BURGESS: And also it should be included in curriculums, I think that is a very important point. DR. MITCHELL: Even among police services in the county that I work in, we have added a six-hour component to the police academy so that they are trained in this stuff before they arc released to work in the street.

21

DR. FIGLEY: There is a concept called folie deux, which is the illness of one. It basically suggests that when you live with someone with a particular disorder that you take on that disorder. How this whole thing with regard to Compassion Fatigue emerged was when we studied families of people who have been traumatized and how in turn their family members were traumatized. So, yes, definitely. MS. SWITZER: In just a moment Dr. Figley will be talking with Gail Davies about her personal experiences dealing with Compassion Fatigue. We are going to give him a chance to move and get ready on that next set. First, our next guest is Dr. Zahava Solomon, joining us by phone line from Israel. Dr. Solomon is a professor of social work at Tel Aviv University and commissioned officer in the medical corps of the Israeli Defence Forces. Welcome, Dr. Solomon. Are you there? DR. SOLOMON: Yes, I am. MS. SWITZER: Hello. Thank you so much for being with us. You have been a very important figure in the emergence of the literature dealing with PTSD and what we are calling Compassion Fatigue. You have done a great deal of war-related study, looking at the responses of the spouses and children of those returning from war. Tell us about what youve found? DR. SOLOMON: We actually followed up with the wives of traumatized veterans, large numbers of them, and we found that they suffered from symptoms that are very similar to the ones that their husbands had suffered since their war experiences. For instance, they had FTSD-related symptoms, they had elevated rates of somatization, of depression, obsessive-compulsive problems, elevated levels of anxiety, paranoid ideation, and a host of other psychiatric symptoms. In addition to that it was also evident that their somatic health had been impaired and, similarly to their husbands they reported a host of somatic illnesses with onset after the exposure of their husbands in war. Those phenomenon were not observed among comparable control, where the husbands did not suffer a war-induced psychiatric disorder. In addition to that these ladies have also described impaired family environment. For instance, these families are characterized by lesser cohesion, lesser expressiveness, and increased conflicts. Obviously they shared with us their dissatisfaction and distress over their diadic insurrection within the marital relationship. Unfortunately they were not able to compensate for these losses within the social network and they also reported increased levels of loneliness. Some of those symptoms were very much similar to the ones reported by the traumatized husbands. MS. SWITZER: Did you find the same kind of impact on professional population, such as clinicians, and perhaps even researchers dealing with these veterans and their families? 23

A Model of Compassion Fatigue Charles Figley

| chart 8 |
MS. SWITZER: Lets go to Maine. We have Rosella on the line. Rosella, are you there?

Rosella: Yes.
MS. SWITZER: Go ahead with your question, please. Rosella: I wanted to know if it was possible, after many years of practice, for a therapist or a psychologist to take on the characteristics of the chronically ill? MS. SWITZER: Good question. Charles? 22

DR. SOLOMON: Let me just stress just before that, that secondary traumatization or fatigue was also experienced by children whose parents had undergone traumatic experiences, particularly combating PTSD in offspring of Holocaust survivors seems to be extremely debilitating and long-enduring. With regards to professionals, we did in fact see Compassion Fatigue and particularly on the battle field, not just after the war had ended. We had several cases where clinicians had to be evacuated. Even more to the point that we have a doctrine of treating traumatized veterans on the combat zone and only 7% of our therapists--of all professions--did in fact adhere to this doctrine. And the reason for that is that it entails the return of traumatized veterans who are successfully treated to the battle zone. This seems to be a very difficult task for the therapists because they had to deal with their own guilt and their own problems about sending soldiers whod recovered back to the front. As far as researchers go, I think that we are all sensitized by the material that we work with. Even more than that, there isnt a random choice or selection into professions and I believe most of us in the area of trauma are doing so, or have chosen these lines of work because, in many instances, they relate to our own experiences. But I do believe that researchers are in a better position than clinicians because we are a little more distant from our subject/clients and on top of that we are kind of immune or at least protected to a certain degree by the type of procedures that is in place, questionnaires and the like. MS. SWITZER: Dr. Solomon, one of the things that we have heard about today is a very high incidence of Compassion Fatigue within those in the helping professions here. Did you see a very high incidence, and we have heard statistics approaching 90% here, did you see such high incidence with those spouses that you studied and with other clinicians and professional populations that you have taken a look at within your culture? DR. SOLOMON: We certainly noticed that among spouses and offspring of traumatized individuals. I dont know of any sound study that was done in Israel with regard to helping professionals, so I can only share my clinical impression. MS. SWITZER: Dr. Solomon, we would like you stay on the line with us. In a moment we will be taking questions from our satellite locations. But first, Gail Davies was a nurse in Vietnam who found, upon years after her return to the States, that she could no longer continue in the practice of nursing. Lets go to Dr. Charles Figley and Ms. Davies to find out more about her personal perspective on PTSD and Compassion Fatigue. Dr. Charles Figley. DR. FIGLEY: Thanks, Beth. Well, we work together and we see each other fairly regularly and I know you as someone who has made lots of presentations, you train people, you supervise professionals. You are, in many ways, clearly an 24

expert in this area. Yet I know you and you have experienced, many years ago in Vietnam, Compassion Fatigue. Tell us about that.
Ms. Davies: The experience of nursing in Vietnam was one that was quite a bit different

in many ways and quite similar in many ways to what we do as a nurse in regular stateside nursing. After listening to some of the identification of some of the symptoms and the characteristics of Compassion Fatigue, I can now sit here and look back and say that I can know what I could call what my personal response in coping in Vietnam was. It involved emotional numbing, not being available emotionally, not talking about what we did, drastic measures to escape it psychologically and emotionally when we werent on duty. There was no time during that 12-month period to do any processing and on return to this country I exited the military as did many and went right back into the civilian force, into civilian nursing, never again to talk about this because I did not understand the process of what went on. So I wasnt able to explain it to anybody. Then it wasnt until several years later that I began to notice in my nursing practice that I was no longer emotionally available for my patients. It was one particular situation in which I had a patient that was dying with cancer. Im a caring nurse; I was a good nurse. I noticed that I was coming up with ridiculous reasons to not go into that room and be with that patient and that family. Fortunately, something in my mind said, You cant nurse if you cant deal with death and dying because the patients need something and youre not giving it. I also can now look back and see in my home life how emotionally unavailable, irritable, unable to focus, unable to pay attention to the things that I truly valued--but I didnt have the energy, either the physical, the psychological, or the emotional energy to put into it. I didnt relate what was going on in my insides with my job and I didnt see the connection to all of them together. And then I did, I left nursing. DR. FIGLEY: And you are not really in nursing now. You have an M.S.W. and are on the faculty at F.S.U. and doing supervision. How did you get from there to here?

Ms. Davies: Well there is an interesting story that I was relating to Ann Burgess before we started the conference. Basically, when I decided to leave nursing, somebody had mentioned to me that there was a job that I could make nearly twice what I was making as a nurse and that I could get special recognition because of being a military veteran, that I could get special points as it was a federal job, so I needed some help in filling out the application. So I went to the Vet Center and somebody said they would help me, as a veteran, fill out this application. What I was applying for was the janitors job at the post office. Fortunately, the therapist there, the team leader, when I introduced myself and said what I needed help with and who I was and why I was eligible to take advantage of these services, he recognized that you dont go from nursing to janitor without trying to understand why. 25

DR. FIGLEY: Something is wrong with this picture.

Ms. Davies: Right. And he was gentle and compassionate himself and he had recently--its interesting because he had, two years prior to my meeting him, lost his child to leukemia, so he knew about pain. He got me into therapy and began to help me make some sense of all the variables that went into my experience. Gradually I came to the decision that I did want to work with people, it just wasnt working for me to be in nursing anymore and that is what lead me to social work.
DR. FIGLEY: Thats great and you are doing very well in that. What would you say to

DR. SOLOMON: Well, during the recent Gulf War and also during the previous Lebanon War we have seen combat reactions of Compassion Fatigue, reactions among professionals shortly after the exposure because in those instances the professionals are directly exposed to the traumatic experiences themselves. So they actually have to face the challenge. They have to respond to the needs of the clients and they also have to be engrossed with their own survival. So, obviously, under those circumstances, combat fatigue or Compassion Fatigue could also be observed immediately or starting during the exposure itself. MS. SWITZER: And how long do the symptoms for Compassion Fatigue persist, in your experience? DR. SOLOMON: Well, we have seen instances where they crystallized into acute reactions and into chronic PTSD, and in other instances they were experienced as transient crises and resolution occurred within a short period of time. MS. SWITZER: We want to thank you. I know that it is quite late where you are. Thank you so much for joining us and bringing your world closer to ours this afternoon. Thanks. That is Dr. Zahava Solomon joining us from Israel. I want to follow up with our guests here in the audience and our panelists here, Charles, Ann, and Jeff about this. Anything you would like to add to what Zahava has said about the persistence of symptoms as well as the immediacy of onset? DR. MITCHELL: The persistence of symptoms among, not only the workers, but also their families is pretty extensive. Last year I had occasion to work with a group after a disaster, 3-l/2 years after the disaster. We spent four months working with that group and we did a lot of repair work and got some people back on track again. But the one thing that did not change regardless of any intervention whatsoever, was the negative effect it had on the family system. That is going to take a lot of therapy to get that to turn around. When the family system is damaged from the emergency workers who had done disaster work, the family did not return well at all. MS. SWITZER: That is one of the things that these folks in Portland are specifically referring to. Nurses who assisted in the L.A. earthquake are still experiencing the symptoms that you described. That doesnt sound like that is unexpected to you folks. Ann? DR. BURGESS: No. I can say certainly parents, following knowledge of their children being abused, in, say, the day care setting, it lasts for a very long time. MS. SWITZER: Charles, anything you would like to add? 27

people entering the profession, those that you supervise, in order to avoid going through what you went through as a nurse?

