Research I. Week 16 (Literature Review)

Compassion Fatigue and Mindfulness: Comparing Mental Health Professionals and MSW Student Interns Jodi L. Constantine Brown, Jacqueline Ong, Jessica M. Mathers*, and James T. Decker

Department of Social Work, California State University Northridge, Northridge, California, USA

ABSTRACT The relationship between compassion fatigue and mindfulness in mental health professionals compared to Master of Social Work (MSW) students is explored. A convenience sample of mental health professionals (n = 40) and MSW students (n = 111) completed the Five Facet Mindfulness Questionnaire and Professional Quality of Life Scale. Results indicate a medium, negative correlation between compassion fatigue and mind- fulness, with high levels of compassion fatigue associated with lower levels of mindfulness. There was no statistically significant difference between mental health workers and MSW students on the combined dependent variables. Results suggest that mindfulness protects against compassion fatigue regardless of professional or student status.

KEYWORDS Compassion fatigue; mindfulness; mental health; social work students

The presence of trauma is a natural and expected factor in most mental health environments, and it is often the desire to bring about a healing response to the client that prompts the professional to enter such a field. However, another common and lesser known by-product in the very same environment is compassion fatigue, which can have a negative effect on the professional. Compassion fatigue may occur as professional helpers are exposed to secondary trauma; manifesting as a diminished ability or interest in bearing another’s suffering (Figley, 2002), and it can be problematic for helping professionals, inflicting negative thought patterns and job dissatisfaction among employees (Bush, 2009). A study of the medical industry shows that demands in the workplace can create psychological stress, which interferes with personal/ family responsibilities (Minnotte, Gravelle, & Minnotte, 2013). For instance, a social worker or Master of Social Work (MSW) student who is overwhelmed by client trauma might show chronic unavailability and emotional withdrawal from loved ones (Cerney, 1995).

Trauma and compassion fatigue are endemic to the mental health field making it unlikely that either can be eliminated; however, research supports various approaches that may diminish the effect of compassion fatigue. One such approach is the cognitive concept of mindfulness, which helps an individual receive and evaluate occurrences and stressors in a non-judgmental manner, and is believed to be beneficial when dealing with job dissatisfaction (Hulsheger, Alberts, Feinholdt, & Lang, 2013). The current study explores the relationship between compassion fatigue and mindfulness in mental health professionals compared to MSW students.

CONTACT Jodi L. Constantine Brown [email protected] Department of Social Work, California State University Northridge, 18111 Nordhoff Street, Northridge, CA 91330-8226, USA.

*Jessica Mathers died on January 12, 2014. She is greatly missed.

JOURNAL OF EVIDENCE-INFORMED SOCIAL WORK 2017, VOL. 14, NO. 3, 119–130 http://dx.doi.org/10.1080/23761407.2017.1302859

© 2017 Taylor & Francis

Compassion fatigue

According to Bush (2009), prolonged exposure to stressful environments can lead to second- ary stress reactions, such as compassion fatigue. Unlike the gradual emergence of frustration, which can accompany burnout and is more often associated with job satisfaction (Najjar, Davis, Beck-Coon, & Doebbeling, 2009), the onset of compassion fatigue presents as a sudden stress response and is defined as a reduced capacity to bear the suffering of others (Figley, 2002). Risk factors associated with compassion fatigue include personal distress and an inability to be compassionate while tending to a client’s needs. Professionals experiencing compassion fatigue may show signs of empathy over-arousal, or countertransference, some- times even making a client’s problems their own (Bush, 2009). Compassion fatigue increases a health professional’s emotional exhaustion and decreases personal accomplishment charac- terized by impaired functioning, feelings of dissatisfaction and isolation, and physiological problems (Najjar et al., 2009; Sprang, Clark, & Whitt-Woosley, 2007).

