For A-plus Writer Only

Book Reference

James, R. K. & Gilliland, B.E. (2017). Crisis intervention strategies (8th ed.). Boston, MA: Cengage Learning.

Respond to the following questions with a yes or no.

1. Have you left parties early because the occasions offered you no opportunity to counsel?

2. Do you continue to counsel even though it inter- feres with your earning a living?

3. Do you sometimes have the "shakes" in the morning and find that this unpleasantness is relieved by counseling a little?

4. Do you repeat everything you hear? I mean, do you repeat or paraphrase everything you hear?

These questions are part of Adam's (1989) humorous, satirical test of counseling addiction. Yet the ques- tions may not be too far off target when viewed in terms of another severe problem that strikes many professionals in the human services business - burnout- and its handmaidens, compassion fatigue and vicarious traumatization.

So you are a brand new human services worker with a diploma fresh off the presses and ready to go out and cure the world. You are full of vim and vigor and one salty dog! What's with burnout? That's just old dudes that are washed up! Apparently, since the last edition of this book went to press in 2012, 1~75 articles on burnout retrieved from the Ameri- can Psychological Association (2015) search engine, Psychinfo, felt otherwise. They also seem to be talking about you, young grasshopper! Research indicates that if you are younger and female you are more likely to wind up in the burned out category of human services workers (Baum et al., 2014; de Figueiredo et al., 2014; Star, 2015; Volpe et al., 2014).

If you were a teacher from Ireland (Foley & Mur- phy, 2015), a Chinese civil servant (Hao et al., 2015), or a Peruvian correctional officer (Clemente et al. , 2015), there was some concern you might be burning out.

546

Indeed, it appears that about every country a n occupation in the world is concerned about burnouL and it is far from humorous. Burnout is not just some pop psychology term designed to elicit sympathe t ic responses from one's coworkers or spouse. It is a complex individual-societal phenomenon that affec ts the welfare of not only millions of human services workers but also tens of millions of those workers· clients (Farber, 1983, pp. vii, 1). Put in economic term s. billions of dollars are lost each year because of wo rk- ers in all fields who can no longer function adequately in their jobs. Signs and symptoms of burnout include turnover, absenteeism , lowered productivity, a n · psychological problems (Golembiewski, Munzenrider, •-

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 547

Stevenson, 1986; Leiter & Maslach, 2005, pp. 3- 9). Yet if burnout has been discussed in all occupations, why should it be endemic to the helping professions?

Helping Professionals: Prime Candidates The bulk of writing and research that has been done on burnout has come from the helping professions because of its poorer job satisfaction and higher turnover and burnout compared to other occupations (C oates & Howe, 2014). The very nature of the job is to be intensely involved with people, and generally these are people who are not at the highest levels of self-actualized behavior (Maslach, 1982b, pp. 32-33). Burnout tends to afflict people who enter their profes- sions highly motivated and idealistic and who expect their work to give their life a sense of meaning (Pines & Aronson, 1988, p. 11). When many of the clients get worse instead of b etter despite all of the workers' skill and effort, burnout becomes a high probability for these idealistic people.

Compounding the harsh realities ofhistorically low success rates, the human services business is becoming more difficult. Human services workers are likely to intervene with people with severe psychological and physical traumatic problems connected with sexual and physical assault, murder, Alzheimer's disease, and AIDS. Because of managed care and restricted budgets, human services workers are expected to handle larger caseloads in shorter time periods . These traumatic problems call for tremendous amounts of the work- er's energy, resilience, and hardiness . Day in and day out, the severity of these problems and their duration can wear down the optimism and motivation of any worker (McRaith, 1991).

AIDS counselors are an outstanding example of prime candidates for burnout. They must deal with concerns about safe working practices, fear of infec- tion, intensity of counselor/client/significant other relationships over long periods of physical decline to death, the broad range of services needed, transcrisis events involving a variety of issues, increasing num- bers of clients, lack of support by other organizations, and shunning by many health care providers (Miller, 1995; Oktay, 1992).

The foregoing problems are at the core of the helping professions, making them not just some of the most challenging but also some of the most stress- prone occupations. Thus, human services profes- sionals must be able to tolerate a variety of complex

problems that are generally couched in ambiguity, deal with conflict from both clients and institutions, and somehow meet a myriad of demands from the ecological framework in which they operate (Paine, 1982 , p. 21).

For the crisis worker, this is true many times over. Crisis center work settings are notorious for long and erratic hours, low pay, poorly functioning clients, im- mediate deadlines, a lack of control over when clients will arrive or phone, few second chances, repeat callers with chronic problems, hostile and emotiona 'ly "raw" clients, and interagency red tape . These are only a few of the stressors that assault crisis workers , making them prime candidates for burnout (Distler, 1990). Because the crisis worker is exposed to a high incidence of trauma for extended periods of time, phrases such as "co mpassion fatigue " (Figley, 1995, 2002), "traumatic" or "event" countertransference (Dahlenberg, 2000, pp. 12- 13), "vicarious trauma- tization" (McCann & Pearlman, 1990; Pearlman & Mac Ian, 1995; Pearlman & Saakvitne, 1995a, 1995b; Saakvitne, 2002), and "traumatoid states" (Thomas & Wilson, 2004) have found their way into the literature to describe what happens when workers are faced over and over with unspeakable trauma.