Ms. Davies: I think when I take a look at some of my experiences and some of my
colleagues that I talk with, that one of the critical things is to create peer support relationships in which there is permission and encouragement to discuss

things. The caretaking role allows us to be focused almost exclusively on the others and minimize our own experience with distress and pain and if we avoid that tendency and if we legitimize the opportunity to dialogue and discuss and cry and share the experiences of our clients with one another, the buildup and the pattern of emotional numbing, distancing I think is eliminated. Its preventing that. Im also a firm believer that we need to do our own work in order to be able to effectively assist someone else in their healing. Not that you have to have been wounded to be a healer necessarily, but if you have your own experience with trauma or distressful experiences in life, whether thats trauma or not, and you havent done your own healing, there may be some blind spots as there was with me before I got into therapy. DR. FIGLEY: Thats helpful. I think the rest of most of the program will be focusing on what do we do about it and how do we prevent it. Thats great. Thanks, Gail.
MS. SWITZER: I want to thank Gail Davies for sharing that experience with all of us.

We have some questions from our audience and I want to go, first, to Dr. Zahava Solomon who is holding on and is joining us in Israel this evening. Dr. Solomon, this is a question that all of our panelists can answer but I want to come to you first. This is coming from Portland, Oregon from the medical center there. The question is, how long after a disaster would you expect to see Compassion Fatigue? And I would imagine we can look at this from two perspectives: How long after the disaster would you expect to see the onset, perhaps, of symptoms affiliated with Compassion Fatigue and how long they would persist? What have you seen in your research? 26

DR. FIGLEY: Much of it really is the notion that it shatters our assumptions, as Ronnie Janoff Bowman talks about. We think of life as sort of bumbling along doing the best that we can and then some shocking experience happens, whether it happens to us or someone we love that brings it home. Unless we face it and focus on it, it is going to be alien to us. We have to sort of figure out why it happened and what do we do about it and what if something like this happens again, we will be able to move on. Until we have that kind of confidence we are always on edge and always uncertain. MS. SWITZER: I want to make sure that we tell the folks that part of the things that we are talking about here is a sense of helplessness and hopelessness and we dont want to impart that it is all helpless and hopeless in what we are doing. We will talk about prevention as we move along. I want to move to Lexington, North Carolina, if we could. Linda is on the line. Thank you so much for calling. Go ahead, please.

MS. SWITZER: One of the things you talked about is saying out loud that this is Compassion Fatigue lets folks know that this is a normal kind of occurrence. One of the things I noticed in Gails interview when she was talking about her movement away from nursing, she had applied for a job as a janitor. You were saying thats incredible, but at the same time nodding as if its not that unusual. DR. BURGESS: No, its not, and thats a perfect example of where someones not aware of the link--in that they have the Compassion Fatigue, they know theyve got to get out of the situation, and it takes that third party to come in and say, you know, something is wrong that you want to go from your nursing position to this janitors position. DR. MITCHELL: Its part of the experience of wanting to run away from whatever is causing the most pain. If people are causing the pain then you go into a profession where you dont really have to deal with people so much. So its the run-and-hide phenomenon. Its okay to have that reaction but its not okay to act on it in most cases, so we have to find all the other solutions. MS. SWITZER: And certainly the idea of losing folks like Gail and others who care is something that we want to make sure we can prevent. DR. BURGESS: She also gave something very important. She said in her thinking it was, "All I can do is push around some dirt. In other words, that is a metaphor that could be used, if you will, in helping her to explain more about what that meant to her. MS. SWITZER: This is coming from the Bay area hospital. Others who have been in these fields for many years are reluctant to buy into burnout or Compassion Fatigue, saying,"It's just psyche stuff. Before the terms, no one had burnout." How can we respond to them and help those who are supporting or experiencing this? DR. FIGLEY: Absolutely. And before we had PTSD no one was traumatized. And before we had substance abuse no one ever got drunk. This is the march of science, the evolution of knowledge. Its the sharing of information, comparing notes, and recognizing it. It really is what Jeff was talking about before. There are all kinds of ways of denying that are very appealing and, in some ways, very functional. MS. SWITZER: We had a caller earlier that wanted to know how you got beyond the denial. How do you get those who are in the process of denial by calling this just a bunch of psyche stuff?

Linda: Hi. We thank you for this opportunity. How can we help all the vulnerable caregivers who are not even aware of their vulnerability?
DR. FIGLEY: All of us have talked about this. I'll jump in for a little bit. How do you tell someone that they seem depressed? How do you approach someone who has just lost a child? How do you approach someone who has just lost their job. How do you approach someone who clearly is, it seems, out of control? You do it with respect, you do it with kindness, and, again, you use the terms. This is Compassion Fatigue which essentially suggests that it is an absolutely normal part of working with traumatized people. If you are not sensitive, you wont feel it. If you dont care, you wont feel it. DR. BURGESS: I would also say, just listen. Allow them the opportunity to talk. That is so helpful. And encourage them to talk. If they seem like they are denying it, just find ways to encourage them to talk. MS. SWITZER: Ann, one of the things that you spoke of earlier as a warning sign had to do with recurring thoughts. We have a caller from Indianapolis who wants you to please give some specific examples of recurring thoughts that are characteristic of Compassion Fatigue. DR. BURGESS: Well, the recurring thoughts would actually come from the content of what they have heard or seen. So if it is a patient that comes in with a particular issue, that is the issue that the person cant get out of their mind. It may be just one little fragment of it. It is not the whole situation. But for some reason they focus in on one. It could be hearing that the child was ill or having a life-threatening illness or something like that. They just cant get that out of their mind. It doesnt have any place in their usual work. They are going about their usual work and they just cant seem to get that out of their mind. 28

29

DR. MITCHELL: The problem is that there are a significant amount of growing studies that are showing that its not just psyche stuff, that it may be, in fact, a neurological manifestation and that it may show up in the nerve pathways of the brain. And especially if its significant traumatic stress it can change the brain chemistry and brain structure permanently. So the more research that we get on that, the more argument that we get of its just psyche stuff, people saying its all in your head. Well, it may be. Its all in the neurons. And we need to start working on those kinds of things. And, in fact, some of the newer techniques which have come up, like eye movement desensitizations, are actually on the borderline of getting into really stimulating nerve pathways which may reverse some of this. So there is a lot more to it than that. MS. SWITZER: I wanted to follow up on that in just a moment, but, Charles, you wanted to add something. DR. FIGLEY: Just briefly. I think its losing the point if you see it as just psyche stuff. Because obviously if somethings in your head and it comes in, it can come out, too. In other words, its an optimistic perspective that its only psyche stuff because it, hopefully, can be treated very effectively. But if you dont know what youre looking for, for example, I guess its just psyche stuff to suggest someone is grieving. But the fact is that someone died and they are hurting as a result of it. To give it a label suggests that there is hope that they will recover and that is really what we are all about here. MS. SWITZER: In following up a little on what you brought up, one of our callers from Indianapolis has asked the question, Have any of the panel used EMDR (eye movement desensitization and reprocessing) for treatment? DR. MITCHELL: I have been trained in the process and I have used it a few times and have found it to be quite remarkable: however, it is something that people need to be trained in and we need to have appropriate guidelines to use it or else it, like many other things, could be possibly harmful. So I think that its important to be trained in it. But, yes, it does work and it does work for traumatic stress. MS. SWITZER: It sounds like its pretty new but any results that you can report without having to give hard numbers at this time. Im not asking you to pull them out of your pocket, but... DR. MITCHELL: It may be hard for me to come up with the numbers but I have actually seen and witnessed the turnaround of some highly traumatized people who very rapidly recovered from the traumatic stress by having the eye movement desensitization and reprocessing done. MS. SWITZER: How available is that kind of training? 30

DR. MITCHELL: Its quite available now. It wasnt very much a couple of years ago, but it is quite available now. Many more people are using it. MS. SWITZER: Okay, Charles? DR. FIGLEY: I dont know if that is my colleague Don Hartsoe from Indianapolis, but Don is aware that there is an endless number of very effective methods of dealing with traumatic stress symptoms. And that is really what we are talking about. There is a great deal of overlap between Compassion Fatigue symptoms and post-traumatic stress symptoms-and EMDR is the latest wrinkle. But there are lots of other ways and thats why I am saying to those that are watching this, once they are able to calibrate their clients and see their colleagues who are traumatized, see them as clients, they can use the methods they have used successfully with other kinds of clients. MS. SWITZER: Staying with treatment, this is another one from Indianapolis. Have any of the panel used informal support networks, such as family and friends, in treating Compassion Fatigue? How is Compassion Fatigue evidenced in support networks? How can the members be treated? We talked about this a little bit earlier, but can we address it again more specifically for this caller? DR. BURGESS: I can just give an example of partner counseling as one very good method, or marital counseling, where you use a lot of the principles of psychoeducation around the phenomenon of the trauma and then move into the supportive counseling. DR. MITCHELL: I think its very important that people recognize that when one in the family system or one in an organization has been wounded by their Compassion Fatigue, that it then has an overshadowing effect on everyone else. And one of the things that I have tried to always encourage is making sure that its not looked at as the individuals situation or problem, but that its a family situation or an organizational situation or problem and working at it at that level, it distributes some of the pain and helps for a rapid recovery. MS. SWITZER: We are going to be continuing our discussion on Compassion Fatigue in just a moment, but we will give you this opportunity for a brief break. Stay with us.

