Ethics of Self Care

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C H A P T E R 14

Competence and the Ethics of Self-Care

I don’t know if it is I’m just overworked or whatever. I’m having trouble sleeping, don’t want to do anything or go out with friends, and truthfully, I look at my appointment schedule and start hoping clients cancel. I’m not sure what’s up, but I sometimes wonder if it’s time to simply get out of this profession?

T he experience being described by the human service provider who opened this chapter is sadly neither unique to this profession nor that unusual. For all who work as human service providers, the

mental fatigue and emotional exhaustion that accompany the intense work we do can be destructive to our health, mental well-being, and ability to provide ethical and effective service to our clients.

Table 14.1 highlights the fact that our professional codes of ethics are clear in their mandating of professional competence as a primary ethical requisite to providing service.

As suggested in the codes posted (see Table 14.1), the primary focus rests on competence as defined by one’s knowledge, skill, and experience. While these are clearly essential to effective, ethical practice, they are not the only considerations that should be made when assessing one’s ability or one’s competency to perform professional service.

Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from capella on 2021-09-12 17:41:50.

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Table 14.1 Addressing Competency

Professional Organization Principle

American Counseling Association (2014)

C.2.a. Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience.

American Psychological Association (2010)

2.01.a. Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

American Association for Marriage and Family Therapy (2015)

Standard III. Marriage and family therapists maintain high standards of professional competence and integrity.

International Association for Group Psychotherapy and Group Processes (2009)

Principle 3. Group psychotherapists who are members of the IAGP should have either completed formal education in group psychotherapy or be presently receiving supervision in an ongoing educational program by an established training organization that meets specific requirements.

National Association of Social Workers (2008)

1.04. a. Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

The current chapter reviews the ethical principles of provider compe- tence with special emphasis on the threats to competency emanating from the experience of burnout and compassion fatigue.

● OBJECTIVES

As such, the current chapter will help you to

• Describe what is meant by burnout and compassion fatigue • Explain the difference between burnout and compassion fatigue • Describe the ethical challenges burnout and compassion fatigue pres-

ent for the human service provider

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Chapter 14. Competence and the Ethics of Self-Care –●–349

• Identify ways a human service provider can reduce the possibility of burnout and compassion fatigue

• Articulate a personal wellness plan

COMPETENCY: MORE THAN KNOWLEDGE AND SKILL ●

In their book, Field Experience: Transitioning From Student to Profes- sional, Zhang and Parsons (2016) introduced the concept of self-care with an Anton Wildgans’s (1881–1932) quote, which has been made famous by Viktor Frankl, the author of Man’s Search for Meaning (1963): “What is to give light must endure burning.” While Wildgans’s quote is clearly reflective of his own experience as a provider of care and support to self and others during the Holocaust, the simple quote speaks volumes for all human service providers who have been engaged in providing care and support to others.

Perhaps, you are just starting your training in the field or are coming to the end of your training. In either case, it is likely you have already experi- ence the awesome gift and responsibility of serving in the role of human service provider. Being invited to journey with another, especially during a time of turmoil and challenge, demands knowledge and skill of the helping process, awareness of that which constitutes “best practice,” and the physi- cal and emotional energy to engage in a dynamic and challenging therapeu- tic relationship. They are responsibilities that provide light, while at the same time opening the provider to the possibility of emotional “burning.”

Helping: Being With, Not Doing To

Unique to the role and function of a human service provider is the fact that we are required to “walk with” our clients and not simply do for them. Our clients are not cogs on a conveyor belt needing to be assembled, nor are we simply information providers to those requesting direction. Our cli- ents are those navigating through a challenging time in their lives, for whom support, emotional, social and physical, is required.

As human service providers, we are engaged in a service that requires our personal, emotional engagement with the client (Bakker, Van der Zee, Lewig, & Dollard, 2006). The very process of engaging with others who are suffering can pose a threat to the human service provider (O’Brien, 2011). The work we do is fertile ground for stress. The fact that we work in situa- tions of physical and social isolation, where we often encounter unexpected and unpredictable schedules and demands and by definition immerse

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ourselves in intense personal interactions, provides the conditions to make this work stressful and emotionally demanding (Bakker et al., 2006). The stress of taking on the responsibility for assisting one in crisis, especially when work conditions are such as to add to that stress or, conversely, fail to provide the essential support necessary for providing ethical, effective service, can accumulate and will negatively impact the provider’s ability to perform competently. Research would suggest that those engaged in the helping professions are vulnerable to effects of enduring stress (Lee et al., 2007).

Given the nature of our work it is not unexpected to find that many find it difficult to maintain their own health and well-being. According to a study by the American Counseling Association (ACA, 2010), of those surveyed, over 63 percent reported knowing a colleague whom they would consider impaired. The magnitude of the finding moved the ACA to develop a task force for the sole purpose of decreasing impairment and enhancing wellness among its members.

The impact of enduring stress and the toll it can take on both the pro- fessional and the clients whom they serve makes it a clear ethical concern. While the impact of enduring stress can take many forms, two—burnout and compassion fatigue—are the focus of the remainder of this chapter.

● BURNOUT

Burnout has been described as the “gradually intensifying pattern of physi- cal, psychological and behavioral responses to a continual flow of stressors” (Gladding, 2011, p. 24). Burnout is experienced as emotional exhaustion and often manifests in form of apathy, negative job attitude, and perhaps most concerning from an ethical perspective of competence, a loss of con- cern and feeling for the client (Gladding, 2011).

For some practitioners experiencing burnout, the impact is evident in their tendency to withdraw from social contact, become defensive and aggressive in relationships, and when it comes to clients, exhibit a dehu- manizing attitude (Lambie, 2002). That dehumanization often reveals itself in the provider’s identification of clients by a diagnostic label such as “my borderline” or in personal characteristics, for example, the “divorcee,” and serves to distance and detach the counselor from the person of the client and thus his or her suffering (Maslach, Schaufeli & Leiter, 2001). Consider the case of Dr. L., one practitioner for whom burnout clearly impacted her ability to provide effective, ethical service (Case Illustration 14.1).