However, a question arises about whether burnout and its newer derivatives are really dynamically iden- tifiable. There is a lively ongoing discussion in the profes sional literature at this writing as to whether burnout is an identifiable, stand-alone malady or is really just clinical depression dressed up in work clothes and struggling through a workday (Bianchi & Lauren t, 2015; Bianchi et al., 2015; Chiu et al., 2015). Indeed, Hafkenscheid (2005) proposes that the term vicarious traumatization is no more than a fancy term made up to excuse therapeutic failure. Paine (1982, p. 11) and Maslach (1982b, p. 29) report that crit- ics propose that burnout is "part of the job," so if a human services professional "can't stan:d the heat then he or she ought to get out of the kitchen" be- cause there "always has been stress on this job and always will be." Such cursory dismissal of burnout does not consider the major personal, social, and or- ganizational costs that accrue when job stress turns into crisis (Paine, 1982 , p. 11). Burnout is connected to loss of job productivity, impairment of inter- and intrapersonal relationships, and a variety of health problems (Golembiewski et al. , 1992; Golembiewski & Munzenrider, 1993; Golembiewski, Munzenrider, & Stevenson, 1986). Indeed, there is ominous research accumulating that indicates people who manifest

548 • PART THREE On the Home Front: Crisis in the Human Services Workplace

burnout have significant changes in body chemistry that are biomarkers for cardiovascular disease (Grossi et al., 2005; Melamed et al., 2006; Toker et al., 2005). Burnout is not just part of the territory; it has major ramifications for both individuals and institutions (Maslach, 1982b, p. 39). It is a very real problem, with chronic occupational stress as the pri- mary cause (Paine, 1982, p. 16; Tubesing & Tubesing, 1982, p. 156).

Dynamics of Burnout A historical definition of burnout places it l!iJI as a child of the 1970s. The term comes from the psychiatric concept of patients who were "burned out" physically, emotionally, spiritually, interpersonally, and behaviorally to the point of exhaustion (Paine, 1982, p. 16). It was first coined as a workplace term by Herbert Freudenberger to describe young, idealistic volunteers who were working with him in alternative health care settings and who started to look and act worse than many of their clients (Freudenberger, 1974, 1975). Yet defining burnout adequately is not simple.

A very broad definition depicts burnout as an internal psychological experience involving feelings, attitudes, motives, and expectations (Maslach, 1982b, p. 29). Being burned out means that the total psychic energy of the person has been consumed in trying to fuel the fires of existence. This energy crisis oc- curs because the psychic demand exceeds the supply (Tubesing & Tubesing, 1982, p. 156). It is experienced as a state of physical, mental, and emotional exhaus- tion caused by long-term involvement in emotionally demanding situations. It is accompanied by an array of symptoms including physical depletion, feelings of helplessness and hopelessness, disillusionment, negatix_e self-concept, and negative attitudes toward work, people, and life itself It represents a breaking point beyond which the ability to cope with the en- vironment is severely hampered (Pines & Aronson, 1988, pp. 9- 10) and the inability to work effectively (Stamm, 2010).

Put in plain language, burnout is lost energy. You are exhausted. A good night's sleep is out of the ques- tion and sleep aids (including alcohol) don't help much. Aborted attempts to get away don't help and you come back feeling worse than ever. Work is de- manding beyond reason and exceeds the best you are able to do. Burnout is also lost enthusiasm. As Rhett Butler said to Scarlett O'Hara in Gone with the Wind,

"Frankly my dear, I just don't give a damn!" Passion h as been replaced by cynicism. You despise your bo sses and the clients, and aren't overly thrilled with your coworkers either. All the zeal, energy, creativity, exp er- tise, and enthusiasm you brought to the job are long gone. Going the extra mile has turned into wondering whether you can go the few yards to the break ro om. Finally, your confidence has gone out the window. T he less effective you become, the more your self-wo rrh shrinks. Why keep going (Leiter & Maslach, 20 05. p. 2)? Indeed you are now a candidate for the lon6 shopping list of maladies you'll soon see that com e out of this thing called burnout!

Burnout is not generally perceived as a crisis evem because its onset is slow and insidious. There is no one point or incident that is readily identifiable as t he instigating trauma. Rather, it is a slow and steady ero- sion of the spirit and energy as a result of the daily struggles and chronic stress typical of everyday life and work (Pines & Aronson, 1988, p. 11). Becau se of the difficulty in identifying burnout, it becom es much easier to chalk it up as a character deficit. A crisis appears only when people are so defeated anc exhausted by the environment that they take extraor- dinary means to find relief, such as quitting a job or occupational field, developing a serious psycho so - matic disease, becoming a substance abuser, or at- tempting suicide. What is even more problemat ic is that recovery from burnout is not always linear a m: tends toward chaos and crisis as the individual tr ies to come to grips with core issues of vocation, person - ality, and relationships (Kesler, 1990). As a result, the precipitating crisis of job burnout may move toward a more global, existential crisis wherein the person is in a state of crisis over living.