MS. SWITZER: Well, were back. Weve got a lot of questions to answer. One of the questions that well begin discussing with our panel that also came up with a number of you that called in is, What can I do about it? Jeff, we want to 31

start the discussion with you, talking about during and following exposure to traumatized folks. What can I--what can we--do about it? DR. MITCHELL: During the exposure we have developed a number of processes that have worked very well. One of those is making sure people get appropriate breaks, not letting them work too long a period of time at one time, not letting them work on one situation for too long a period of time. We usually limit it like two hours of work and then they get a half hour down time or twelve hours tota1 work on one patient then transferred to somebody else. We also make sure that they get fed properly and get enough fluids in their system. We try to make sure that if they have a very difficult patient that they may be rotated off to a less intense patient. So there are a number of those kinds of things that can help right while they are in the situation. MS. SWITZER: Ann, when we talk about implications for nurses and other emergency medical personnel, what would you like to add to what we are saying here in terms of what can I do about it? DR. BURGESS: What I would like to add is to get a little bit of history as to how we solve this in working with victims. One of the things when we were training the nurses to carry on the victim counseling program, it became clear as they would describe the people that they were working with that they were beginning to experience many of the symptoms from the rape victims. These included not being able to sleep, having nightmares, being afraid to go out, a lot of somatic complaints. That is one of the very early signs, I think, a feeling of unrest in the body and so with the aches and the pains--very minor little things, but thats early on. So one of the things that we decided to do was to move to a group supervision kind of thing, to allow people to talk about the victims that they were seeing and to get the support from their colleagues as well as from the supervisors. In studying it even more, it became clear that the closer there was something in the nature of the experience they were listening to and identifying with, then we could almost predict that there was going to be an increased risk. We like to talk about an increased risk for developing Compassion Fatigue. So say somebody came in that was raped and was about the same age as the nurse. As we saw that, they could almost make assignments in a way that would try to counter as much as possible. So thats another way, kind of from a supervisory standpoint, built into the system of ways that you can help mitigate some of the intensity. MS. SWITZER: Before we take a phone call and ask some of our other viewer questions, what about the implications from mental health personnel on the question what can I do about it? DR. FIGLEY: They are in a perfect position to do something about it. They are in the business of helping other people. And if they include in their network of 32

potential clients their colleagues, then we are in business. The thing that I would say is that typically the people who recognize this are in the minority. So one thing I would say is to shout it from the rooftops. Dont be discouraged when other people deny it. Dont be discouraged when people dont want to talk about it. Its not to force them to talk about it but to suggest there needs to be an institutional change, that we need to recognize that its hard work and to do something about it and not shut up. MS. SWITZER: Anything you want to add Jeff? DR. MITCHELL: Well, I think it is like he says. Theres a lot of energy that has to be exerted. The more education we do, the more we get in to let people know, the better off we are going to be with this. MS. SWITZER: Well, lets travel to a part of a country thats a little bit cooler than Florida. Lets go to Cape Cod. Marcy is on the line. Marcy, hello. Marcy: Hello. This question is for Charles Figley. Thank you for your excellent presentation on Compassion Fatigue as it relates to professionals. But I was wondering if you could comment on the lay-public witnesses to critical incident stress that is broadcast live on TV and the effects of that and is there a general society Compassion Fatigue syndrome? Thank you. DR. FIGLEY: That is an excellent question. I think she already knows the answer probably because it is such an excellent question. What do you do about your kids or just yourself day in and day out watching television and the violence happening in our own neighborhoods? In other words, Compassion Fatigue happens to other people, not just us. I think that it is probably a normal response to the times that we are in. I think inevitably what happens is that we, perhaps, dont really respond very effectively. In other words, its one thing to turn the television off so you dont see reminders of it, its another thing to not being able to differentiate between those things that you have no control over, like the war in Bosnia, and with whats happening in your own neighborhood because we dont take the extra effort to care enough and to do something. The Tallahassee Democrat has a section, The Caring Connection, and on a regular basis they talk about families that are suffering tremendously. I understand that a lot of people skip over that section because they dont want to feel the compassion, perhaps because they feel they cant do anything about it. There are lots of things we all can do about it. MS. SWITZER: We want to move into a question now from Portland, Oregon. Gail, this question is for you. This caller is asking if you meant to imply that changing professions from a nurse to a social worker would be less stressful? 33

Ms. Davies: No, I did not intend to imply that at all. In social work and particularly clinical social work and any helping profession, you are at risk for the same kinds of experiences with Compassion Fatigue as in nursing. That was my attempt to get out of Compassion Fatigue before I knew what it was and it was just changing hats. But the only difference was that the color was different. The work that I do has also given me the opportunity to experience Compassion Fatigue and it has also given me the opportunity to learn how to find ways to minimize it and to address it. Im now at a point where I can avoid it if I pay attention to my own internal clues and listen to my colleagues and my friends who can clue me in on when they see changes in my behavior. MS. SWITZER: Thanks Gail. Im very glad that this next caller from Indianapolis phoned in this question because this is something that we had a chance to discuss off screen and then it kind of trails in with Gails smile on the beginning of her answer. This caller wants to know and wants you to comment on the role of humor in Compassion Fatigue. Weve talked a little bit about this. Jeff, Im going to come to you first. DR. MITCHELL: Im not sure why. Basically, I think that humor is one of the most helpful things that we can do. If we can laugh about something we can put it in perspective. I think we have to have a balance in it, that we have to be careful that our humor is not used at the wrong time, in the wrong place, under the wrong circumstances. I dont think that if we thought that something was funny professionally that the clients might think that it was quite as funny as we did. So I think if you use it well and you use it carefully that humor can really be a very positive thing, like all things when youre talking about recovering or staying out of Compassion Fatigue. I think it really is a balance that needs to be, a work balance, a home balance, a spiritual balance, an emotional balance, a balance in life and humor is one of those things that you have to keep in balance--but it sure can reduce the tension. DR. BURGESS: I would just like to say that this is one of the warning signs: people that become less humorous or they aren't laughing as much. I always add that as one of the signs. The other thing that you can do is to make sure that people read the funny paper, the comics. You know, have they stopped doing that. There has to be something on the page that they find funny. If they dont find anything funny on the page, then theres something wrong. MS. SWITZER: Charles? DR. FIGLEY: Its just fun to laugh. Its a natural stress reducer. I mean we can trace the biology of it to endorphins and all the mechanisms that take place. But, typically when we laugh, we laugh with other people. If we can feel comfortable in laughing with other people, we can tell them about our sorrows 34

as well. So I think it is just a very good indicator, as indicated here, that you are on the right track. DR. MITCHELL: It also keeps you from taking yourself all too seriously. And if you can have a balance in that then you are going to come out of it okay. MS. SWITZER: And thats exactly right. I know its saved my life on a number of occasions. Weve got a caller from Lexington, North Carolina. Linda, are you there? Linda: Yes. Weve heard a lot today about Compassion Fatigue for caregivers but we want to know what about the family members of these caregivers, these professionals, these volunteers who return home who are stressed out because of the trauma they have experienced. How do we help these families understand what their loved one is experiencing? How do we help them cope with that caregiver? MS. SWITZER: That is a good question Linda. Ann? DR. BURGESS: I would like to say I would like to empower the families that now they have a new label that they can give their partner that they, perhaps, are suffering from that and that might one of the ways to start breaking through some of the denial that may be there and that they need to be able to realize they can help their partner or their family member get out of that problem. MS. SWITZER: You mentioned partners therapy as well a little bit earlier in the program, so I imagine that it is important to involve the whole family unit. Charles? DR. FIGLEY: Well this, of course, at F.S.U. is our area. We see primarily that the unit of intervention is the family. I think something that a lot of people dont keep in mind, however, in working with the families, I want to say to those family members who have caregivers, whether they are cops, fire-fighters, or therapists, or nurses, they have rights, too, as a family member and they have a right to look their loved one right in the eyes and say, I appreciate the fact that you have Compassion Fatigue and in some ways it makes sense because youre a compassionate person, but youve used all your compassion up at work and you need to save some for us. That is a very legitimate thing to say. Typically we trust our family members a great deal in giving it to us straight how things are happening. We need to pay attention to that and do something about it. On the one hand they are very supportive and they can help us get over it, but on the other hand, in the process they may be affected as well, and we need to attend to everyone and not just the individual. MS. SWITZER: Okay. Lets go to Minnesota. Peter is on the line. Go ahead, Peter, with your question. 35

may be only part of it and we dont see this as a replacement, if you build a comprehensive system, we dont see this as a replacement for the psychologist,
Peter: I wanted to ask a question about systems denial. Could you give some advice about how an individual could approach an organization to deal with the reality of Compassion Fatigue within the system? DR. FIGLEY: Let me just jump in because I have the least experience than these two and so they can finish it up. I think the main thing is that managers are on a bottom line. They are concerned about productivity. They are concerned about competence, effectiveness, reputation. If you can link those important, critical, bottom line outcomes to the kinds of symptoms of stress and the disability that is connected to it, then you wont have much of an argument at all with those folks, at least. MS. SWITZER: I want to follow up with a question here and you can jump in on this one, Jeff, that came from Coos Bay, Oregon. What should employers do to assist employees in dealing with issues associated with Compassion Fatigue. You mentioned associating it with the bottom line, time off, financial support, support services. What should employers be doing? Jeff? DR. MITCHELL: I think they should start off that the entire organization is exposed to an education program of some sort on this to get it going. That would be a good place to go. But also there should be, if its a really traumatic event, critical incident stress debriefing programs for people. There should be one-on-ones where they can get individual counseling, family counseling programs, exercise programs, those kinds of things are very important. It sounds so simple to say, Well, exercise can help reduce this. Exercise can be one of the biggests defenses against this. So good exercise programs, good programs that empower people to get them to make decisions. Have them part of the management structure. Have an interactive management where people who are working in the field can say, Hey, can I make a suggestion, or, I think this would really work this way better." If you feel you have a stake in the organization youre going to put much more energy into working with it and youre probably going to feel more satisfied about the job overall. MS. SWITZER: Another caller says, Our hospital has a psychologist, so why do we need another or more comprehensive medical plan specifically for this problem? DR. BURGESS: The bottom line, is it working? MS. SWITZER: It may not. DR. MITCHELL: And often the psychologists is dealing with individuals and not looking necessarily totally at the entire organization with the health and welfare of all the people there. So I think you need to look at the job of the psychologist
36 we see it as another part of the whole system.