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Chapter 14. Competence and the Ethics of Self-Care –●–351

Case Illustration 14.1

Dr. L.: A Case of Burnout

Dr. L. is a 48-year-old clinical psychologist working in a community mental health center. She has worked as a clinician for over 19 years and has been employed within this center over the past 8 years. Over the course of the past 8 years, she has experienced a decline in both professional and support staff, while at the same time an increase in both the number of clients seen and the level of severity of the issues being presented. The pressure from external funding sources as well as internal administration placed emphasis on a mandate to see more clients and produce results with fewer sessions. The increased workload resulted in her working late hours, often 10 hour days, and twice a month being required to work a sixth day, Saturday, to increase her “productivity” figures.

The physical exhaustion of the increased workload, the reduction of physical and emotional support, and a general dissatisfaction and discomfort with what she saw as her inability to provide “adequate” service began to take its toll. As one who considered her work more than a job, a true vocation, the situation left her feeling professionally inadequate.

While these changes developed slowly, it became obvious that Dr. L. was experiencing a deep sadness and a lack of interest in engaging in previously enjoyable activities (e.g., racquet ball, golf, etc.). She was finding it difficult to make decisions within her practice, even to the point of failing to develop meaningful treatment plans for her clients. Dr. L. reported a concern that her ability to attend to her clients seemed diminished and that she had on occasion experienced moments when her memory went “blank.” She reported entering sessions in which she brought the wrong case file and even had three occasions where she either could not remember the client’s name or referred to the client by using another client’s name.

She found the experience to be such that she “dreaded” going to work and hoped that clients would cancel. In addition, she began call- ing out and taking sick days, often canceling appointments at the last moment. While her colleagues privately expressed concern, no one reached out to Dr. L. Fortunately, her diminishing level of professional

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As is evident in our case illustration, the experience of burnout is multidimensional. In addition to somatic and cognitive symptoms, burnout can affect a professional’s emotional stability, resulting in conditions rang- ing from annoyance and frustration to more severe presentations, such as depression and anxiety (Maslach, Schaufeli, & Leiter, 2001). For others, burnout results in apathy, fatigue, anger, and conflict (Gladding, 2011). In any presentation, it becomes clear that burnout will impair one’s ability to provide ethical care and service (Maslach, 1993).

effectiveness along with her increased reliance on alcohol as a means of self-soothing led Dr. L to ask for, and receive, medical leave.

While her break from work was brief, only two weeks, it was a time when, with reflection and discussion with a supervisor, Dr. L gained insight into what she was experiencing and the steps she needed to take to engage in her own healing. After this break, during which time she returned to a regimen of healthy eating, regular exercise, engage- ment with friends, and getting 7 to 8 hours of sleep each night, her symptoms diminished and she found not only a desire to return to her clients but also an energy and enthusiasm to advocate organizational changes in order to bring their services in line with that expected of an ethical, effective center.

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● COMPASSION FATIGUE

A hallmark of the both the helping relationship and the role of the human service provider is our ability to enter into the other’s phenomenological field, experiencing their world as they do, sharing their feelings, and better understanding their world and self-views. This ability to experience deep empathy is both a gift and a potential risk. Sharing in the pain, the anxiety, the sadness, or the sense of hopelessness often presented by our clients can challenge our ability to balance professional objectivity and distance while at the same time truly walking with our client. For clinicians lost in the lived experience of their clients, the result can be quite destructive, leading to increased stress and an inability to continue to feel and convey the compas- sion so characteristic of the helping professions.

Compassion fatigue has been defined as a “state of exhaustion and dysfunction—biologically, psychologically, and socially—as a result of

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Chapter 14. Competence and the Ethics of Self-Care –●–353

prolonged exposure to compassion stress (Figley, 1995, p. 253). Compassion fatigue differs from burnout in that it occurs suddenly, rather than gradually as is the case with burnout, and presents often with symptoms that mirror post-traumatic disorders (Trippany, Wilcoxon, & Satcher, 2003). As such, it is often referred to as secondary post-traumatic stress disorder.

The impact of compassion fatigue is both broad and deep. Compassion fatigue can result in mental fatigue and an inability to concentrate, a deterio- ration of one’s ability to work effectively, a change in a person’s fundamental values and beliefs, and an increase in feelings of sadness, anxiety, and guilt (Zhang & Parsons, 2016). In addition, for some, compassion fatigue results in excessive emotional numbing and, like those with post-traumatic stress syndrome, the experience of intrusive images and thoughts of their cli- ent’s traumatic material. This experience can reduce the clinician’s ability to empathically engage with a client and thus presents a very real threat to one’s ability to provide competent, ethical service.

THE ETHICAL CHALLENGE ●

Burnout and compassion fatigue must be recognized and accepted as real threats to ethical practice. Consider the following case (Case Illustration 14.2) as reflecting the unethical decisions and behavior that result from compassion fatigue.

Case Illustration 14.2

Compassion Fatigue: Undermining Ethical Behavior

While serving as a middle school counselor for 18 years, Mr. E. had spent the last 2 years working in the capacity of crisis interventionist. In that role, he engaged with students who were physically and sexu- ally abused, those exhibiting suicidal ideation and behavior, and oth- ers with depression and debilitating anxieties. Now, halfway through the academic year, he began experiencing a reduction of energy and a loss of enthusiasm for his job. He began to exhibit attitudes and behaviors that could best be described as atypical for him and clearly unprofessional.

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It would be easy to dismiss both compassion fatigue and burnout as things that happen to those who have worked “too long” in the field. How- ever, failing to embrace the reality of burnout and compassion fatigue as real possibilities for ourselves, regardless of our tenure within the profes- sion, positions us to engage in unethical behavior (Everall & Paulson, 2004). These conditions not only attack the professional’s physical stamina but also as detailed above result in psychological exhaustion, emotional distress, and potential exploitation of clients (Norcross, 2000), and they can occur at any stage of our professional life.