Compassion fatigue can cause personal distress and negatively affect one’s ability to maintain job satisfaction and overall happiness. It can create higher levels of negative verbal expression and difficulty relating to clients, which in turn can negatively influence quality of life and job satisfaction (Thomas, 2012). Social workers and other professional caregivers can pay a heavy cost for caring, including depression, sleep disturbance, social withdrawal, and headaches/GI disorders (Showalter, 2010). Compassion fatigue has been explored in several populations including community-based mental health services staff (Rossi et al., 2012), audiologists (Severn, 2012), and nurses (Hegney et al., 2014; Hinderer et al., 2014), and Zerach (2013) compared residential child-care workers to boarding school social workers, but no studies have compared working professionals with students in a helping professional field.

Knowledge and use of self-care practices early in a professional career may mitigate the onset of compassion fatigue and increase worker retention (Hegney et al., 2014). Given the high risk of secondary stress for social work staff, in one form or another, it can be beneficial to examine literature that considers factors that influence a professional’s path toward resilience versus burnout and compassion fatigue (McFadden, Campbell, & Taylor, 2014). Thomas (2012) indicates that clinical decision making and quality of care may be highly compromised when helping professionals experience compassion fatigue, thus, learning self-care practices that encourage good health is a “critical dimension of professional development” (Newsome, Christopher, Dahlen, & Christopher, 2006, p. 1882).

Mindfulness

While Tran, Gluck, and Nader (2013) suggest that there is no universal operational definition of mindfulness, many texts refer to the definition offered by Jon Kabat-Zinn, which explains mindfulness as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” (Kabat-Zinn, 2003, p. 145). Similarly, Christopher and Maris (2010) propose that mindfulness is awareness that makes room for present thoughts, experiences, and feelings with equanimity, while Thomas (2012) suggests that mindfulness practice offers various benefits to helping professionals including improved cognitive abilities, stress management, and client attune- ment. Benefits experienced by professionals who practice mindfulness may also overflow to client outcomes (Grepmair et al., 2007). Hulsheger and colleagues (2013) suggest that

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mindfulness is characterized by a present-oriented consciousness in which individuals are able to focus on moment-to-moment experiences rather than thinking about the past or fantasiz- ing about the future, and mindful individuals are able to encounter a stressful event without attaching meaning to it as they process in a non-judgmental manner.

Mindfulness has been explored with medical personnel (Fernando, Consedine, & Hill, 2014; Krasner et al., 2009; Ludwig & Kabat-Zinn, 2008), college undergraduates (Shapiro, Oman, Thoresen, Plante, & Flinders, 2008), and community members reporting distress (Nyklíček & Kuijpers, 2008), but few studies have implemented mindfulness training with students (Harr, Brice, Riley, & Moore, 2014) and none have compared students to mental health professionals. Mindfulness is commonly explored as an intervention following Kabat- Zinn’s (1990) standard mindfulness-based stress reduction protocol (Creswell, 2017; Nyklíček & Kuijpers, 2008), with more recent studies focusing on introducing mindfulness to help individuals develop resilience to stress (Johnson et al., 2014).

Compassion fatigue and mindfulness

Although there remains a significant research gap regarding compassion fatigue and mind- fulness, increasingly studies link mindfulness practice to higher quality of life for mental health professionals (Thomas, 2012). Medical students randomly assigned to mindfulness training showed reduced psychological distress and increased empathy compared with a waitlist control group (Ludwig & Kabat Zinn, 2008). Shapiro, Brown, and Biegel (2007) revealed similar results in a sample of counseling psychology students who participated in an 8-week mindfulness-based stress reduction (MBSR) course. In 2006, Siebert studied the prevalence of compassion fatigue in a representative sample of 751 National Association Social Work members, which revealed a burnout rate of 39% and life time rates of 75% for compassion fatigue. Siebert’s (2006) findings suggest that compassion fatigue is highly pre- valent and problematic among helping professionals, such as social workers. Berceli and Napoli (2007) agree with Siebert’s (2006) findings and propose prevention programs that are based on mindfulness as an effective intervention to protect social work professionals from trauma exposure, while Fortney, Luchterhand, Zakletskaia, Zgierska, and Rakel (2013) show a negative relationship between mindfulness and compassion fatigue for primary care clinicians who take a relatively short mindfulness based training course. Besides its potential to mitigate compassion fatigue and burnout, mindfulness has been associated with better task perfor- mance and physical health (Hulsheger et al., 2013). Glomb, Duffy, Bono, and Yang (2011) revealed that mindfulness can serve as a protective factor for helping professionals as they process emotionally charged encounters that could otherwise contribute to the onset of compassion fatigue.