MS. SWITZER: What warning sign for the organization or for the system would there be that what they have in place isnt working? DR. MITCHELL: Organizations are in some ways like individuals. What you look for is lowering of performance, lowering of productivity. When you start seeing that, thats a pretty clear sign that your organization is starting to get sick and it needs some resolution. MS. SWITZER: Okay. Lets travel to Michigan for Larise's question. Go ahead, please. Larise: Hi. My first question is, what is the safest way for an employee to approach an employer if Compassion Fatigue is becoming a concern? The second question is how do you recognize symptoms in fellow family members if affected by another's Compassion Fatigue? MS. SWITZER: The first question, whats the safest way to approach? DR. FIGLEY: I dont know. I think a lot of it has to do with the particular employer. The thing that you have to keep in mind is the employers have to deal with lots of things as supervisors. For example, is this going to be a workers comp issue? If theyre afraid that if they admit that something is happening here that they will be liable for, there are all kinds of cautions. Compassion Fatigue is simply attending to our own needs and emotions as caregivers. Thats not complicated. Thats not suggesting anyones sick or ill or even that the system is letting you down, that the hospital or wherever it is, is letting you down. I think its really one of consciousness-raising anyway. MS. SWITZER: Jeff, quickly. DR. MITCHELL: Many people like to start off by going with the threats first. I think reach out as a friend, as a concerned person, you know, we are concerned about what you are going through. How can we help to make this better? MS. SWITZER:Dr. Matthew J. Friedman is the executive director of one of the systems that we will be talking about. We will be hearing from him a little bit later in the program. He is going to actually join us live on the line. But Dr. Figley had a chance to talk with him in Vermont a little bit earlier. Lets lake a look at this prerecorded message. 37

DR. FIGLEY: Matt, weve been talking about compassion stress and Compassion Fatigue. We are going to be with you live in a little bit. Tell me, who is most susceptible to this? DR. FRIEDMAN: These are people who really have just been so immersed in their work that they really do become susceptible to the kinds of symptoms that you talk about. These are people who sometimes--in the same way that we know that theres a dose response curve in PTSD between exposure to trauma and the likelihood of having post-traumatic symptoms--that these people, I would argue, have a greater dose of exposure as therapists to the traumatic problems and symptoms of their clientele and I think that if you dont come up for air, if you dont take care of that by having the debriefing with colleagues, knowing when youre just in too deep, that you, I think, do become susceptible to the material that youre getting and we know, those of us in the field, that when you do too much of this and when you dont do debriefing and other kinds of what I would call therapist hygiene, that you do start having secondary traumatic nightmares and you do start incorporating the traumatic material that may really belong to your client. DR. FIGLEY: I like the therapist hygiene term. It makes a lot of sense to me. So really what you are saying is that if you attend to therapist hygiene you are able to avoid Compassion Fatigue? DR. FRIEDMAN: And I think that the major occupational hazard that we professionals have is that we dont give ourselves permission to be upset, to react emotionally to the real life trauma that is going on as we, perhaps courageously but also I think ill-advisedly, proceed to provide professional care when we are really in no shape to do that. I think the first dictum is to take care of yourself so that you can take care of others. Because if you fail that, you are not going to be doing your job. DR. FIGLEY: Matt, what if our professionals, our colleagues succumb to Compassion Fatigue and are having an acute reaction? What do you think about drugs at that point? DR. FRIEDMAN: We feel that, particularly drugs like benzodiazepines, like Valium type of drugs are particularly useful in the acute phases. We are not advocating long term use of them but to calm people down. We think other drugs that can be used in acute anxious states such as clonidine and perhaps propranolol that can really calm down the sympathetic autonomic arousal that often accompanies such states, I think are also maybe very well tolerated and may be quite beneficial. Again, Im just giving you speculation. None of this has been proven. I think when the acute reaction progresses to a bona fide PTSD and one is dealing with the depressive and guilt types of symptoms as well as the anxiety and rage, I think then one has to think about other classes of drugs 38

and we, in particular, are thinking about perhaps some of the serotonin reuptake inhibitors such as fluoxetine, Prozac, and members of that family as drugs that we would think would be very attractive to test. We also think perhaps drugs like clonidine and also I think I wouldnt count out the tricyclic antidepressants such as imipramine and amitriptyline as well. So thats sort of where our thinking is at this point in time. I dont think that we would advocate using a drug like Valium for long-term treatment but I think for a short-term acute intervention we think it may be an excellent choice. DR. FIGLEY: So, Matt, given all of this, given all of your years of experience in this area, and you are clearly a leader, and all of the people that are worried about this, what would you say to professionals who may be at risk for Compassion Fatigue? DR. FRIEDMAN: We have to be honest with ourselves. We have to have an earlywarning system. We have to protect against our own denial and we have to give ourselves permission to be human beings. Because if we dont do that we are. I think, at a greater risk than other people. I think that we need to understand that the work that we do is extremely difficult. To have the courage to listen empathetically and to struggle to come up with some kinds of helpful therapeutic measures, tools for these people that are in such extreme states of suffering, bewilderment, hopelessness, etc. This is hard work and we dont have a limitless reservoir of resources to help them and if we think we do, were not only fooling ourselves, but I think we become dangerous. I think that one needs to approach this work with a profound sense of ones own vulnerability, fallibility, and how easy it is to lose ones objectivity when one becomes immersed in this kind of work. So we really have to have all kinds of safety valves, fail safe systems so that we can have a knowledgeable colleague or group of colleagues with whom we can do our own integration, processing, debriefing, call it what you will, and we will be open to the possibility that we have lost our way and maybe we need to stop the music as therapists until we have taken care of our own stuff so that we can then proceed as the kind of professionals that we want to be. DR. FIGLEY: That was really helpful, very helpful, Matt. MS. SWITZER: Dr. Friedman is also joining us by phone line. We are glad that you could join us. Dr. Friedman, are you there? DR. FRIEDMAN: I am. MS. SWITZER: We are going to, hopefully, give you a chance to answer some questions from some of our sites around the country, but Ive got a couple of questions that Id like to ask you first. In listening to your discussion, Im wondering, do you feel that medical personnel and, in particular doctors, are more resistant 39

to being open to taking a look at this kind of behavior or to the existence of Compassion Fatigue within themselves? DR. FRIEDMAN: Is the question are we more resistant? MS. SWITZER: Yes. DR. FRIEDMAN: I think we are and I tried to address that head on in my prerecorded comments. I think that there is an arrogance or just a misunderstanding that gets inculcated into us in terms of what one is supposed to be like when one is a helping professional whether he or she is a physician or a nurse or a social worker or a psychologist or what have you. I think that many people feel that it is being unprofessional to be a human being and I think we see this. Unfortunately I have missed the rest of the program so I guess that youve probably covered this in great depth, so whether one is an emergency care practitioner or mental health or a medical practitioner, I think that we are resistant out of ignorance because we, as I said, as a profession havent given ourselves permission that we are a very high-risk group of people and to acknowledge the risk and to have the kind of the structure through which that risk, after it has been acknowledged, can be addressed systemically and through what I call therapist hygiene. MS. SWITZER: It seems that underlying what you have said is that you are quite hopeful in dealing with Compassion Fatigue. Is that an accurate assessment, sir? DR. FRIEDMAN: I think the first step is, I guess, identification. I think Charles has done that and other people have done that. After identification, I think is acknowledgment. If one can acknowledge this then I think that we need to create a professional environment in which, after one acknowledges that there is a problem that there is someplace to go and there is someone who can help them. As with all other types of post-traumatic problems, the earlier one can acknowledge and detect this, the better the outlook and the outcome and then the shorter the suffering and the incapacity. MS. SWITZER: As if Charles Figley didnt have enough time in talking with you before, he has a question hed like to ask you live. Charles, you have an opportunity. DR. FIGLEY: Hi, Matt. DR. FRIEDMAN: Hi, Charles. DR. FIGLEY: Hows the weather in St. Louis?

DR. FRIEDMAN: Im in St. Louis. Its hot and humid. DR. FIGLEY: Not like Vermont. Matt, as you are very well aware, the National Center for PTSD Studies where you direct really has done seminal work, cuttingedge work in this area. Could you tell us your experiences in California and in many ways the discovery of how critically important intervening with professionals are? DR. FRIEDMAN: I will try be real brief. Basically, when the Loma Prieta earthquake hit in 1989 it wiped out the Palo Alto division of the V.A. Hospital and it shook up, literally, the Menlow Park division of the Palo Alto V.A. which is where the National Centers California division is located. So that, not only our patients, but more importantly for purposes of this question, our staff were very traumatized. They were very shook up. It was rush hour, they didnt know where their families were, they didnt know whether there kids were on the Cypress Expressway or on the Oakland Bay Bridge, etc. So the morning after the earthquake when Fred Gusman, who runs our Palo Alto division, was meeting with his staff and was about to let them go and do their clinical work, he looked around the room and he could see very easily from their remarks and their nonverbal communication that they were in no shape to deal with anybody, much less themselves, and basically Fred locked the door and said were going to have to do our own debriefing ourselves before Im going to let any of you near any of our patients. I am going to have to add that this is one of the most talented and experienced groups of post-traumatic therapists in the world, as far as I am concerned. They did their own debriefing and they did their own comparisons and emotional work with one another. After that took place they were able to work with patients and with other members of the hospital community. Four days later we went down to Santa Cruz, which is where the earthquake began. At this point in time I had flown out from the East Coast and was with Fred. We went down to Santa Cruz and we met with community leaders, etc., and tried to figure out what kind of a program could we put in place that would make sense and also that would have the biggest impact, perhaps, over the shortest time because we didnt know how long the V.A. was going to let us work with the civilians in Santa Cruz. So we came up with a program of helping the helpers since we felt, as I said earlier, and Im sure youve been saying throughout the program, that this is a very high-risk group. So during the course of the next 18 months we debriefed about 500 Red Cross workers, hundreds of mental health and medical personnel, school teachers who had a major role in debriefing the kids, law enforcement people, road crews, etc. So I think that this was my real experience with something I didnt know was called Compassion Fatigue at the time but it is clearly the phenomenon that this program is to address. Its very important to acknowledge it and to address it. I think we made a major impact. 41