Occupationally, burnout occurs when past and present problems from the job continuously pile up. Leiter and Maslach (2005, pp. 14-19) propose that there are six major sources of burnout: workload, when the work is too complex, too much, too urgent, or just too awful; control issues from being micro- managed or having ineffective leaders or teams; lack of reward in the form of compensation, recognition, or pleasure; an absence of community that provides social support; lack of fairness , with little justice and lots of arbitrary and secretive decision making and favoritism; and discordant values that indicate you and the organization are severely at odds regarding your belief in the validity and worth of the organiza- tion and the organization's belief about your valid- ity and worth. The foregoing problems may vary in

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 549

degree and kind, but the result is a continuous and grinding interface between the person and the work environment (Pines & Aronson, 1988, pp. 43 - 44; Riggar, 1985, p. xvi). From the worker's standpoint, no short- or long-term relief is forthcoming.

The body's nonspecific response to any demand is stress. Humans need some stress for optimal per- formance. However, there comes a point of maximal return for each person. That point is a function of genetic, biological, behavioral, and acquired physi- ological factors. Beyond that point, stress is harm- ful (Selye, 1974). Environmental events may either "cause" the activation of the stress response or, more often, set the stage for it through cognitive-affective processing (Everly, 1989, p. 45). The stress response itself involves enervation of neurological, neuroen- docrine, and endocrine systems either singularly or in tandem with one another, which in turn activates various physiological mechanisms directed toward numerous target organs (p. 47). In Selye's (1956) gen- eral adaptation syndrome (GAS), overstimulation and excessive wear of target organs lead to stress - related dysfunction and disease. If the stressor is persis- tent and there is a chronic drain on adaptive energy, eventual exhaustion of the target organ will occur. The end result physiologically may be as dramatic as a heart attack or as common as a headache. Indeed, where GAS is found burnout may not be far behind, and it has been linked to a wide range of both physical and mental illnesses (Maslach et al., 2001).

Stress occurs when there is a substantial imbal- ance (perceived or real) between environmental de- mands and the individual's response capability. Burnout occurs when the stress becomes unmediated and the person has no support systems or other buffers to ease the u~relenting pressure (Farber, 1983, p . 14). The outcome is a person affected in every dimension of life by unlimited combinations of symptoms. Such a description very adequately meets the crisis conditions of being in a state of disequilibrium and paralysis.

Cornerstones of Burnout

Let us now look at two human services profession- als who are experientially and professionally differ- ent, but by almost any definition are in the process of burning out.

Mr. Templeton. Mr. Templeton has worked as a school counselor at Central Junior High School for 2 years. In that time he has instituted some sweeping changes

in a guidance program that was, before he came, no- torious for running attendance checks and not much more. Mr. Templeton's counseling approach changed all that. Formerly, the last place that students would have gone for help with personal problems would have been the counseling office. By getting out and explain- ing what his job was all about to students, faculty, parent groups, civic organizations, and anybody else who would listen, and indeed making good on his promises, Mr. Templeton has turned the guidance office into something akin to a land office ·during the California gold rush. His principal would now fight a circular saw to keep Mr. Templeton around.

What the principal does not know is that Mr. Templeton has fantasies about sending the en- tire ninth grade to an Outward Bound camp in the Sahara Desert. He has not had a new idea about how to improve the counseling program in 6 months and is wondering if maybe that stockbroker's job that h e so capriciously turned down las t year was not such a bad idea after all. As he considers all this, he wistfully looks at his wristwatch, then at the ninth grader sit- ting across from him, and wonders whether she is in his office because of grade problems or a problem at home. She has been talking for 30 minute s, and he cannot remember two sentences she has said.

Josh. Josh is asocial worker at an outpatient clinic for a community mental health center. He has worked there for 5 years. His patient load resembles something on the order of bus traffic to Mecca. He has just received a memorandum from the director further increasing his caseload by 20%, along with a rather curt directive to move on some of those old cases and get them off the clinic rolls.Josh is sitting in his friendly local tavern quietly getting drunk and wondering how h e is going to put 20 people out on the street with no support. He is also mulling over what response h e will make to his wife, who just this morning asked for a separation. Among the complaints she voiced, his job was prominent: the lousy pay for somebody with a master's degree, the long hours with no compensatory time, the emergencies in the middle of the night, and particularly forgetting he is the father of their two children and a husband to her. Josh stares across the bar and orders another drink. While waiting for his order, he swallows an antacid tablet for the dull, burning pain slowly working its way outward from the pit of his stomach.