In studies exploring the relationship between compassion fatigue and mindfulness, mind- fulness has been operationalized as an 8-week MBSR intervention (Shapiro et al., 2007), a 15- week class loosely based on MBSR techniques (Christopher & Maris, 2010), an abbreviated MBSR intervention (Fortney et al., 2013), and a 9-week meditation instruction (Grepmair, Mittlelehner, & Nickel, 2008). The commonality between these studies, regardless of qualita- tive (Christopher & Maris, 2010), simple pre/post (Fortney et al., 2013), or quantitative randomized controlled trial (Shapiro et al., 2007) design, is the presence of a mindfulness- based intervention taught to study participants. Participants self-report their outcomes, such as stress, somatization, or their experience, with mindfulness using standardized measures, for

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example, the Questionnaire of Changes in Experience and Behavior (Grepmair et al., 2008) or the Perceived Stress Scale (Fortney et al., 2013), or diary reports (e.g., Christopher & Maris, 2010; Hulsheger et al., 2013).

Several studies have shown mindfulness improved quality of life and reduced compassion fatigue in helping professionals (Christopher & Maris, 2010; Figley, 2002). Since previous research shows that there is greater risk for compassion fatigue in less experienced helpers (Bush, 2009), exploring the relationship between mindfulness and compassion fatigue in mental health professionals and graduate social work students may bring attention to the necessity of exposure to self-care strategies in the classroom and the field as a protective factor for interns and professionals alike. Furthermore, it could serve to clarify and enrich curricula for some of the core competencies (e.g., professional identity) that the Council on Social Work Education (CSWE) recognizes as crucial to the education of Bachelor of Social Work (BSW) and MSW students. Scholars agree that greater well-being stems from self-care, including elements such as self-compassion, coping strategies, exercise and healthy choices, co-worker support, and mind- fulness (Thompson, Amatea, & Thompson, 2014; Ying, 2009). While there continues to be a need to study the quality and frequency of varying definitions related to self-care practices, the current study exploring compassion fatigue and mindfulness, even in its broadest definition, can assist in creating improved student education and quality of life among mental health professionals.

Purpose of the study

The primary purpose of this research is to explore the relationship between mindfulness and compassion fatigue in mental health professionals and second year interns in a MSW program. Currently, there are few, if any, studies that compare these two populations without implementing a formal mindfulness-based intervention. The specific relationships and questions being explored in the present study include:

(1) There is an inverse relationship between compassion fatigue and mindfulness. (2) Is there a difference between mental health care workers’ and MSW students’

compassion fatigue and mindfulness?

Method

Sample

A non-probability sample of Mental Health America (MHA) employees (n = 40) and MSW interns (n = 111) comprise the overall sample (N = 151) for this study. The sample includes MHA participants employed in the following departments: Transitional Age Youth, Supportive Services, Adult Integrated Services, Opportunity Center, Recovery Center, Military Resource Center, and Employment. All MHA employees with a graduate degree and license in social work or marriage and family therapy who work directly with clients (n = 53) were invited to participate in the study, resulting in 75% participation rate for professionals. Unlicensed employees, those without post-master’s experience, were excluded from the study. MSW interns in their second year of a 2- or 3-year academic program (n = 136), which includes field

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placement in an agency for a minimum of 24 hours per week, were invited to participate in the study. The participation rate for students was 82%. Students in their first year of their educa- tional program were excluded from the study.