A Challenge to Core Values

A review of the core values that serve as the foundation of our codes of ethics, values such as autonomy, beneficence, nonmaleficence, and justice

Whereas students historically sought out his service and support and parents spoke highly of his effectiveness and real care for the students, it was clear by student complaints about his lack of availability and tendency to be sarcastic when interacting with them that something was changing. Even faculty began to report on the apparent changes in his demeanor and professional behavior, noting that something was negatively impacting his ability to function in his role as crisis intervention counselor.

Faculty reported experiencing his increased venting and complain- ing about the students he was seeing. They noted that he often referred to the students and their life conditions as hopeless and that he, as one person, was impotent in “rescuing” them from the “hands they were dealt.” While concerned about the apparent heavy heart he exhibited when speaking of some of the students, the faculty were equally con- cerned by what appeared to be his angry, dismissive, and devaluing attitude toward other students. Faculty reported hearing him use inap- propriate terms, such as referring to some students as “diagnosable” or others as falling into the category of “P.I.T.A.” (pains in the ass). The dismissiveness and depersonalization was even experienced by teach- ers seeking consultation who were told to “do their own damn jobs.”

While certainly unprofessional, the language and labeling was so out of character for Mr. E., a person who had previously been a model of caring and professionalism, that faculty went to the district supervisor to report their concerns.

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Chapter 14. Competence and the Ethics of Self-Care –●–355

(See Chapter 3), illuminates the ethical challenge presented when a practi- tioner is experiencing burnout and/or compassion fatigue.

As ethical providers, we are directed to respect and attend to the welfare of our clients. Respecting the integrity of those with whom we work, committing to serving their welfare, and engaging in competent best practice are principles found across our professional codes of ethics. For example, the American Psychological Association (APA, 2010) notes that psychologists, embodying the values of beneficence and nonmaleficence “strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally” (Principle A). Consider this standard in light of the two previous case illustrations (i.e., Case Illustrations 14.1, 14.2). Certainly, meeting this ethical standard and the similar standards expressed by the other professional human service organization is difficult, if not impossible, when one is experiencing burn- out and/or compassion fatigue.

A Challenge to Developing and Maintaining an Ethical Therapeutic Relationship

As noted by Everall & Paulson (2004), a counselor who is having diffi- culty meeting her personal needs appropriately may violate boundaries and become more deeply enmeshed with her clients. The physical, psychologi- cal, and emotional exhaustion that accompanies burnout and compassion fatigue can result in the human service provider disengaging from the client to a point of negating the client as person and not only demonstrating the inability to maintain a sense of empathy but even a basic respect for the client. Since responsible caring requires professionals to actively demon- strate a concern for the welfare of individuals, the practitioner’s diminished ability to function as a result of burnout or compassion fatigue may con- stitute a serious violation of a fundamental principle of ethical practice. Further, with a personal sense of exhaustion, a human service provider not only runs the risk of failing to engage and maintain a therapeutic alliance but also runs the risk of aligning with a client’s feelings of frustration, anger, and hopelessness to the point of conveying a doubt in the effectiveness of their service. Under these conditions, the practitioner risks exploiting the client through boundary violations or role reversal in order to meet personal needs.

Disengagement from one’s client or using clients to meet personal needs clearly violates the primary directive to respect the dignity and promote the welfare of our clients (e.g., ACA, 2015, Principal A.1.a;

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AMHCA, 2010, Principle I.A.1.a). The inability to care and respect truly undermines one’s competence to engage in effective therapeutic rela- tionships and as such is a violation of our ethical principles. For those experiencing the inability to perform competently because of burnout and/or compassion fatigue, the directive, as noted the APA, is to “refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner” (2010, Principle, 2.06).

A Challenge to Enacting Ethical, Effective Treatment Plans

Engaging in ethical, effective treatment is a keystone of professional practice. For example, the ACA directs its members to devise treatment plans that offer reasonable promise of success (2014, Principle A.1.c). In support of this principle, other organizations have directed practitioners to continue to seek out on-going training and supervision as a means of maintaining and upgrading competence. For example, social workers are directed as follows:

[to] strive to become and remain proficient in professional prac- tice and the performance of professional functions. Social workers should critically examine and keep current with emerging knowledge relevant to social work. Social workers should routinely review the professional literature and participate in continuing education rel- evant to social work practice and social work ethics. (NASW, 2008, Principle 4.01)

Similarly, psychologists are ethically mandated to maintain competence by undertaking “ongoing efforts to develop and maintain their competence” (APA, 2010, Principle 2.03).

While it is notable that our professional organizations recognize the need for the maintenance of a practitioner’s knowledge and skill as foun- dational to competent service, it is equally important that we recognize the fundamental need and value of maintaining a practitioner’s physical and psycho-emotional well-being as equally foundational to competent service. For example, the ACA not only calls for its members to maintain knowledge of best practice and to devise treatment plans that offer a rea- sonable promise of success but calls for its members to do so in concert

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Chapter 14. Competence and the Ethics of Self-Care –●–357

with their clients (ACA, 2014, Principle A.1.c). One may question how such collaboration is developed and maintained when the practitioner has disengaged and devalued the client as a result of his or her experi- ence of burnout and compassion fatigue. Clearly, the disengagement and devaluing of the client that often accompanies burnout and compas- sion fatigue diminishes a practitioner’s interest and ability to effectively engage with a client to devise, implement, and maintain an effective treatment plan.

The reality of this challenge of enacting ethical effective treatment plans has been noted across the profession and has been clearly articulated by the ACA:

Counselors monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired. They seek assistance for problems that reach the level of professional impairment, and, if neces- sary, they limit, suspend, or terminate their professional responsibilities until it is determined that they may safely resume their work. (2014, Principle, C.2.g)

It is evident that effective, ethical practice is threatened when the practitioner is experiencing burnout or compassion fatigue. As we close this section of the chapter, we invite you to review Exercise 14.1. In the exercise you are asked to reflect upon and perhaps discuss with a colleague, guiding principles of ethical practice and how these may be impacted by the experi- ence of burnout and/or compassion fatigue.