40

MS. SWITZER: Dr. Friedman, we have a question here for you from Jackson Community College in Michigan. And this particular caller wants to know if you can identify a certain personality type that has a better tolerance for Compassion Fatigue? DR. FRIEDMAN: Well, I think that would go far beyond the data that we have right now and I think there are three different issues that I would like to address about that. Hopefully, I will answer the question, even though its not the question that was asked. Number one, I think mental health and therapist workers who have themselves been traumatized through working with patients who have been exposed to similar kind of trauma are particularly a high-risk group and I would argue that the work with the patients can actually trigger their own PTSD and I would call it PTSD in this case and not Compassion Fatigue (see chart 9). Im not talking about personality types. I think secondly people who have better coping and adaptive skills are probably less vulnerable to Compassion Fatigue than people who arent. Thirdly, we know there is a dose response relationship in PTSD, the greater the dose or the exposure to the trauma, whether its combat exposure or sexual assault exposure, the more likely one is going to have PTSD or some other kind of problem. I think fourthly, what we know from our work with PTSD is that the healing environment, the environment that the individual finds him or herself in after this exposure is crucial, whether its a workplace environment in which there is debriefing and some other kind of structural support available, whether its a family that can be supportive. So I would say that those are four major issues. As far as a particular personality type, I think it goes beyond personality types. I dont think thats the relevant issue. I think the relevant issues are the ones I have outlined. Maybe some of the panelists would disagree with that. MS. SWITZER: They are all shaking their heads so no one is going to disagree with that particular bit of information, Dr. Friedman. One other question. This caller wants to know about some of the myths that surround caregiving and caregivers that might actually inhibit not only our recognition of Compassion Fatigue but our effective dealing with it as well. Anything you would like to add Dr. Friedman? DR. FRIEDMAN: Well, I think weve addressed that partly, at least I think I have, in terms of part of the role of being a mental health or emergency or medical professional is to be tough, to be like in the movies, courageous and noble under fire and not to be a normal human being but to be somehow above that. I think part of the myth and it is a myth that is self-inflicted, although I think the culture invites this, is the professional as hero or heroine. I think, at least in western culture, heroes or heroines dont cry when theyre in pain, they grit their teeth and they smile and then they go out and save a hundred more lives. So I think that in one sense we are hostages to some of our own mythology, that like some self-inflicted mythology, it doesnt address the reality and I 42

Primary v. Secondary Traumatic Stress Disorder

PRIMARY
A. Stressor: Experienced an event outside the range of usual human experiences that would be markedly distressing to almost anyone: 1. Serious threat to self 2. Sudden destruction of ones environ

SECONDARY
A. Stressor: Experienced an event outside the range of usual human experiences that would be markedly distressing to almost anyone: 1. Serious threat to traumatized person (TP) 2. Sudden destruction of TPs environ

B. Reexperiencing Trauma Event 1. Recollections of event 2. Dreams of event 3. Sudden reexperiencing of event 4. Distress of reminders of event C. Avoidance/Numbing of Reminders of Event 1. Efforts to avoid thoughts/feelings 2. Efforts to avoid activities/situations 3. Psychogenic amnesia 4. Diminished interest in significant activities 5. Detachment/estrangements from others 6. Diminished affect 7. Sense of foreshortened future D. Persistent Arousal 1. Difficulty falling/staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hypervigilance for Self 5. Exaggerated startle responses 6. Physiologic reactivity to cues

B. Reexperiencing Trauma Event 1. Recollections of event/TP 2. Dreams of event/TP 3. Sudden reexperiencing of event/TP 4. Reminders of TP/event distressing C. Avoidance/Numbing of Reminders of Event 1. Efforts to avoid thoughts/feelings 2. Efforts to avoid activities/situations 3. Psychogenic amnesia 4. Diminished interest in significant activities 5. Detachment/estrangements from others 6. Diminished affect 7. Sense of foreshortened future D. Persistent Arousal 1. Difficulty falling/staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hyperviligance for TP 5. Exaggerated startle response 6. Physiologic reactivity to cues

Symptoms under one month duration are considered normal, acute, crisisrelated reactions. Those not manifesting until 6 months or more following the event are delayed PTSD or STSD. 1994, Charles Figley

| chart 9
43

think we need to address the reality and again acknowledge our own humanness, our own frailties, our own vulnerabilities, and how poor our judgement may become under such circumstances. MS. SWITZER: Dr. Friedman, I want to thank you for taking time out of your very busy schedule to join us today. Thank you so much. DR. FRIEDMAN: Thank you all. Good-bye. MS. SWITZER: Anything that you would like to add to Dr. Friedmans comments on the myths surrounding caregiving and caregivers. Ann? DR. BURGESS: I have one and I think we heard it very eloquently from Gail Davies on her interview and I think it speaks to not talking about something. There is the myth that an event can occur or you can hear something and you dont have to speak anymore about it. Thats just not the way the mind works and it does come out at some point. In terms of Compassion Fatigue we need to really emphasize that it is important to talk about concerns, intrusive thoughts, whatever. It is really important. DR. MITCHELL: Youre basically showing more maturity and strength by making the decision to talk it out and to bring it out to people you trust and who can help you with it rather than to try to bottle it all up inside. MS. SWITZER: Charles, did you want to make a brief comment? DR. FIGLEY: The myth that if you dont talk about it everything will be fine. The myth that if you say something that youre hurting that youre less a person, you should get out of the field, I think thats the biggest in my opinion. MS. SWITZER: Now we are going to travel to South Dakota where we have a very patient Derrick on the line. Derrick, go ahead with your question, please. Derrick: Thanks very much. Weve been dealing with flood victims in South Dakota since last August and as time goes on, many of the resources we have relied on to help our clients have run out of funding. As a result, our staff has started to express feelings of being less effective or even helpless. What my questions are, are, first of all, what can we do ourselves to deal with those helpless feelings and, more importantly, what do we need to do to make sure that we dont pass on our helpless feelings to the clients that we are trying to serve? DR. MITCHELL: First of all, regards to Jerry Jacobs students in South Dakota. One of the things that I would say is that we need to really make sure that we understand our limitations. As soon as we start thinking we have all the power and we have all the goodies, we set ourselves up for big problems. Realizing 44

that we are limited, that we can make a tiny drop in a bucket, but thats all we can make. Its a big bucket, especially when you are talking about the flood situation out there and its very, very difficult to go beyond that. And at the same time you dont want to be approaching people who are depressed and looking cheery, cheery, cheery, and happy all the time because that can kind of drive them down further. So you need to acknowledge their pain, take the things that can be enlightening and fun and use those and the things that are really down, listen to that, acknowledge the pain, try to do what you can to help and make that small dent but dont expect that you have all the answers because you are only one part of the whole process. MS. SWITZER: Charles? DR. FIGLEY: I would say the essence of it is connectiveness with people that are in the same situation. I dare say, people that are watching this in a group setting, there has to be some that they have never met before. My hope in this program is that they look at least one other person in the eye and say lets talk and they compare notes about how their life is going, including Compassion Fatigue. The people that I worry about out in the field are those that dont have access to other people, that rarely have an opportunity to talk about it, and that their close friends they fear that they will traumatize them in the process. That is another myth that is not going to happen. MS. SWITZER: We have got a couple of questions in this area. This is coming from Coos Bay, Oregon. Is Secondary Post-Traumatic Stress Disorder in the new DSM-IV and if so, can caregivers get health benefits to deal with Compassion Fatigue? If not, how do caregivers avoid negative labels to get help? Good questions. DR. FIGLEY: I worked on the DSM-IV and as a matter of fact, very close to a point in which we closed off all discussion was when the notion of secondary traumatic stress emerged. It takes a very long time for this to emerge. Essentially, it is very similar and a lot of overlap with Post-Traumatic Stress Disorder. Its essentially, if you look at the criteria A in DSM for PTSD, it indicates not only exposure to traumatic events, but people that you care about who have been exposed. And as therapists, as husbands, as children, whoever, we care about lots of people beyond ourselves. DR. MITCHELL: When we talked about myths before, one of the myths to be careful of is just because it doesnt appear in DSM-IV, doesnt mean it doesnt exist. MS. SWITZER: Thats a good one. This question comes from the North Bend Police in Oregon College, Coos Bay. Can office morale and supervisors failure to commend subordinates for their work efforts be a contributing factor? I would 45

imagine in the experience of lack of support, it could indeed aggravate a situation. DR. MITCHELL: Thats the big picture of burnout again, thats that larger umbrella. So, yeah, can it contribute to it? Sure. If you dont feel appreciated and then you have to go work with clients youre certainly not going to have as much energy to work with those clients as if somebody had said, Hey, you know, we really like your work and you did a good job. MS. SWITZER: This is coming from Peoria, Illinois. At what point does a clinical supervisor determine that it is no longer an issue of supervision, but that the person is in need of treatment for his or her Compassion Fatigue? DR. FIGLEY: Id like to try that out. We have a Ph.D. program here at F.S.U. and we train lots of doctoral students to go on to become, we hope, very good psychotherapists. Endlessly, as supervisors, we are concerned about that issue of when the therapist crosses a line and it appears to be not necessarily a professional judgement issue but a personal issue. I think a lot of it has to do with obvious things that a therapist should pick up on, should be doing something about, should be noticing and theyre not. Then we try to figure out why thats happening. In my opinion, personal reasons are down the list a while. I always assume that I simply havent told them this or they dont have enough experience. But typically its a notion of your supervisee not doing as an effective job as youve come to expect and then look around for reasons and one of those reasons may be Compassion Fatigue and it may not.
MS. SWITZER:

ELEMENTS IN CRISIS INTERVENTION PROGRAMS WITH PROFESSIONALS

RESPECT
Respect - for the compassion trapped; appreciate sources of stress, stress reactions Educate - about range of reactions, burnout v. traumatization Stabilize - help become functional for self, supporters, and clients Pamper - increase endurance with attention to own needs Empower - enabling them to discover and take credit for relief and solutions Calm - concentration on hope and road to recovery Transfer - to another person or support group for long-term, post-crisis attention Charles Figley
| chart 10 |

MS. SWITZER: Lets focus for a little bit here, because were winding out of time, on prevention efforts. And Ill begin with a question from Indianapolis. Can you expand on types of training that are available to professionals who are susceptible to Compassion Fatigue? This is right on the line with prevention. Ann? DR. BURGESS: First of all I think we all need to remember that we all are vulnerable to it. Its not like somebody is more or less likely, that we all have to address that and that the model for intervention that Id like to suggest is something that we train in nursing for at the programs at the University of Pennsylvania and that has to do with a six step. Very quickly and very briefly, the first two steps the person themselves are responsible for and that first step is the autodiagnosing and the self-awareness, always constantly asking after seeing patients and so forth. The second step has to do with building resources and has to do with everything that weve talked about here, how to take care of yourself, the rest, the sleep, etc. But then three, four, and five have to do with when there is an issue of Compassion Fatigue, to raise it as an issue, to surface it, to begin processing it, talking about it, and that needs to get to someone else. You cannot do this part alone. The fifth is that if its been adequately processed it can go to long-term memory, using the information processing model and it doesnt come back as a repetitive thought. The last step is to kind of go back and reevaluate. MS. SWITZER: Charles? DR. FIGLEY: Thats great. I cant top that. Thats just superb. Essentially, its suggesting its an empowerment model, isnt it? Because its up to us to do something about it (see chart 10). If we recognize that we are a sensitive, caring person, that we tend to take on the issues of other people then we know 47

Were going to ask one other question before we focus on perhaps some efforts for prevention. This has to do with a specific question from Hays, Kansas. How does Compassion Fatigue differ from countertransference? Weve got a lot of takers on this one. Yes, Ann?

DR. BURGESS: There are similarities and there are crossovers. I believe countertransference may be a part of Compassion Fatigue. It has much more to do with reaction to the patient and reaction to rather than what we are saying is the intrusive thoughts, the mulling over what the patient has told us and we have heard. That is much more in line with the Compassion Fatigue than the countertransfer. Maybe Jeff has some more?
DR. MITCHELL:

I agree. Once somebody personalizes the patients situation and they start looking at it as if they were in that situation, how would they be, I think then that you are setting up that countertransference which really then can have a fairly debilitating effect upon people later. So its really the perception of some have a client that patient is just like me or I could be just like them.

46

we are vulnerable and if we go through those steps, there is a beginning and end to it and theres hope. MS. SWITZER: Jeff, anything youd like to add for prevention strategies? DR. MITCHELL: I think we start with education, we make sure we focus on support services while the situation is going on, rapid intervention before people lock in their concepts like Gee, I really failed or Im no good and then one-on-one support and broaden it out to the family or the systems approach. And if you do those things and combine it with what weve said here, I think you could pretty well handle it. MS. SWITZER: Lets talk a little about some of the resources available. I also want to hit on the self-test information that is available in their packet. Lets tell folks about whats out there. DR. FIGLEY: Well, just very quickly, I hope that those who are watching this program will go back to their hospitals and universities but also I hope theyll go back to their professional organizations. Thats one of the reasons why professional organizations exist is to take care of their membership and their personal aspects of their membership are certainly one element to it. With regard to the self-test, we developed the self-test for psychotherapists and for practitioners and health caregivers mostly because they could take this test and they know just themselves how they do. Essentially it gives a readout, a score of their potential vulnerability for burnout and their potential vulnerability for Compassion Fatigue. Its very quick and easy. MS. SWITZER: Anything youd like to add, folks? Weve got a couple of other questions before I give you the opportunity for concluding remarks. These have come in from our viewers around the country. This one is from Jackson, Michigan. It also came from several other folks. I see this question repeated as theyre handed in. How would you address clergy who perceive themselves as having to be perfect in living up to Gods expectations? This is a category that we havent really talked about, but several folks are concerned about. DR. FIGLEY: Im so delighted that this caller mentioned this because we keep forgetting the clergy and its very interesting, isnt it, that we havent mentioned them once yet. In my opinion, they are among the most vulnerable because theirs isnt limited to traumatic stress. Theirs isnt limited to anyone in acute care or critical incidences. Their issues are the issues of everyone who see them as a minister or a rabbi or a priest and actually everything that weve said, I think, applies to them. MS. SWITZER: One other question. Any gender differences in developing Compassion Fatigue or in recognizing Compassion Fatigue? 48

DR. MITCHELL: My experience with emergency personnel is that women tend to express it faster. First of all they tend to express the compassion faster and then they also express the symptoms faster; however, it doesnt mean that men are not reacting to it. They do have those reactions and they do get traumatized by the stuff and they need to express it. They feel less safe in expressing it because society says big boys dont cry, so it makes it more difficult. I also find that when people do express it they stay healthier. They tend to just stay on their jobs longer and they stay much more functional. MS. SWITZER: And as Dr. Friedman said a little earlier, weve got to give ourselves permission to be human. DR. FIGLEY: Just quickly, one of the most important studies in American history in terms of mental health epidemiology was done focusing on the long term impact of the Vietnam War. They included women nurses like Gail as well as others who were in Vietnam. They found that the incidence of Post-Traumatic Stress Disorder related to war was about 15% among males. It was about 8% among females. So certainly women are more sensitive, more aware, but also they do something about it and as a result their incidence level is about half that of men, if you can generalize. MS. SWITZER: One other question. How can we help caregivers who are not on a professional level, such as our foster parents, our big brothers, big sisters, recreation advisors, or volunteers who seem to stay in this area? DR. BURGESS: I would suggest getting training programs made available to them, to invite them in when training programs are going on, getting workshops, getting the word out to them. DR. FIGLEY: Thats part of their training. Its part of the curriculum. You want to develop skills in being able to help people as a paraprofessional but in order to hold onto those volunteers you need to be able to do what Ann is saying, have training programs just for themselves, focusing on their issues. MS. SWITZER: Weve got a few minutes left, a chance for about a one minute closing statement from each of you. Jeff, Ill begin with you. DR. MITCHELL: I think what people need, again, is back to that balance, keep the balance in life. Balance all the levels of life. You can survive through this stuff. If you get Compassion Fatigue, get help. MS. SWITZER: Ann? 49

DR. BURGESS: I go for the education model to make sure that this is talked about. Compassion Fatigue is maybe a new concept for many people. Start taIking about it, get educated on it, and get the word out. MS. SWITZER: Charles? DR. FIGLEY: I cant really add to that much. The only thing I guess I can say is that were human beings and that if anyone gives us any kind of indication as a human being that they are suffering these kinds of symptoms, the one main thing we need to do is show our respect for them. Because typically when we show disrespect it says more about ourselves and how much were worried about this than about the other person. MS. SWITZER: I want to thank you all, Charles Figley. You folks have just been wonderful being here, Ann Burgess, Jeff Mitchell, a wonderful job. Weve had a great job done by our folks that are joining us by phone line as well, Dr. Solomon and Dr. Friedman. We are glad that they were with us. We also want to thank all of you who joined us by telephone and by satellite today with your questions. I think our panelists were genuinely impressed by the depth of your compassion and caring and professionalism and the degree to which you had researched your questions and the questions you asked were indeed challenging and good ones for this inaugural broadcast on Compassion Fatigue. We want to make sure that we thank all of our sponsoring organizations. We had a lot of folks that took part in making this broadcast possible to over 30 states around the country and to all of our endorsing organizations because there were a number of professional organizations that let us know that what was happening here today is very important. We also want to thank you for your participation as I mentioned before. We want to leave you with these thoughts from the professionals you met early in the program who are sharing their thoughts and feelings about caring too much.

JOYCE: Thats where I think you have to develop an attitude of where your responsibilities are, what your limits are, and set goals for yourself that dont exceed your limits. LARRY: It really takes a real man or a real woman to step forward to admit that they have a problem because if something happens to yourself, you cannot help anybody else. KEN: Because if we arent taking care of ourselves, loving ourselves, then were not going to be able to help other people in a very therapeutic fashion. GLORIA: Ill say its balcony time. And that means I need to get away, I need time out right now. And so I know that thats a resource that I can use when Im at my wits end. LARRY: I want to stress that theres no problem with seeking help, whether its a support group and psychologist, psychiatrist, or just a personal doctor can help out in this area, a good friend. You need to open up, you need to talk. GLORIA: Its mandatory to have someone else to listen to you and to cry with you. JOYCE: Its so important for all persons who are caregivers to watch their fellow caregivers and to pick up the slack and to recognize this and to give people crying space because cryings okay. In fact, its very good. If you dont cry and you dont deal with it, then it doesnt go away and you dont resolve it.

[Closing prerecorded vignette featuring the same professionals in the opening...] JOYCE: Compassion Fatigue is loving and caring and extending yourself to your very limits for people. KEN: I myself cannot heal anyone or make them well, make them better. Theres a lot of other variables involved in caregiving. LARRY: There is no real macho man in uniform. I dont care how anybody displays, we are all human beings.