Data collection

All data were collected anonymously and voluntarily. MHA, located in Lancaster, California, is one of Los Angeles County’s oldest nonprofit mental health organizations and an affiliate of the national MHA in California. MHA is a leading advocacy organization addressing the full spectrum of mental and substance use conditions and their effects nationwide. MHA employ- ees strive to inform, advocate, and enable access to quality behavioral health services for all Americans. MHA employees were given a research packet that included a cover letter, information sheet, and survey. Research packets were placed in employee boxes. Participants were instructed via the cover letter to return completed surveys to a locked collection box near the employee break room that was emptied daily by one of the investiga- tors between November 6 and December 14, 2013.

MSW students who participated in this study are enrolled at California State University, Northridge (CSUN); a large, public university in Southern California. CSUN serves over 40,000 students, with approximately 400 students in the MSW program. Between November 6 and December 14, 2013, full-time MSW student interns with at least 1 year of field placement experience were provided a link to an electronic version of the survey via e-mail. Participants were not asked to give personal information, such as age, name, or ethnicity, but the survey did ask about the length of employment in terms of months and years employed at MHA, and the length of direct practice time within a social service agency for MSW student interns. No incentives were offered to participants. The California State University Standing Committee for the Protection of Human Subjects approved this study.

Design and measurement

Compassion fatigue and mindfulness were measured using two standardized instruments: (a) Five Facet Mindfulness Questionnaire (FFMQ) and (b) the Professional Quality of Life Scale (ProQOL).

FFMQ The FFMQ is a 39-item inventory containing five facets: (a) observe, (b) describe, (c) act with awareness, (d) non-judge, and (e) non-react (Tran et al., 2013). The inventory was developed from an analysis of five unrelated mindfulness questionnaires, which showed that the resulting characteristics of the five categories appear to capture the concept of mindfulness. The FFMQ helps determine results of self-regulated attention/orientation to experience. Essentially, it explores how self-regulated attention, or modulating one’s behavior (Vago & Silbersweig, 2012), can interfere with or assist mindfulness as implied by orientation to experience and acts of awareness. The FFMQ uses a 5-point range scale from “very often or always true” to “never or very rarely true” and “demonstrated adequate to internal consistency, with alpha coeffi- cients ranging from .75 to .91” (Baer et al., 2008, p. 330). The subscales show good reliability for the current study (α = .81 for observe, .81 for describe, .87 for act with awareness, .88 for non-judge, and .77 for non-react). Baer and colleagues (2008) report that correlations between

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the FFMQ and other mindfulness measures are high, suggesting the usefulness of the FFMQ as a solitary mindfulness measure.

ProQOL The ProQOL is a structured 30-item self-report measure with three discrete subscales with respondents instructed to indicate how frequently each item was experienced within the past 30 days. The first subscale measures compassion satisfaction defined as the pleasure derived from being able to do one’s work while helping others. Higher scores on this subscale represent greater satisfaction related to one’s ability to be an effective helper. The second subscale measures burnout, or feelings of hopelessness and difficulties dealing with one’s work or doing one’s job effectively. Higher scores on this subscale represent a greater risk for burnout. The third subscale measures compassion fatigue/secondary traumatic stress, with higher scores representing greater levels of compassion fatigue/secondary traumatic stress. The compassion satisfaction, fatigue, and burnout subscales show good reliability for the current study (α = .88 for compassion satisfaction, .75 for burnout, and .73 for compassion fatigue/secondary traumatic stress) and have been used in numerous previous research studies (Figley, 1995; Stamm, 2002).

Results

Preliminary analyses were conducted to check for violations of the assumptions of normality, linearity, and homoscedasticity, as well as further examine outliers and missing data. Univariate analyses reveal normal distributions, no outliers, and randomly missing data comprising less than 5% of the sample. Scatterplots reveal linear relationships between variables of interest. Mean imputation was used to replace missing values (Allison, 2002).

The length of employment (N = 151) ranges from 1 year to more than 10 years (M = 3.54 years, SD = 2.59 years). An independent-samples t-test compares the amount of direct practice work experience for MHA employees (M = 4.10, SD = 3.04) and MSW students (M = 3.33, SD = 2.40) with no significant difference in employment length between the two groups (t(149) = 1.60, p = .11, two-tailed). Compassion fatigue and mindfulness univariate scores fall within an average range for this sample (see Table 1). Scatterplots reveal no evidence of floor or ceiling effects for compassion fatigue or mindfulness facets. The mean level of risk for compassion fatigue is similar to other studies that utilize the ProQOL among helping professionals (Bride, Robinson, Yegidis, & Figley, 2004; Stamm, 2002).