What do these two human services profession- als have in common? They are alike in that they are empathic, sensitive, humane, idealistic, and people

550 • PART THREE On the Home Front: Crisis in the Human Services Workplace

oriented and have been highly committed and dedi- cated to their profession. However, like most other human services workers prone to burnout, they also tend to be overly anxious, obsessional, enthusiastic, a bit neurotic , extraverted, conscientious, and sus- ceptible to identifying with their clients (Farber, 1983, p. 4; Piedmont, 1993). For both of them, one or more of the following foundation blocks of burn- out have been laid (Borritz et al., 2005; Farber, 1983, p. 6; Harnois , 2015; Lee & Ashforth , 1993; Olivares - Faunqez et al., 2014; Powell, 1994; Rupert, 2015).

1. Role ambiguity. They lack clarity concerning rights, responsibilities, methods, goals, status, and ac- countability to themselves or their institutions.

2. Role conflict. Demands placed on them are incom- patible, inappropriate, and inconsistent with val- ues and ethics.

3. Role overload. The quantity and quality of demands placed on them have become too great.

4. Inconsequentiality. They have a feeling that no mat- ter how hard they work, the outcome means little in terms of recognition, accomplishment, appre- ciation, or success.

5 . Isolation. They have little social support either in the institution or outside of it.

6. Autonomy. Their ability to make decisions as to what they will do and how they will deal with their clients is co-opted by the bureaucracy of their place of employment.

These foundation stones are not thrown down haphazardly. They are built up slowly but surely over time through a variety of dynamics.

Research on Burnout Dynamics The following points have been supported to vary- ing degrees by research on burnout (Baird & Jenkins , 2003; Bianchi et al., 2014; Borritz et al., 2005; Carroll & Whrte, 1982; Decker, Bailey, & Westergaard, 2002; Golembiewski & Munzenrider, 1993; Golembiewski, Munzenrider, & Stevenson, 1986; Golembiewski et al., 1992; Grossi et al., 2005; Grouse, 1984; Hoeksma et al., 1993; Koeske, Kirk, & Koeske, 1993; Lee & Ashforth, 1993; Linley,Joseph, & Loumidis, 2005; Lyndall & Bick- nell, 2001; Oerlamans & Bakker, 2014; Maslach, 1982a; Mather et al., 2014; Melamed et al., 2006; Piedmont, 1993; Pines & Aronson, 1988; Powell, 1994; Rupert et al., 2015; Salston & Figley, 2003; Toker et al. , 2005).

1. All stressors are cumulative and can help lead to burnout.

2. Burnout is psychobiological. 3. Environmental factors other than work can be

contributors. 4. A lack of effective interpersonal relationships co n -

tributes to burnout. 5. Signs of burnout will occur, but recognition of

them depends on the observer's astuteness. 6. Symptoms sometimes appear quickly, but most

usually occur over time. 7. Burnout is process oriented rather than event

oriented. 8. Burnout varies in severity from mild energy loss

to death. 9. Burnout also varies in duration.

10. Burnout and resulting crisis ~an occur more than once.

11. Awareness varies from complete denial to full co n - sciousness of the problem.

12. Burnout is infectious in that it puts additional stress on other workers.

13. Burnout is greatest for beginning and long-term workers and least for midduration workers.

14. Those who are single experience the most burn- out, whereas those with families experience th e least. However, stressors that enter family life can exacerbate burnout.

15. Restorative and preventive measures have to be individually tailored because of the idiosyncratic nature of burnout.

16. Burnout has progressive phases that can b e identified by the varying degrees of depe r- sonalization, personal accomplishment (o r lack thereof), and emotional exhaustion the individual exhibits.

17. Burnout is not a disease, and the medical model is not an appropriate analytical model.

18. Burnout should not be confused with malingering. 19. Progressive deterioration in physical and mental

health occurs as burnout increases. 20. Job autonomy, sense of coherence, and social sup-

port buffers are critical to preventing, containing, and reducing burnout.

21. Making time for leisure and using it wisely are as important as any job variable.

22. Burnout can lead to personal and professional growth as well as to despair and trauma.

23. More education, training specific to trauma work, supervision, and institutional support are all related to lower burnout rates.

24. A personal history of trauma is a contributing factor.

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 5 51

Myths That Engender Burnout Candidates for burnout believe a numbe r l!!ll of myths about themselves and how they must operate in their environment (Everly, 1989; Friedman & Rosenman, 1974; Kesler, 1990; Maslach, 1982a; Pines & Aronson, 1988; Rodesch, 1994). They tend to distort the reality of the situation in typical type A personality patterns (Friedman & Rosenman, 1974), generating a variety of irrational statements about themselves and their work. Thes e statements are modeled after Albert Ellis's (Patterson, 1980, pp. 68-70) unhealthy thoughts people say to themselves about their predicaments .

1. "My job is my life." This means long hours, no leisure time, and difficulty delegating authority. Anxiety, defensiveness, anger, and frustration are the result when things do not go perfectly.