50

51

SPONSORS
Compassion Fatigue: The Stress of Caring Too Much

Ann Wolbert Burgess, DNSc, RN

Division Head and van Ameringen Professor of Psychiatric Mental Health Nursing, University of Pennsylvania School of Nursing; and Associate Director of Nursing Research, Department of Health and Hospitals, City of Boston.

was presented by PBS Adult Learning Satellite Service; National Mental Health Association; Florida State University Psychosocial Stress Research Program; and Visionary Productions. This program is endorsed by

Professional Affiliations American Nurses Association; American Academy of Nursing; Fellow, American Orthopsychiatric Association; National Organization for Victim Assistance; Society for Traumatic Stress Studies; American Professional Society on the Abuse of Children; Chair, Study Section on HIV and Related Research, National Institutes of Health; et al. SELECTED RECENT PUBLICATIONS

The National Center for Post-Traumatic Stress Disorders, Department of Veteran Affairs; The American Association of Critical-Care Nurses; The International Association of Psychosocial Rehabilitation Services; The International Association of Trauma Counselors; The International Union of Police Associations; The National Association of Hispanic Nurses; The National Association of School Nurses; The National Leadership Coalition on AIDS; and The National Organization for Victim Assistance. For more information on Compassion Fatigue, contact Dr. Charles Figley (address on page 5), or call Florida State University Psychosocial Stress Research Program, (904) 688-1588 International Association of Psychosocial Rehabilitation Services, (410) 430-7190 International Union of Police Association, (703) 549-7473 National Association of Hispanic Nurses, (202) 387-2477 National Association of School Nurses, (207) 883-2117 National Leadership Coalition on AIDS, (202) 429-0930 National Mental Health Association, (800) 366-6642 National Center for PTSD, U.S. Department of Veteran Affairs, (802) 296-5132 This program was approved by the American Association of Critical-Care Nurses for 2 contact hours, CERP category E, and by the Florida State University Center for Professional Development and Public Services for 0.3 continuing education units or 3 contact hours for social workers, mental health counselors, and other human services professionals. Those seeking AACN continuing education credits through March 1995 should write Visionary Productions (2809 West 15th Street, suite 202, Panama City, Florida 32401) for evaluation materials and instructions. 52

Childrens Drawings. With C. R. Hartman. In Child Abuse and Neglect, forthcoming. Memory and Cognition in Children. With C. R. Hartman. In Child Abuse and Neglect, forthcoming. Workplace Fear of AIDS. With B. Jacobson, T. Baker, J. Thompson, and C. Grant. In Journal of Emergency Nursing,18(3), 1992. Research on AIDS and Sexual Assault. With T. Baker. In Hospital and Community Psychiatry, 43(5), 1992. Child Trauma: Issues and Research, (Ed.), New York: Garland, 1992. The Crime Classification Manual, with J. E. Douglas, A. G. Burgess, and R. K. Ressler. New York: Macmillan, 1992. Nursing Interventions with Children and Adolescents Experiencing Sexually Aggressive Responses. With C. R. Hartman. In P. West and C. Evans (Eds.), Psychiatric and Mental Health Nursing with Children and Adolescents ,Gaithersburg, MD: Aspen Publications, 1992. Victims of Rape and Sexual Abuse. With C. R. Hartman. In L. Aiken and C. Fagin (Eds.), Charting Nursings Future: Agenda for the 1990s, Philadelphia: Lippincott. 1992. Child Molesters who Abduct. With R. A. Prentky, R. A. Knight, R. Ressler, J. Campbell, and K. V. Lanning. In Violence and Victims, 6(3), 1991. Psvchiatric Nurshing in the Hospital and the Community, Englewood Cliffs, NJ: Prentice Hall. Fifth ed.. 1990; fourth ed., l985; third ed., 1981; second ed., 1976; first ed., 1973 with A. Lazare. 53

Charles R. Figley, PhD

Professor of Family Therapy, Florida State University; and Director, FSU Marriage and Family Therapy Center and Director, Psychosocial Stress Research Program.

Matthew J. Friedman, MD, PhD

Executive Director, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs; and Professor of Psychiatry and Pharmacology, Dartmouth Medical School.

Professional Affiliations International Society for Traumatic Stress Studies (Board of Directors); International Advisory Board, American Critical Incident Stress Foundation; American Psychological Assocation Family Psychology Division (Board of Directors); Director, National Consortium on Veterans Studies; Institute for Victims of Terrorism (Board of Directors); Fellow, American Association for Marriage and Family Therapy; National Association of Social Workers: et al. SELECTED RECENT PUBLICATIONS Compassion Fatigue: Secondary Traumatic Stress Disorder from Helping the Traumatized, (Ed.) Wasington: Brunner/Mazel, will appear in February 1995.
Beyond Trauma, with R. Kleberand B. Gersons (Eds.), New York: Plenum Press, 1994.

A leading authority on the clinical psychopharmacology of Post-Traumatic Stress Disorder, Dr. Friedman has authored numerous scholarly articles and practice papers focusing on this and other topics. He has been recognized for his contributions, incIuding receiving twice the National Commanders Award, Disabled American Veterans (for his work with Vietnam veterans) and receiving other honors from organizations from Hospital and Community Psychiatry to the Association of Military Surgeons of the United States. Dr. Friedman is a Fellow of the American Psychiatric Association and a member of the Board of Directors of the International Society for Traumatic Stress Studies; he is the Editorial Director of the PTSD Research Quarterly and serves on the editorial boards of other scholarly journals. SELECTED RECENT PUBLICATIONS s of Post-Traumatic Stress Disorders, with A. J. Marsella, E. Gerrity, and R. M. Scurtield (Eds.), Washington: American Psychological Association, in preparation. Clini cal Consequences of Stress: From Normal Adaptation to PTSD. With D. S. Charney and A. Y. Deutch (Eds.). New York: Raven Press, in preparation. PTSD as a persistent mental illness. With R. A. Rosenheck. In S. Soreff (Ed.), The Ill: The State __ the - Art Treatment Handbook, of Seattle: Hogrefe & Huber, in press. PTSD among refugees. With J. M. Jaranson. In A. J. Marsella, T. H. Bomeman, and J. Orley (Eds.), Peril and Pain: The Mental Health and Well-Being of the Worlds Refugees, Washington: American Psychological Association, in press. Psychobiological and pharmacological approaches to treatment of PTSD. In J. P. Wilson and B. Raphael (Eds.), The International Handbook of Traumatic Stress Syndromes, New York: Plenum Press, 1993. The effects of hospitalizations on medical and psychiatric outpatient service utilization in a VA setting. With P. M. Massad and A. N. West. In Hospital and Community Psychiatry, 44, 1993. Pharmacotherapy for recently evacuated military casualties. With D. S. Charney and S. M. Southwick. In Military Medicine,198, 1993. 55

Post-Traumatic Stress Disorder in Family Psychologists. In R. H. Mikesell, D. Lusterman, and S. H. McDaniel (Eds.) Family Psychology and Systems Therapy: A Handbook, Washington: American Psychological Association, 1994. Weathering the Storm at Home: Gulf War-related family stress and coping. In F. W. Kaslow (Ed.) The Military Family in Peace and War, New York: Springer, 1993. Coping with stressors on the home front. Journal of Social Issues, 49(4). 1993. Intervention with Families and the Children of the Troops: War-Related Secondary Traumatic Stress. In L. A. Leavitt and N. A. Fox (Eds.). Psychosocial Effects of War and Violence on Children, New York: Erlbaum, 1993. Helping the Traumatized Families, San Francisco: Jossey-Bass, 1989. Treating Stress in Families, (Ed.) New York: Brunner/Mazel, 1989. Trauma and its Wake, volume II: Traumatic Stress Disorder: Theory, Research and Treatment, (Ed.) New York Brunner/Mazer, 1986. Commuters and Familv Therapy, (Ed.) New York: Haworth Press, 1985. Trauma and its Wake: The Study and Treatment of Post-Traumatic Stress Disorders, New York: Brunner/Mazel, 1985. 54

Jeffrey T. Mitchell, PhD

President, International Critical Incident Stress Foundation, Inc.; Clinical Associate Professor of Emergency Health Services, University of Maryland Baltimore County; Associate Member of the Graduate Faculty, University of Maryland; and Adjunct Faculty, Emergency Management Institute, National Emergency Training Center

Zahava Solomon, PhD

Associate Professor of Social Work, Tel Aviv University; and Lieurenant Colonel, Medical Corps, Israel Defense Forces.