Exercise 14.1

Undermining Ethical Practice

Directions: Below you will find a listing of ethical principles found across the spectrum of human service professions. Consider the multi- dimensional impact that conditions such as burnout and compassion fatigue can have on a human service provider’s ability to engage in ethical practice and identify the specific threat these conditions pose to the specific ethical principle listed. Share your reflections with a colleague or supervisor.

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● ETHICAL RESPONSE

The possibility of encountering burnout and/or compassion fatigue in one’s professional life presents the human service provider with two immediate ethical challenges. The first one is understanding how one should respond to the experience of either of these conditions, be that a personal experi- ence or that of a colleague. Secondly and perhaps more importantly, the human service provider is to be clear about what one should do to prevent the experience of either of these conditions. Ignoring and/or denying the possibility of a personal encounter with burnout and/or compassion fatigue is neither practical nor ethical.

Preventative Measures: An Ethical Response to Self-Care

In the best of all worlds, the human service provider will be insulated from the possibility of burnout and/or compassion fatigue. However, human service is by definition a form of one-way giving, therefore in the absence of the practitioner’s emotional replenishment, he or she will soon run dry (Skovholt, 2001).

Principle Burnout Empathy Fatigue

Promoting well-being/welfare of the client

Establishing, maintaining professional boundaries

Respecting client autonomy

Respecting client privacy

Providing competence service

Termination of service

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Chapter 14. Competence and the Ethics of Self-Care –●–359

Thus, while absolute protection and insulation from these conditions is not possible, measures can be taken that will reduce the risk. Understanding and implementing preventative measures as counteraction to the possibili- ties of burnout and compassion fatigue is not only a rational response to self-care but also truly an ethical one. As noted by Parsons & Zhang (2014), “One cannot foster health and well-being in another if such is lacking in oneself” (p. 284).

Self-care is essential to ethical, competent practice. The ethics of self- care have been made clear by a number of our professional organizations. The ACA, for example, directs counselors to “engage in self-care activi- ties to maintain and promote their own emotional, physical, mental, and spiritual well-being to best meet their professional responsibilities” (2014, Introduction, Section C). Further, a review of the literature (e.g., Trippany, White Kress, & Wilcoxon, 2004; Rupert & Kent, 2007; Ulman, 2008) high- lights the importance of human service providers engaging in a program of self-care, as protection from burnout and compassion fatigue. While there are many ways one can care for self, those that have been identified as effec- tive for intervening and preventing burnout and compassion fatigue involve cognitive, emotional, and behavioral self-care strategies (Baird, 2008).

Exercise 14.2 lists a number of self-care strategies and invites you to engage in a self-assessment. The hope is that engaging in this self- assessment will result in your further commitment to your own self-care as a way of strengthening your ability to engage in competent, ethical service.

Exercise 14.2

Self-Care Worksheet

Directions: Below is a list of activities that can contribute to one’s gen- eral state of health and wellness and could prove valuable in lowering one’s risk of compassion fatigue. Your task is to engage in an honest self-assessment and plan for a commitment to a healthier lifestyle. Identify at least one of the items of self-care that you feel you have been lax in performing and commit to increasing your engagement in that form of self-care starting immediately. It is suggested that you repeat this process monthly as a way of promoting your own health and wellness.

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Domain Specific

I am committed to . . .

Physical Health

Eating 4 to 6 meals a day

Eating well-balanced meals including fruits and vegetables

Reducing sugar intake

Monitoring caffeine intake

Exercise: some form of exercise, 30 min at least three times a week

Dental care 2x annually

Consistent, sufficient sleep

Engage in enjoyable physical activities: dance, swim, golf, bowl, etc.

Other (your ideas)

Social Connections

Go out with friends

Talk with friends and family

Visit family member/friend

Smile and say “hi” to those you encounter in the course of your typical day

Disengage from thoughts of clients when in non-work social settings

Attend a group educational or recreational experience (lecture, concert, sporting event)

Connect with colleagues around professional issues/questions and concerns

Connect with colleagues around nonprofessional issues/activities

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Chapter 14. Competence and the Ethics of Self-Care –●–361

Domain Specific

I am committed to . . .

Other (your choice)

Psychological Domain

Engage in self-reflection

Read for recreation

Contract for personal counseling, coaching, or spiritual direction

Increase awareness of personal baggage and issues as well as ways of managing them

Engage in stress-reduction activities

Employ anxiety-reduction techniques

Seek out opportunities to learn and expand skill and knowledge outside the professional realm (e.g., learn foreign language or to play an instrument)

Give permission and take the opportunity to “zone” out as a way of decompressing (e.g., watching television, playing a video game, etc.)

Affective Domain

Engage in activities that make you laugh

Find opportunities to celebrate “life” with others (e.g., birthday, holidays, anniversaries)

Provide self with affirmation and praise

Freely express feelings of sadness or loneliness (freedom to cry)

Reconnect via review of old pictures or tapping memories of loved ones and loving experiences

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Domain Specific

I am committed to . . .

Appropriately disclose feelings of anger, frustration (rather than repressing or displacing)

Sing like you can . . .

Dance like you wish . . .

Grant yourself permission to do or attempt to do those activities you always wished you could do

Other

Inner Life Engage in meditational readings

Engage in personal reflection

Meditate

Commune with nature

Participate in structured spiritual activity (church service, prayer group, retreat, etc.)

Engage with spiritual director or mentor

Find opportunities for expressing gratitude

Celebrate your gifts of life

Read about another’s spiritual journey

Seek a moment, an opportunity to be in awe

Other

Professional Domain Set realistic daily task demands

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Chapter 14. Competence and the Ethics of Self-Care –●–363

Domain Specific

I am committed to . . .