2. "I must be totally competent, knowledgeable, and able to help everyone." Unrealistic expectations of performance, a need to prove oneself, lack of confidence, and overriding guilt occur when one is not perfect.

3. "To accomplish my job and maintain my own sense of self-worth, I must be liked and approved of by everyone with whom I work." Such work- ers cannot assert themselves, set limits, say no, disagree with others, or give negative feedback. Therefore, they get manipulated by others in the work setting-including by clients. Self-doubt, passive hostility, insecurity, and subsequent depression are the reward.

4. "Other people are hardheaded and difficult to deal with, do not understand the real value of my work, and should be more supportive." Stereotyping and generalizing about specific problems and people occur, and lack of creativity, wasted energy, and decreased motivation result. The person has a defeatist attitude and a passive acceptance of the status quo.

5. "Any negative feedback indicates there is some- thing wrong with what I do. " The person cannot evaluate his or her work realistically and make constructive changes. There is a great deal of anger with critics, which may manifest itself in either passive or aggressive hostility, dep ending on the person toward whom the anger is directed. Frustra- tion and immobilization are the outcomes.

6. "Because of past blunders and failures by others, things will not work the way they must." Old pro- grams are not carried to fruition, nor are new ones

created. Stagnation and decay in the work setting are the result.

7. "Things have to work out the way I want." The person's behavior is thus characterized by working extra hours and checking up on staff members' work, an inability to compromise or delegate, over attention to detail, repetition of tasks, impatience with others, and an authoritarian style.

8. "I must be omniscient and infallible." The person can never be wrong. The very act of doing therapy with humans in all their infinite ways ofibehaving means fallibility for the worker, particularly when the client is in crisis.

These dynamics lead to a wide array of symptoms.

Symptoms of Burnout Burnout is a multidimensional phenomenon, lmJ consisting of behavioral, physical, interpersonal, and attitudinal components. Table 16.1 is a ready refer- ence. While the list is lengthy, it is undoubtedly not all-encompassing. Certainly not all human services workers in crisis manifest all the symptoms listed. Yet for the watchful observer, many will become notice- able, particularly if one looks back in time and notes any pronounced changes in the worker.

Levels of Burnout Burnout can be categorize d as occurring lliJI at one of three levels: trait, state, and activity (Forney, Wallace-Schutzman, & Wiggers, 1982). At a trait level, it is all-pervasive, encompassing every facet of the worker's life. The worker is completely nonfunctional in regard to person, place, and time . The trait level of burnout is extremely serious and calls for immediate intervention in the worker's life. At a state level, burn- out may be periodic or situational. A classic example is what occurs during the period of full moon at a crisis line center. At such times it seems as if every crisis-prone person in town takes a signal from a lunar clock to go berserk. Although problematic, such crisis situations are relieved when the moon wanes, and the crisis line worker returns to some semblance of nor- malcy. However, over the long term, such state events contribute mightily to anticipatory anx iety, which if not dealt with can precipitate total burnout.

Finally, burnout may be activity based. Any activity that is performed over and over at an intense level, as in encounter group counseling of substance abusers or serving as a chaplain to the grief stricken in a trauma center, will invariably wear the armor off the most

552 • PART THR EE On the Home Front: Crisis in the Human Services Workplace

Use and abuse of alcohol and Lower resistance Compulsion to do all and be all at Feeling of emptiness, meaning-

illicit drugs home lessness

Increase in absenteeism Maladies occurring at organ No mature interactions-keeping Ranging from omnipotence to weak points: ulcers, migraines, hidden agendas incompetence gastrointestinal upset, facia l tics, etc.

Increase in risk taking Colds and vira l infections Keeping everyone subservient Cyn icism

Increase in med ication Poor coordination Feel ing drawn to people who are I Paranoia less secure

Clock watching Insomnia, nightmares, and Reduction of significant others to Compulsiveness and obsessive- excessive sleeping status of cl ients ness

Complaining Muscular tension Breaking up of long-lasting relation- Callousness sh ips

Changing or quitting the job Addiction to alcohol and /or I Becoming therapeuticall y minded I Gu ilt drugs and overreacting to comments of

friends

Inabil ity to cope with minor Increased use of tobacco and No separation of professional and I Boredom problems caffeine social life

Lack of creativity Over- or undereating Allowing cl ients to abuse privacy of Helplessness and/or hope lessness home by cal ls or visits at any time Suicidal/ homicidal ideation

Loss of enjoyment Hyperactivity No opportunity for or enjoyment in Ter rifying and paralyzing feelings just being oneself and thoughts

Loss of control Sudden weight gain or loss Lonel iness, trust issues Stereotyping

Tardiness Flare-ups in preexisting medical Loss of authenticity Depersonalizing conditions: high blood pressure, ulcers, asthma, diabetes, etc.