Partial correlation explores the relationship between compassion fatigue and mindfulness while controlling for years of employment. Preliminary analyses ensure no violation of the assumptions of normality, linearity, and homoscedasticity. There is a medium, negative correla- tion between compassion fatigue and mindfulness, controlling for years of experience, r = –.31, n = 149, p < .00, with high levels of compassion fatigue being associated with lower levels of mindfulness. An inspection of the zero order correlation (r = –.30) suggests that controlling for years of employment experience has very little effect on the strength of the relationship between these two variables. Table 2 details the relationship between compassion fatigue, the five individual facets of mindfulness, and years of direct practice work experience.

A one-way between-groups multivariate analysis of variance investigates differences between mental health workers and MSW students in compassion fatigue and mindfulness. The independent variable is profession and the dependent variables are compassion fatigue

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and mindfulness. Preliminary assumption testing to check for normality, linearity, univariate and multivariate outliers, homogeneity of variance-covariance matrices, and multicollinearity reveals no serious violations. There is no statistically significant difference between mental health workers and MSW students on the combined dependent variables, F (2, 148) = 2.58, p = .08, Wilks’ Lambda = .96.

Discussion

This study explores the relationship between compassion fatigue and mindfulness in mental health professionals compared to MSW students with no formal mindfulness intervention, although it is possible that some subjects may have had previous personal exposure to mindfulness. The FFMQ measure used in the current study assesses everyday mindfulness, which pertains to the degree that a person is mindful while going about their daily activities, as opposed to a measure that might look at mindfulness and sitting meditation (Thompson & Waltz, 2007). Results show a medium, negative correlation between compassion fatigue and mindfulness, with no statistically significant difference between the two populations on the combined dependent variables. In other words, high levels of compassion fatigue are related to lower levels of mindfulness in mental health professionals and MSW students alike. The correlation between mindfulness and compassion fatigue in this study further adds to the body of evidence that mindfulness may be useful for individuals working in a mental health environment, regardless of their professional or student status.

Due to the exploratory nature of this study and lack of a formal mindfulness intervention, no conclusions can be made regarding the effects of formally practicing mindfulness and how it relates to compassion fatigue. However, the consistency of the findings in this study lend support to previous research that has established mindfulness as an effective intervention promoting positive affect and self-care for mental health professionals and students (Berceli &

Table 1. Mean, standard deviation, range, and potential range for compassion fatigue and mindfulness facets (N = 151). Variables of Interest M SD Range Potential Range

Compassion fatigue 22.25 5.06 10–42 5–50 Mindfulness facets Observe 26.41 5.43 10–39 8–40 Describe 28.96 4.57 16–39 8–40 Act aware 27.71 5.09 13–40 8–40 Non-judging 28.34 5.36 13–40 8–40 Non-reacting 22.77 3.87 13–34 7–35

Table 2. Pearson product-moment correlations between compassion fatigue, mindfulness facets, and years of direct practice experience (N = 151). Scale 1 2 3 4 5 6 7

1. Compassion fatigue — .12 –.24** –.29** –.38** –.14 .14 2. Observe — .35** –.01 –.11 .26** –.12 3. Describe — .33** .19* .25** –.10 4. Act aware — .44** .19* –.03 5. Non-judgmental — .09 .05 6. Non-reactive — –.13 7. Years direct practice —

*p < .05 (two-tailed). **p < .01 (two-tailed).

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Napoli, 2007; Brown, Marquis, & Guiffrida, 2013; Shapiro et al., 2007; Thieleman & Cacciatore, 2014). Since this study did not have an intervention component, the application and results of the FFMQ to two different populations in this study acknowledges the benefits of everyday mindfulness practices that might have been learned by intuition rather than instruction. The gains that can be made by broadening the research related to formal and/or informal practices that prevent compassion fatigue in mental health care workers and social work students may benefit professionals and clients alike.