Jeffrey T. Mitchell, Ph.D., is a Clinical Associate Professor of Emergency Health Services at the Catonsville Campus of the University of Maryland and President and cofounder of the International Critical Incident Stress Foundation. He has authored over seventy-five articles on stress, Critical Incident Stress Debriefing, disaster psychology, and crisis intervention. He has made presentations at the United Nations and has spoken in twelve nations and all fifty states. He is also the the senior author of four books: Human Elements Training for Emergency Services, Public Safety. and Disaster Relief Personnel (1994), Critical Incident Stress Debriefing (1993), Emergency Services Stress (1990), and Emergency Response to Crisis (1981). Dr. Mitchell is one of the leading authorities in the world on crisis intervention and traumatic stress management for high-risk occupations. He is the developer of the Critical Incident Stress Debriefing (CISD) intervention. Professional Affiliations American Psychological Association; International Society of Traumatic Stress Studies; National Registry of Emergency Medical Technicians; National Association of Emergency Medical Technicians; National Association of Search and Rescue; Director, Critical Incident Stress Debriefing Team Network; et al. SELECTED RECENT PUBLICATIONS Critical Incident Stress Debriefing (CISD): An operations manual for the prevention of traumatic stress among emergency services and disaster workers. With G. S. Everly. Ellicott City, MD: Chevron Publishing Corporation, 1993. Comprehensive traumatic stress management in the emergency department. In Journal of Emernency Nursing, in press. Law enforcement applications of critical incident stress teams. In J. T. Reese (Ed.) Critical Incidents in Policing, Revised. Washington, DC: US Department of Justice, Federal Bureau of Investigation. Emergency Services Stress: Guidelines for preserving the health and careers of emergency services personnel. With G. P. Bray. Englewood Cliffs, NJ: Brady Publishing, 1990. Development and functions of a critical incident debriefing team. In Journal of Emergency Medical Services 13(12), 1988. 56

A leader in the field of post-traumatic stress and secondary stress, she is the author of two books and more than one hundred articles on trauma. She has studied CSR casualties, ex-POWs and their spouses, Holocaust survivors and their offspring, as well as the reaction of the civilian Israeli population to war. She is an advisor to the Israeli Ministry of Defense, the Israeli Academy of Sciences, the Ministry of Health and the Ministry of Science, and is a member of the American Psychiatric Association DSM-IV advisory subcommittee for Post-Traumatic Stress Disorder. Professional Affiliations American Association for the Advancement of Science; World Psychiatric Organization; Military Psychiatry (elected board member); The Section of Medical Sociology; The Israeli Society for Traumatic Stress Studies; The International Society for Traumatic Stress Studies (elected board member); The Israeli Association of Epidemiology; et al. SELECTED RECENT PUBLICATIONS Coping with War-Induced Stress: The Gulf War and the Israeli Response, forthcoming in the Plenum series on Stress and Coping, New York. Aged Holocaust Survivors: the Effect of Prior Experience on Anxiety Symptoms Resulting from a Stale of War. Forthcoming in Clinical Gerontologist. With S. Hantmann and E. Prager; 1994. Combat Stress Reaction: The Enduring Toll of War, New York: Plenum Press, 1993 Stress reaction of school-age children to bombardment by Scud missiles. Journal of Abnormal Psvchology 102(3), 404-410. With J. Schwarzwald, M. Weisenberg, M. Waysman, and A. Kligman; 1993. Secondary Traumatization among Wives of Post-Traumatic Combat Veterans: A Family Typology. Journal of Familv Psvchology, 7:1-17. With M. Waysman, M. Mikulincer, and M. Weisenberg; 1993. Immediate and long-term effects of traumatic combat stress among Israeli veterans of the Lebanon War. In J. P. Wilson & B. Raphael (Eds.), The International Handbook of Traumatic Stress Svndromes, vol. 1, New York: Plenum Press, 1993. From Front Line to Home Front: Secondary Traumatization Among Wives of Combat Stress Reaction Casualties. Medical Corps, Department of Mental Health. Israel Defense Forces, 1992. 57

Index
A
anxiety -- 23, 38 auto-diagnosing -- 17, 47

Why should one care about it? -- 12 compassion stress -- 37 model - 21 countertransference -- 46 v. compassion fatigue - 46 critical incident stress -- 19, 20, 33, 36 v. compassion fatigue - 14 critical incidents -- 13, 15, 48 curriculum -- 16, 21, 49

B
biology -- 12 brain -- 12, 15, 29 Burgess, Ann Wolbert, DNSc, RN -- 53 burnout -- 10-11, 17-18, 29, 45, 48 defined in chart - 11 v. compassion fatigue - 10

D
Davies, Gail, RN, MSW -- 24 debriefing -- 14, 36, 38-39, 41-42 denial -- 18- 19, 28-29, 32, 39 in the family - 35 institutional - 19, 35 professional - 15 depression -- 16, 23, 28, 38 drugs -- 38 DSM-IV -- 45

C
charts 1, definition of burnout -- 11 2, definition of Compassion Fatigue -- 11 3, vulnerability of emergency personnel -- 13 4, most upsetting incidents -- 15 5, a Hippocrates magazine survey (extracts) -- 16 6, emotional suppression -- 18 7, a model of Compassion Stress -- 21 8, a model of Compassion Fatigue -- 22 9, Primary v. Secondary Traumatic Stress Disorder -- 43 10, Elements in crisis intervention programs with professionals: RESPECT -- 47 checklist -- 17 clergy -- 48 clients -- 1l-12, 15, 19, 24, 26-27, 31-32, 34, 38, 44, 46 combat fatigue -- 27 compassion fatigue -- 10-l 1 cost of - 13 critical incident stress -- 14 defined in chart -- 11 model -- 22 purpose of the name - 17, 30, 35 v. burnout - 10 v. countertransference -- 46 v. post-traumatic stress disorder -- 11, 23, 31, 42-43, 45 What can one do about it? - 31-32 58

E
education -- 16, 19-20, 33, 36, 48, 49 emergency personnel -- 13, 15, 18, 27, 32, 41-42, 48 employees/employers. See workplace ethics -- 16, 18, 20 exercise -- 36 eye movement desensitization and processing (EMDR) -- 30-31

F
family -- 13-14, 16, 23-25, 27, 31, 35-37, 45, 48 Figley, Charles R., PhD -- 54 folie deux -- 22 Friedman, Matthew J., MD, PhD -- 55

H
Hippocrates magazine -- 16

humor -- 34 I information processing model -- 47

59

L
limbic system -- 12, 15

M
mental health workers -- 32, 40- 42 Mitchell, Jeffrey T., PhD -- 56 morale -- 13, 45

stress disorder: secondary traumatic stress; secondary traumatic stress disorder; traumatic stress supervisors. See workplace susceptibility. See vulnerability symptoms -- 11, 17-18, 20, 23, 25, 3 1-32, 36-38, 50 onset of - 13, 23, 26-27, 48 Persistence of - 27, 40

N
nurses -- 24-27, 29, 32-33, 35, 40, 47, 49

T
television -- 33 therapist hygiene -- 20, 38 therapists -- 22, 39, 41-42, 45-46 training -- 13, 16, 20, 30, 32, 46, 49 traumatic stress -- 10, 29-3 1, 48 treatment -- 30-32, 39, 44, 46-47

0
obsessive-compulsive problems -- 23 P paranoid ideation -- 23 personality types -- 4l-42 physicians -- 16, 40 post-traumatic stress disorder (PTSD) -- 10, 14-15, 23-24, 27, 29, 38, 40, 42, 45, 49 v. compassion fatigue - 11, 23, 31, 42-43, 45 practitioners -- 17, 19, 48 prevention -- 13-14, 26, 28, 46-47 professionals -- 10, 12-13, 16, 20, 24, 39 psychoeducation -- 31 psychotherapists -- 17, 46, 48

U
universal vulnerability -- 13, 18

V
victim counseling program -- 32 vulnerability -- 11, 13, 16-19, 22, 28, 32-33, 37, 39-42, 46-47, 51. See also universal vulnerability

W
warning signs -- 12, 16-17, 19, 28, 32, 34, 37 women -- 48-49 workers compensation -- 37 workplace -- 11-14, 17-19, 26, 3 1-33, 35-37, 42, 45-46, 49

R
RESPECT anacronym -- 47 risk. See vulnerability

S
secondary traumatic stress -- 10, 23, 38, 45 secondary traumatic stress disorder -- 43 self-auditing -- 17 self-test -- 5-6, 17, 48 sensory system -- 15 social workers -- 23, 26, 33, 40 Solomon, Zahava, PhD -- 57 somatic illnesses -- 23 somatization -- 23 stress -- 12, 34. See also compassion stress; critical incident stress; post-traumatic 60 61

Some other titles in Visionary Productions Mental Health Video Library

A leader in distance education products

Mental Ill-Literacy: Sharing the Light: This three-hour program takes a look at the intimately personal side of mental illness and provides informative and encouraging clinical information on mental illness by qualified experts. Specific topics discussed include anxiety disorders, mood disorders and schizophrenia. The flexible format features documentary film reports, studio discussion with experts and call-in backgrounders to frame the issues surrounding mental illness, including symptoms, clinical explanations, community issues and current research and treatment. 1991, in cooperation with National Mental Health Association,
et. al.

Depression in Children Adolescents and the Elderly: This program presents in-depth information on the impact of depression on children, youth and the elderly. Originally broadcast as a live videoconference, this two-hour program includes presentations by nationally-renowned experts who provide clinical explanations and insights into this illness, and personal accounts from patients who reveal how they coped with depression and its impact on their lives. The program addresses etiology, subtypes of depression, biological studies, treatment and suicide. 1992, in cooperation with National Mental Health Association and PBS Adult
Learning Satellite Service, et. al

Understanding Childhood Mental Disorders: The goal of this two-hour program, originally aired as a live videoconference, is to increase the knowledge and awareness of those in the best position to help children and adolescents who have or may be at risk of suffering, a mental disorder. Specific disorders discussed include obsessive-compulsive disorder, attention-deficit disorder and depression. This is an excellent professional development opportunity for all those who work with children. 1993, in cooperation with National Mental Health
Association and PBS Adult Learning Satellite Service, et al.

Mental Health Matters: A Global Concern: In recognition of the 2nd Annual World Mental Health Day, the worlds foremost experts in the field of mental health gathered in Washington and Paris to make visible the consequences of mental and emotional disorders and to heighten the publics awareness of treatment and prevention. This program examines how mental disorders are viewed in different parts of the world, what mental illness means to society and what can be done to educate the public to the importance of mental illness awareness. Dr. Norman Sartorius, Director of the WHO Mental Health Division, leads world-renowned experts in a presentation of the most current and essential information on epidemiology of mental illness; the biological, psychological and social aspects of mental disorders and services available. 1993, in cooperation
with the World Health Organization, World Federation for Mental Health and NHA Communications, et. al.

Compassion Fatigue was both interesting and informative... An excellent panel of highly qualified experts discussing a topic just recently recognized to be of major importance to caregivers.
Harry Croft, MD Balanced Living Communications

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