Dread of work I Injury from high-risk behavior Loss of ab ility to relate to fr iends, Pessimism fami ly, or clients

V~cillation between extremes of Missed menstrual cycle Avoidance of close interpersonal I Air of righteousness overinvolvement and detach- contact ment

I

Mechanistic responding Increased premenstrual tension Switch from ope n and accepting to I Grandiosity closed and denying

Accident proneness I Injury from accident Inabi lity to cope with minor inter- Sick humor, particularly aimed personal problems at clients

Change in or cessation ofreli- Rapid heartbeat Iso lation from or overbonding with Dist rust of management, supervi- gious affiliation staff sors, and peers

Errors in setting therapeutic Breathing difficulties Increased expression of anger and Hypercritical attitude toward boundaries mistrust institution and coworkers

Errors in judgment and strategy Anxiety and panic attacks Increased vigil ance and safety issues in and outside therapy for selfand loved ones

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicariou s Traumatization, and Compassion Fatigue • 5 5 3

PTSD-like symptoms of intrusive Dizziness

thoughts, numbing of affect,

sleep disturbance, nightmares,

and hypervigi lance

Regression Impaired immune system

Impatient and irritable

Withdrawn

Losing things

Suicide attempts

Homicide attempts

emotionally bulletproof crisis worker. A simple way of decreasing chances of burnout when the stressor is activity based is to change the routine . However, such change is not always easily accomplished or even recognized as needed.

Stages of Burnout Another way of characterizing the road to IDJI burnout is by stages. Edelwich and Brodsky (1982 , pp. 135-136) delineated four stages through which the typical candidate for burnout goes.

Stage 1: Enthusiasm. The worker enters the job with high hopes and unrealistic expectations. If such idealism is not tempered by orientation and training programs that define what the worker can reasonably expect to accomplish, such a rose-colored view of human services work will inevitably lead to the stage of stagnation.

Stage 2: Stagnation. Stagnation occurs when the worker starts to feel that personal, financial, and career needs are not being met. Awareness may come from seeing people perceived as less able moving up the career ladder faster, pressures from home to meet increased financial obligations, and lack of personal intrinsic reinforcement for doing the job well. Astute manage- ment policy will head off stagnation by providing a variety of incentives that clearly say to the worker, "You're doing a good job here, and we appreciate it." If intrinsic and extrinsic reinforcement does not occur, the worker will move into the next stage, frustration.

Overprotection as a parent Entrapment in job and relations

Decreased interest in intimacy or sex Free-Aoating feelings of inad-

equacy, inferiority, incompetence,

and survivor guilt

Self-criticism and perfectionism

Rapid mood swings

Loss of faith, meaning, purpose

Change in religious beliefs

Sense of grounding, inner balance lost

Increased sense of vu lnerability to

world at large

Stage 3: Frustration. Frustration clearly indicates that the worker is in trouble. The worker starts questioning the effectiveness, value, and impact of his or her efforts in the face of ever-mounting obstacles. Because the effects of burnout are highly contagious in the organi- zational setting, one person's frustration is likely to have a domino effect on others. One appropriate way of meeting frustration is to confront the problem head on by arranging workshops or support groups to increase awareness of the burnout syndrome, and generate problem solving as a group to bring about changes within both the institution and the individual. Catching the problem at this stage may well lead back to a more tempered stage of enthusiasm. If the problem is not resolved, then the final stage, apathy, is reached.

Stage 4: Apathy. Apathy is burnout. It is a chronic indifference to the situation and defies most efforts at intervention. Apathy is truly a crisis stage: The person is in a state of disequilibrium and immobility. Further compounding this stage are denial and little objective understanding of what is occurring. At this point psychotherapy is almost mandatory for reversal to take place .

Worker-Client Relationships As crisis intervention h as spread to more IDB and more areas of psychological trauma, interest in what happ ens to the workers who deal with these clients has led to the concept of secondary traumatic stress disorder (STSD) . STSD is a consequence for

554 • PART THREE On the Home Front: Crisis in the Human Services Workplace

health care professionals who are frequently exposed to the stress and trauma of others in the course of treating them (Hensel et al., 2015) or what McCann and Pearlman (1990) call vicarious traumatization (VT). Compassion fatigue (CF) is manifested in the continuous negative aspects of care provision for tough cases and customers in a demanding work environment that generally revolve around some type of trauma (Stamm, 2010). These terms are often used interchangeably to describe what is going on when the crisis worker- client relationship becomes pathological. These are the very real, concrete negative effects that occur when human services workers have prolonged exposure to traumatized clients who are 1n cns1s .

Research does indicate that health services work- ers experience more negative effects from crisis work than other types of health services workers (Arvay & Uhlemann, 1996; Blanchard & Jones, 1997; Charney & Pearlman, 1998; Johnson & Hunter, 199 7; Smart et al. , 2014) . The potential for STSD is even more pronounced in crisis workers who work with long- term disasters . Wee and Myers (2002) conducted a study of mental health workers who did long-term follow-up in the Murrah Federal Building bombing in Oklahoma City, and found that about half of the respondents reported being more stressed than do- ing normal mental health work and being at high risk for both compassion fatigue and burnout. Why is this so?