Identity those tasks/activities that are exciting and life giving and integrate those with those activities that tend to be more draining

Move away from the desk by way of a simple break, a quick visit with a colleague, or a short walk

Close your door to allow for quiet, uninterrupted time to complete a task

Say no to an invitation to do more when you already have enough

Leave work issues and concerns within the office

Engage in peer support around client and case issues as well as around personal questions and concerns

Engage with a supervisor or mentor

Establish your work space so that it feels both comfortable and comforting

Set boundaries with colleagues, especially when their interactions are intrusions on your limited time or when their requests are overburdening

Take a moment to review your day while identifying one aspect that was professionally satisfying

Other

Source: Zhang, N. & Parsons, R. D. (2016). Field experience: Transitioning student to professional. Thousand Oaks, CA: Sage. Reproduced with permission of the authors.

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Intervening in the Face of Burnout and Compassion Fatigue

Even our best-laid plans will often fall short, and this is true for our efforts to foster wellness. As such, it is possible that any one of us may experience the effects of burnout or compassion fatigue somewhere in the course of our professional life. When prevention is not possible, steps to intervention will be key to our returning to effective practice. The steps necessary are targeted not only to returning the professional to health and well-being but also to protecting those with whom he works.

Awareness and Self-Care

As an initial step, it is our responsibility as professionals not only to broaden our understanding of the impact that burnout and compassion fatigue have on one’s ability to perform ethically and effectively but to moni- tor our own health for signs of impairment. Norcross (2000) reported on surveys of program directors and psychologists in which “self-awareness/ self-monitoring” was identified as the top-ranked contributor to optimal functioning among psychologists. Such monitoring is not simply a “good” idea but is truly an ethical mandate.

A useful tool for the monitoring of both burnout and compassion fatigue is the Professional Quality of Life Scale (ProQOL) (Stamm, 2012). The scale has been included in the section below, identified as “Coop- erative Exercise.” It is provided as both a reference tool that can be used throughout your career and an exercise in which you are invited to take a snapshot of your current state of well-being. Whether one is a student or engaged in a career, monitoring oneself for signs of impairment is an ethical responsibility. The ACA, for example, directs both students and supervisees to do the following:

Monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others. They notify their faculty and/or supervisors and seek assis- tance for problems that reach the level of professional impairment, and, if necessary, they limit, suspend, or terminate their professional

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responsibilities until it is determined that they may safely resume their work. (2014, Principle F.5)

Responding to Impairment

Our professional codes of ethics are clear in directing us to cease and desist our engagement with clients once we become aware that we are com- promised as professionals. The AMHCA, for example, directs its members to do the following:

Recognize that their effectiveness is dependent on their own mental and physical health. Should their involvement in any activity, or any mental, emotional, or physical health problem, compromise sound professional judgment and competency, they seek capable professional assistance to determine whether to limit, suspend, or terminate services to their clients. (2010, Principal C.1.h)

Similarly, counselors are directed by the ACA to “monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired.” (2014, Principle C.2.g.)

Beyond refraining from practice, impaired human service providers should, as noted by the AAMFT (2015), seek appropriate professional assis- tance for issues that may impair work performance or clinical judgment (2015, Principle 3.3). A point echoed by other professional organizations (See Table 14.2)

Seeking and employing professional support is an essential ingredient to the maintenance of the human service provider’s health and ability to per- form ethically and effectively (Everall & Paulson, 2004) and as such should apply to all human service providers and not just those who are challenged with burnout and/or compassion fatigue.

Collegial Corrective Response

In addition to self-monitoring and supervision, the human service pro- vider has a professional and ethical responsibility to address concerns that

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Table 14.2 Mandate for Professional Support and Assistance

Professional Organization Statement on Ethical Principles Regarding Objectivity

American Counseling Association (2014)

Principle C.2.g.

Counselors monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired. They seek assistance for problems that reach the level of professional impairment, and if necessary, they limit, suspend, or terminate their professional responsibilities until it is determined that they may safely resume their work.

American Psychological Association (2010)

Principle 2.06.b.

When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties.

American Association for Marriage and Family Therapy (2015)

Principle 3.3

Marriage and family therapists seek appropriate professional assistance for issues that may impair work performance or clinical judgment.

International Association for Group Psychotherapy and Group Processes (2009)

Principle 2.7

Group psychotherapists shall ensure that their own physical and mental health allows them to undertake their professional responsibilities competently. They shall seek appropriate assistance or professional treatment should they suffer ill health or compromised mental health that interferes with their professional duties.

National Association of Social Workers (2009)

Principle 4.05.b.

Social workers whose personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties interfere with their professional judgment and performance should immediately seek consultation and take appropriate remedial action by seeking professional help, making adjustments in workload, terminating practice, or taking any other steps necessary to protect clients and others.

arise when observing colleagues who are demonstrating signs of impairment (Everall & Paulson, 2004). Clearly a colleague who exhibits signs of fatigue, loss of interest in his work, and an abrasive, dismissive attitude toward his

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clients is giving evidence of impairment and may be providing less than ethi- cal and effective service.

As ethical human service providers, we are directed to protect all cli- ents as well as the image and reputation of our professions. It is our ethical responsibility to confront impaired colleagues by offering support and pro- viding collegial corrective feedback. Counselors, for example, are directed to “assist colleagues or supervisors in recognizing their own professional impairment and provide consultation and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients.” (ACA, 2014, Principle C.2.g). A similar directive is given to social workers who are advised to not only “consult with that colleague when feasible and assist the colleague in taking remedial action” (NASW, 2008, Principle 2.09.a) but even “take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations” (NASW, 2008, Principle 2.09.b) when an impaired colleague, once confronted, fails to take steps to address the impairment.

While it may be uncomfortable to confront a colleague exhibiting clear signs of impairment, it is our ethical responsibility. We are directed to ini- tially attempt to provide support and increase awareness by bringing our concerns to the impaired professionals. However, if such an informal reso- lution fails to bring an ethical resolution, then it is essential for us to take further action appropriate to the situation, including reporting to employer, state boards and licensing agencies, or even national committees when national certification is at risk.