Several limitations are inherent to the study design. The exploratory study design and lack of measurement of age and ethnicity make it impossible to examine or control for those potentially confounding variables. Previous research reveals that women have higher compas- sion fatigue scores than men (Rossi et al., 2012) and higher age is related to higher burnout scores (Severn, 2012). Fouladbakhsh and Stommel (2010) report that Caucasians are more likely to use complementary alternative medicine (CAM) practices than African American and Hispanic cancer survivors, but literature around mindfulness as a specific CAM practice describes differences between users and non-users (Segar, 2012) without detailing prevalence and use by ethnicity. Collecting only length of employment demographic data failed to allow for an exploration of differences in compassion fatigue or mindfulness practices by age, ethnicity, race, or previous experience with mindfulness in the current sample.

Despite having sufficient power to conduct analyses with the sample size, several limita- tions exist in terms of generalizability. Data collection from only one mental health agency via paper survey and one university on the West Coast via online survey limits generalizability due to the many institutions providing mental health services and the varied manner by which data were collected. Future research could compare similar institutions at different locations, which might reveal cultural trends in self-care and/or receptiveness to mindfulness as a mitigating variable to compassion fatigue. Consistency in data collection methods may improve reliability of future studies. Additionally, despite the high response rates, the self- selective nature of the survey potentially eliminates subjects who were included in the survey pool but chose not to participate due to feelings of stress or even the very experience of compassion fatigue.

Besides years of experience in the field, future studies on mindfulness and compassion fatigue should consider additionally relevant information that could influence the afore- mentioned variables, such as work environment perception, self-care practices, and coping resources (Ben-Porat & Itzhaky, 2014; Bush, 2009; Thompson et al., 2014). While research shows that self-care practices, such as mindfulness, serve as a protective factor to mental health care professionals and social work students, there still exists a gap between theory and praxis in many institutions. The integration of mindfulness and self-care practices into educational and workplace training could be beneficial and cost effective for all involved parties (Christopher & Maris, 2010), as well as unifying. It could potentially provide common curricula and exposure to practices and behaviors that prepare the student to meet professional social work competencies such as those established by CSWE. Given that there is a growing interest in mindfulness, it is quite possible that more mental health care professionals and social work students will enter their vocation with awareness of self-care tools related to mindfulness. Mental health care employers and

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educators might consider identifying mindfulness as a resource to assure that even those who have had no previous exposure to mindfulness are aware of its potential benefits mitigating compassion fatigue.

Self-care is crucial to the survival and success of mental health professionals and students. Much of their work is based on giving care and empathy. In order to avoid the environmental hazard of compassion fatigue that is naturally a part of their work, mental health professionals and students need to know how to take care of themselves and practice self-compassion (Shapiro et al., 2007). Distinguishing between self-reported orientation to mindfulness-based cognitive processes and self-care in action is an important consideration in future research. Practices, such as exercise, coping strategies, and seeking coworker support, are tried and true methods that have been known to be beneficial for years, while mindfulness continues to emerge and expand as an effective practice in self-care. Mindfulness-based interventions have been shown to be effective across a variety of outcomes and populations (Creswell, 2017), but studies about the quality and frequency of mindfulness practices beyond randomized controlled trials are vital for determining whether someone is engaging in cognitive processes or mindfulness in action.

Results from the current study show a negative correlation between compassion fatigue and mindfulness, which indicates that while there was no formal intervention, traits of mind- fulness may be helpful in mitigating compassion fatigue. In turn, it is possible that the benefits of mindfulness for the mental health professional and the MSW student can extend to the client (Grepmair et al., 2007), since compassion fatigue has been shown to compromise quality of care. In other words, if the professional benefits from mindfulness then the client will benefit vicariously. Findings from this study may advance awareness to mental health agencies and social work schools about the potential of mindfulness in guarding against the risk of compassion fatigue.

Acknowledgment

This research was supported in part by the College of Social and Behavioral Sciences, CSUN.

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