It is so because trauma work and crisis interven- tion are so potentially addictive and at the same time so potentially destructive! Much like the "rush" that police officers, paramedics, and other emer- gency workers experience from being in the middle of traumatic events, crisis workers feel the "adren- aline high" of successful crisis intervention, and this can become highly addictive. As an example, psyi;.hologists who worked the aftermath of 9/ 11 in New York City reported more positive than negative feelings regarding their work (Eidelson, D 'Alessio, & Eidelson, 2003). Yet the constant exposure to the "highs" that come with dealing with traumatic events also means that the crisis worker is exposed to a constant barrage of some of the most graphic and horrible physical and psychological ramifica- tions that nature or humankind can visit on people. Two psychological concepts are hallmarks of deal- ing with crisis clients and, if not understood and dealt with, have the potential to infect the crisis worker and lead to burnout. Those two concepts are

countertransference and secondary traumatic srress or vicarious traumatization/ compassion fatigu e.

Countertransference

Whenever therapy becomes intense, as in crisis wor'- the potential for countertransference rises dram ar:- cally. Countertransference is the attributing re the client, by the crisis worker, of traits and b eha, -- iors of past and present significant others or evencs in the crisis worker's own life. Countertransferencc responses may be positive or negative, spoken or Ufr spoken, conscious or unconscious. They may includ~ physical, psychological, social, gender, racial, mor~. spiritual, cultural, or ecological factors that have im - pacted the worker through past e xperiences and are manifested in the "here and now" of therapy by t he client. At times , emotional aspects of the client m a;· agitate feelings, thoughts, and behaviors that are deeply buried within the worker's own personality.

When confronted with their own shortcomin gs. fears, faults , prejudices, and stereotypes as mirrorec by the client, human services workers may begin be- having in inappropriate ways . Workers may act ir:. ways designed to meet their own needs and not t he clients'. The result is that clients are made to fit neatly into the workers' preconceived patterns for the way things "ought to be," and not necessarily in reference to the client but how they "ought to be" for the crisis worker (Freudenberger, 1977).

The general axiom of psychoanalytic therapy is that countertransference needs to be guardeci against, and the therapist's refusal to recognize it a nri d eal with it can, at the least, inhibit the therapis t 's effectiveness, and at the most, be destructive to t he relationship (Dahlenberg, 2000, pp. 1-6). If the phe- nomenon of countertransference is not recogn ized and dealt with in positive ways, the human services worker ends up feeling guilty about having negative feelings toward the client and is not even sure why those feelings are occurring. Such feelings are a n - tithetical to what the worker has been taught a n d believes and can significantly compound the occup a- tional stresses that lead to burnout.

However, Pearlman and Saakvitne (199 5a . pp. 22- 24) propose that if crisis workers are to deal successfully and understand the pain of their cliem s in deeply empathic ways, then countertransference is inevitable and necessary. Particularly emotion-laden issues such as physical and sexual abuse of children . terminal illnesses, and chronic suicidal ideation a re prime examples of content that may be exceedingly

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 5 5 5

stressful to the worker because of strong feelings and experiences the worker may have about the problem (Dahlenberg, 2000; Fox & Cooper, 1998; Pearlman & Saakvitne, 1995a). The pluses and minuses of coun- tertransference as it applies to trauma appear to bal- ance precariously on a very thin psychological high wire. Main's (2008) study of sexual offender treat- ment providers found that while they manifested disruptions in cognitions, emotions, and behaviors consistent with those that characterize compassion fatigue and vicarious traumatization, they also possessed many of the components for compassion satisfaction (the positive feelings and intrinsic rewards one feels from helping others who have ex perienced a traumatic event) (Stamm, 2010) and reported that their child sexual abuse histories were an advantage in the treatment of sex offenders. As such, one of the critical components to handling countertransference effectively would appear to be close and competent supervision.

Secondary Traumatic Stress/Vicarious Traumatization/Compassion Fatigue STS/VT and CF are different from the phenomenon of countertransference. As these terms have evolved, they have taken on somewhat different, more discrete meanings. Secondary traumatic stress/vicarious traumatization is the transformation that occurs when an individual begins to change in a manner that mimics a client's trauma-related symptoms. It is a constructivist model in which the individual's experience and worldview are changed as a direct re- sult of secondary exposure to trauma through crisis work (Pearlman & Mac Ian, 1995). As an example, in a study conducted by Alexander and associates (1989), researchers who were deeply involved in reading and reviewing rape cases and not actually talking to the victims started to manifest victim pathology. The bottom line is that all of these terms apply to a worker who has been affected by long-term, intense involve- ment of some type with very traumatized clients.

STS/ VT and CF occur as a result of an accumula- tion of experiences across therapies and clients and are felt far beyond the transference- countertransfer- ence issues of a specific client-therapist relationship. Whereas countertransference is temporary, STS/ VT a nd CF have the potential to permanently change the psychological constructs of workers who engage in intense and long-term trauma and are an inevitable occupational hazard of trauma work (Saakvitne & Pearlman, 1996, p. 31). In summary, a worker who

has a full-blown case of STS/ VT doesn't look and act very much different than the PTSD clients they are treating.