CONCLUDING CASE ILLUSTRATION ●

While the focus of our ongoing case has been on Ms. Wicks and her interac- tion with Maria, the following exchange between Ms. Wicks and her supervi- sor, Mr. Harolds, suggests that Ms. Wicks may be struggling to maintain her ability to provide effective, ethical service to her students. As you read the exchange, be aware of any indications that Ms. Wicks may be experiencing either burnout and/or compassion fatigue and may have either violated an ethical principle or is close to doing so. Finally, after reading and reflect- ing upon the interaction consider the points raised in the section entitled Reflections.

Mr. Harolds: Hi, Michelle, thanks for coming down.

Ms. Wicks: Not a problem . . . a little rushed since I have tons of kids to see. I was kind of surprised to get your invite. Is something up?

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Mr. Harolds: No, I just wanted to check in and see how things were going with Maria and the year so far.

Ms. Wicks: Maria, yikes! I’ll tell you Tom, I can’t get her off my mind. This kid is carrying such a heavy load. It’s just not fair. And truth be told, there are so many others this year that are in the same situation.

Mr. Harolds: It sounds like she has really gotten you concerned.

Ms. Wicks: This is so different than other years. Besides Maria, I am seeing at least four others who are being abused or had been abused. . . .

Mr. Harolds: Michelle, are you saying you have evidence of abuse? Why haven’t you told me before now? We need to report it.

Ms. Wicks: Well, it’s not abuse in the legal sense. It’s just life has dealt these kids unfair demands, and it’s just not fair (starts to tear up). I mean, I feel like I should take them all home and keep them safe and . . .

Mr. Harolds: Michelle, I can see you are concerned and this upsetting, but I hope you really don’t mean what you are saying about taking them home.

Ms. Wicks: I know, and truthfully . . . I go between wanting to hug them and protect them to wanting to grab them by the collar and start pounding some sense in their heads. Their view of sex, babies, being “what their man” wants. . . . I just want to yell “damn girl, what’s wrong with you!”

Mr. Harolds: Michelle, this doesn’t sound like you. It feels like you are getting a little worn down?

Ms.Wicks: Tom, this year has been hell. The entire class seems to be dealing with such heavy stuff. It just seems so unfair (starts to tear up again and is visibly upset). I’m sorry, Tom. I know this is totally inappropriate, but it is mind boggling what these kids are dealing with, and I guess I’m realizing that I am totally impotent in helping them. I look at what is going on and I vacillate from wanting to wrap my arms around them—take them home with me, and keep them all safe— to literally giving up and telling them all to deal with it on their own. I know it’s not professional, but sometimes I get so angry that . . . that . . . I don’t know, maybe the semester

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break coming up is all I need. Just a little time away from this place and the job.

Mr. Harolds: Michelle, I know we have talked about this before . . . but you do give your all . . . I mean you are here early before school and usually the last to leave. Also, I don’t think you ever miss a student activity if you can help, plus all the support you give to parents and faculty. . . . You know maybe you need to cut back a bit.

Ms. Wicks: Cut back . . . really? Tom, there is so much these kids need (again, starts to tear up). I mean, I spent all day Saturday visiting some of them, bringing some clothes, makeup, and a little treat to the girls in Lincoln apartments.

Mr. Harolds: Michelle that truly concerns me. While I am sure that the girls had fun and appreciated you bringing things, that’s not your role, and while it is a nice gesture, it really isn’t necessary or even appropriate. I am worried that you are taking more on and emotionally extending yourself in ways that are not healthy for you and, honestly, can put you at risk.

Reflections

1. What type of “risk” do you feel Mr. Harolds was referring to? Physical? Emotional? Professional? Legal?

2. Is there any evidence that might suggest that Michelle is beginning to experience burnout? Compassion fatigue? Or is she setting herself up for such an experience?

3. What ethical principles has Michelle violated? Are there any that she is coming close to violating?

COOPERATIVE LEARNING EXERCISE ●

Introduction: Below you will find the Compassion Satisfaction and Compas- sion Fatigue (PROQOL), Version 5 scale. We invite you to not only make a copy of this scale and refer to it frequently throughout your career but also take time now to take a snapshot of your current state of well-being. We suggest you work through the scale with your colleague and/or supervisor, discussing your responses.

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Exercise 14.3

Monitoring Burnout and Compassion Fatigue

Directions: COMPASSION SATISFACTION AND COMPASSION FATIGUE

(PROQOL) VERSION 5 (2009) When you [help] people, you have direct contact with their lives.

As you may have found, your compassion for those you [help] can affect you in positive and negative ways. Below are some questions about your experiences, both positive and negative, as a [helper]. Consider each of the following questions about you and your current work situation. Select the number that honestly reflects how frequently you experienced these things in the last 30 days.

1 = Never

2 = Rarely

3 = Sometimes

4 = Often

5 = Very Often

1. I am happy.

2. I am preoccupied with more than one person I [help].

3. I get satisfaction from being able to [help] people.

4. I feel connected to others.

5. I jump or am startled by unexpected sounds.

6. I feel invigorated after working with those I [help].

7. I find it difficult to separate my personal life from my life as a [helper].

8. I am not as productive at work because I am losing sleep over traumatic experiences of a person I [help].

9. I think that I might have been affected by the traumatic stress of those I [help].

10. I feel trapped by my job as a [helper].

11. Because of my [helping], I have felt “on edge” about various things.

12. I like my work as a [helper].

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13. I feel depressed because of the traumatic experiences of the people I [help].

14. I feel as though I am experiencing the trauma of someone I have [helped].

15. I have beliefs that sustain me.

16. I am pleased with how I am able to keep up with [helping] techniques and protocols.

17. I am the person I always wanted to be.

18. My work makes me feel satisfied.

19. I feel worn out because of my work as a [helper].

20. I have happy thoughts and feelings about those I [help] and how I could help them.

21. I feel overwhelmed because my case [work] load seems endless.

22. I believe I can make a difference through my work.

23. I avoid certain activities or situations because they remind me of frightening experiences of the people I [help].

24. I am proud of what I can do to [help].

25. As a result of my [helping], I have intrusive, frightening thoughts.

26. I feel “bogged down” by the system.

27. I have thoughts that I am a “success” as a [helper].

28. I can’t recall important parts of my work with trauma victims.

29. I am a very caring person.

30. I am happy that I chose to do this work.

Based on your responses, place your personal scores below. If you have any concerns, you should discuss them with a physical or mental health care professional.

(Continued)

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Compassion Satisfaction

Compassion satisfaction is about the pleasure you derive from being able to do your work well. For example, you may feel like it is a pleasure to help others through your work. You may feel positively about your colleagues or your ability to contribute to the work setting or even the greater good of society. Higher scores on this scale represent a greater satisfaction related to your ability to be an effective caregiver in your job.

The average score is 50 (SD 10; alpha scale reliability .88). About 25 percent of people score higher than 57 and about 25 percent of people score below 43. If you are in the higher range, you probably derive a good deal of professional satisfaction from your position. If your scores are below 40, you may either find problems with your job, or there may be some other reason—for example, you might derive your satisfaction from activities other than your job.

Burnout

Most people have an intuitive idea of what burnout is. From the research perspective, burnout is one of the elements of compassion fatigue. It is associated with feelings of hopelessness and difficulties in dealing with work or in doing your job effectively. These negative feelings usually have a gradual onset. They can reflect the feeling that your efforts make no difference, or they can be associated with a very high workload or a non-supportive work environment. Higher scores on this scale mean that you are at higher risk for burnout.

The average score on the burnout scale is 50 (SD 10; alpha scale reliability .75). About 25 percent of people score above 57 and about 25 percent of people score below 43. If your score is below 43, this probably reflects positive feelings about your ability to be effective in your work. If you score above 57 you may wish to think about what at work makes you feel like you are not effective in your position. Your score may reflect your mood; perhaps you were having a “bad day” or are in need of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern.

Secondary Traumatic Stress

The second component of compassion fatigue is secondary traumatic stress (STS). It is about your work-related, secondary exposure to

(Continued)

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extremely or traumatically stressful events. Developing problems because of exposure to other’s trauma is somewhat rare but does happen to many people who care for those who have experienced extremely or traumatically stressful events. For example, you may repeatedly hear stories about the traumatic things that happen to other people, commonly called vicarious traumatization. If your work puts you directly in the path of danger, for example, fieldwork in a war or area of civil violence, this is not secondary exposure; your exposure is primary. However, if you are exposed to others’ traumatic events as a result of your work—for example, as a therapist or an emergency worker—this is secondary exposure. The symptoms of STS are usually rapid in onset and associated with a particular event. They may include being afraid, having difficulty sleeping, having images of the upsetting event pop into your mind, or avoiding things that remind you of the event.

The average score on this scale is 50 (SD 10; alpha scale reliability .81). About 25 percent of people score below 43 and about 25 percent of people score above 57. If your score is above 57, you may want to take some time to think about what at work may be fright- ening to you or if there is some other reason for the elevated score. While higher scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your work and your work environment. You may wish to discuss this with your supervisor, a colleague, or a health care professional.

Source: B. Hundall Stamm, 2009–2012. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL).

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In this section, you will score your test so you understand the interpretation for you. To find your score on each section, total the questions listed on the left and then find your score in the table on the right of the section.

WHAT IS MY SCORE AND WHAT DOES IT MEAN?

Compassion Satisfaction Scale

Copy your rating on each of these questions on to this table and add them up. When you have added them up you can find your score on the table to the right.

3. ____ 6. ____

12. ____ 16. ____ 18. ____ 20. ____ 22. ____ 24. ____ 27. ____ 30. ____ Total: _____

The Sum of My

Compassion Satisfaction Questions Is

So My Score Equals

And My Compassion Satisfaction

Level Is

22 or less 43 or less Low

Between 23 and 41

Around 50 Average

42 or more 57 or more High

Burnout Scale

On the burnout scale you will need to take an extra step. Starred items are “reverse scored.” If you scored the item 1, write a 5 beside it. The reason we ask you to reverse the scores is because scientifically the measure works better when these questions are asked in a positive way though they can tell us more about their negative form. For

example, question 1. “I am happy” tells us more about the effects of helping when you are not happy so you reverse the score.

*1. ____ = ____ *4. ____ = ____ 8. ____

10. ____ *15. ____ = ____ *17. ____ = ____ 19. ____ 21. ____ 26. ____

*29. ____ = ____ Total: _____

The Sum of My Burnout Questions Is

So My Score Equals

And My Burnout Level Is

22 or less 43 or less Low

Between 23 and 41

Around 50 Average

42 or more 57 or more High

You Wrote

Change to

2 4

3 3

4 2

5 1

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Source: B. Hudnall Stamm 2009–2012. Professional quality of life: Compassion satisfaction and fatigue version 5 (ProQOL). www.proqol.org. This test freely copied as long as (a) author is credited, (b) no changes are made, and (c) it is not sold. Those interested in using the test should visit www.proqol.org to verify that the copy they are using is the most current version of the test.

Secondary Traumatic Stress Scale

Just like you did on Compassion Satisfaction, copy your rating on each of these questions on to this table and add them up. When you have added them up you can find your score on the table to the right.

2. ____ 5. ____ 7. ____ 9. ____

11. ____ 13. ____ 14. ____ 23. ____ 25. ____ 28. ____ Total: _____

The Sum of My

Secondary Trauma

Questions Is

So My Score Equals

And My Secondary Traumatic

Stress Level Is

22 or less 43 or less Low

Between 23 and 41

Around 50 Average

42 or more 57 or more High

• The stress of taking on the responsibility for assisting one in crisis, especially when work conditions are such as to add to that stress or, conversely, fail to provide the essential support necessary for pro- viding ethical, effective service, can accumulate and will negatively impact the provider’s ability to perform competently.

• Burnout is experienced as emotional exhaustion and often manifests in form of apathy, negative job attitude, and perhaps most concern- ing from an ethical perspective of competence, a loss of concern and feeling for the client.

• Compassion fatigue has been defined as a “state of exhaustion and dysfunction—biologically, psychologically and socially—as a result of prolonged exposure to compassion stress (Figley, 1995, p. 253).

• Compassion fatigue differs from burnout out in that it occurs suddenly rather than gradually, as is the case with burnout, and presents often with symptoms that mirror post-traumatic disorders (Trippany, Wil- coxon, & Satcher, 2003). As such it is often referred to as secondary post-traumatic stress disorder.

• Both burnout and compassion fatigue can impair one’s ability to pro- vide ethical care and service.

• The disengagement and devaluing of the client that often accom- panies burnout and compassion fatigue diminishes a practitioner’s

SUMMARY ●

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interest and ability to effectively engage with a client to devise, imple- ment, and maintain an effective treatment plan.

• Self-care is essential to ethical, competent practice. The ethics of self-care have been made clear by a number of our professional organizations.

• Our professional codes of ethics are clear in directing us to cease and desist our engagement with a client once we become aware that we are compromised as professionals.

• Beyond refraining from practice, impaired human service providers should seek appropriate professional assistance for issues that may impair work performance or clinical judgment.

• It is our ethical responsibility to confront impaired colleagues by offering support and providing collegial corrective feedback.

● IMPORTANT TERMS

beneficence

burnout

collegial correction

compassion fatigue

dehumanization

enduring stress

nonmaleficence

self-awareness

self-care

self-monitoring

wellness

● ADDITIONAL RESOURCES

Baker, E. K. (2003). Caring for ourselves: A therapist’s guide to personal and pro- fessional well-being. Washington, DC: American Psychological Association.

Kottler, J. A. (2012). The therapist’s workbook: Self-assessment, self-care and self-improvement exercises for mental health professionals (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Ladany, N. (2010). Counselor supervision. New York: Routledge Skovholt, T. M., & Trotter-Mathison, M. (2011). The resilient practitioner: Burnout

prevention and self-care strategies for therapists, counselors, teachers and health professionals (2nd ed.). New York: Routledge.

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Web-Based

ACA’s Taskforce on Counselor Wellness and Impairment. Retrieved from www .counseling.org/ wellness_taskforce/index.htm

ProQOL.org. (n.d.). ProQOL 5. Retrieved from http://proqol.org/ProQol_Test.html PTSD Support Services. (n.d.). Compassion fatigue self-test. Retrieved from http://

www.ptsdsupport.net/compassion_fatigue-selftest.html

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American Association for Marriage and Family Therapy. (2015). Code of ethics. Retrieved from https://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/ code_of_ethics.aspx

American Counseling Association. (2014). Code of ethics, Washington, DC: Author. American Counseling Association’s Task force on Counseling Wellness and Impairment.

(2010). Retrieved from http://www.counseling.org/wellness_taskforce/index .htm

American Mental Health Counselors Association. (2010). American Mental Health Counselors Association (AMHCA) Code of ethics. Retrieved from http://www .amhca.org/assets/content/AMHCA_Code_of_Ethics_11_30_09b1.pdf

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code/principles .pdf

Baird, B. N. (2008). The internship, practicum, and field placement handbook: A guide for the helping professions (5th ed). Upper Saddle River, NJ: Pearson/ Prentice Hall.

Bakker, A. B., Van der Zee, K. I., Lewig, K. A., & Dollard, M. F. (2006). The relation- ship between the big five personality factors and burnout: A study among volun- teer counselors. The Journal of Social Psychology, 126, 31–50.

Everall, R. D., & Paulson, B. L. (2004). Burnout and secondary traumatic stress: Impact on ethical behaviour. Canadian Journal of Counselling, 38(1), 25–33.

Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Frankl, V. (1963). Man’s search for meaning. New York: Simon and Shuster. Gladding, S. T. (2011). The counseling dictionary: Concise definitions of frequently

used terms. Upper Saddle River, NJ: Pearson Education. International Association for Group Psychotherapy and Group Processes. (2009).

Retrieved from http://www.iagp.com/about/ethicalguidelines.htm Lambie, G. W. (2002). The contribution of ego development level to degree of

burnout in school counselors (Doctoral dissertation, The College of William & Mary, 2002). Dissertation Abstracts International, 63, 508.

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Lee, S. M., Baker, C. R., Cho, S. H., Heckathorn, D. E., Holland, M. W., Newgent, R. A., & Yu, K. (2007). Development and initial psychometrics of the Counselor Burnout Inventory. Measurement and Evaluation in Counseling and Development, 40, 142–154.

Maslach, C. (1993). Burnout: A multidimensional perspective. In W. B. Schaufeli, C. Maslach, & T. Marek (Eds.), Professional burnout: Recent developments in theory and research (pp. 19–32). Philadelphia, PA: Taylor & Francis.

Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52, 397–422.

National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers (NASW). Retrieved from http://www.socialworkers .org/pubs/code/code.asp

Norcross, J. C. (2000). Psychotherapist self-care: Practitioner-tested, research- informed strategies. Professional Psychology: Research and Practice, 31, 710–713.

O’Brien, J. M. (2011). Wounded healer: Psychotherapist’s grief over a client’s death. Professional Psychology Research and Practice, 42, 236–243.

Parsons, R. D., & Zhang, N. (2014). Becoming a skilled counselor. Thousand Oaks, CA: Sage.

Rupert, P. A., & Kent, J. S. (2007). Gender and work setting differences in career- sustaining behaviors and burnout among professional psychologists. Professional Psychology: Research and Practice, 38, 88–96.

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