The end result of VT and CF is their generalizing effects on countertransference issues . As VT is mul- tiplied and generalized over clients, countertransfer- ence reactions become stronger through the human services worker acting them out against the client or submerging them even deeper from awareness (Saakvitne & Pearlman, 1996, p. 48). For human services workers in general, and crisis workers in partilcular, VT/ STS and CF are major mediating factors that lead to burnout. In fact, Cieslak and associates (2014) conducted a meta-analysis that examined the rela- tionship between STS/ VT and burnout and found a substantial overlap between the two particularly if measured in the framework of compassion fatigue.

Worker Vulnerability. Maslach (1982b, pp. 36 - 37) states that the only human services workers who burn out are the ones who are on fire . For such workers, Saakvitne and Pearlman (1996, pp. 26, 49) and Figley (1995) believe that the deep empathy needed to deal with the heart-wrenching situations that often ac- company crises makes workers vulnerable to intense and overwhelming feelings and profound disruptions in their beliefs, and assaults the very core of their hope and idealism . Over time, such assaults lead to compassion fatigue (Figley, 1995), wherein the crisis workers' energy is literally wrung out by the incidence and amplitude of dealing with the horrific problems that trauma clients fac e.

Between a very real dedicatory ethic and at times an insatiable need to assist everyone with any t ype of problem, the idealistic human services worker sees his or her job as a calling. In an imp erfect world, such an idealistic outlook can lead to over involvement and identification with the client- often to the worker's detriment (Koeske & Kelly, 1995). As the human ser- vices worker becomes more deeply enmeshed in the helping relationship, the worker's strong need to be accepted and liked makes it harder and harder to say no to the client's demands. At this point, the worker has started to take on responsibility for the client.

The worker's over involvement with the client may be manifested in a variety of ways. Some of the many indicators that the worker is not paying atten- tion to his or her own needs, or frankly to the client's, include ex tending the session beyond its usual time limit, taking and responding to phone calls at home at all hours of the night, experiencing hurt feelings

556 • PART THREE On the Home Front: Crisis in the Human Services Workplace

over client failures, attempting dramatic cures on im- possible cases, becoming panic stricken when well- laid plans go awry, refusing to withdraw from the case when it is clearly beyond the worker's purview, becom- ing angry, sarcastic, or bored with clients, changing the subject and avoiding the topic, providing pat an- swers, discounting the client's problems and mini- mizing distress, not believing clients, fearing what the client will say, silencing client trauma talk, wish- ing or suggesting the client would "just get over it," feeling numb or avoidant, not being able to pay attention, being constantly reminded of one's own personal trauma events, hoping the client won't show up, becoming frustrated over lack of progress, and losing one's sense of humor over the human dilemma (Baranowsky, 2002; Dahlenberg, 2000; Van Auken, 1979). The foregoing are all indicators that unre- solved countertransference and vicarious trauma/ compassion fatigue issues are flourishing.

Under these circumstances, the worker comes to see the helping relationship as a chore, and the cli- ent may regress and act out as a way of announcing the client's awareness of the worker's apathetic atti- tude. As this psychological vortex continues to swirl and the worker becomes even more overwrought and discouraged, the client is likely to terminate the therapeutic relationship (Dahlenberg, 2000 ; Watkins, 1983). Such negative reinforcement does little to mollify the worker's already bruised ego and may lead to a further downward spiral into burnout. Whether exposure to these occupational hazards has negative or positive outcomes depends a great deal on how both the individual worker and the human services institution deal with them in proactive ways (Dahlenberg, 2000 ; Deiter & Pearlman, 1998; Figley, 1995; Pearlman & Saakvitne, 1995a; Saakvitne & Pearlman, 1996).

Co qi passion Satisfaction Stamm (2005) describes compassion satisfac- IDiJ tion as simply the pleasure you derive from being able to do your work well. The reason compassion satis - faction as a construct has gained notoriety is that it appears to be an extremely effective buffer against burnout. Human services workers who are satisfied with the effect they have on clients consistently show low levels of vicarious traumatization and burnout (Conrad & Keller-Guenther, 2006; Eastwood, 2007; Killian, 2008; Lafauci Schutt, 2009; Lawson & Myers, 2011; Ling et al. , 2014; Ringenbach, 2009; Sullivan, 2004). Therefore, it would seem reasonable that

organizations do everything in their power to te their workers that they are doing a good job and fu:-- ther to get direct feedback from clients that they a:-~ satisfied with the care they have been given and th~ concern they have been shown by the crisis worker.

The Culpability of Organizations Much of the responsibility for burnout rests lmJ. with the employing agency and its inability to eit he::- recognize or do anything about organizational p rob- lems that lead to burnout (de Figueiredo et al. , 201- Everly, 1989, pp. 295-297; Kulkarni et al., 2013; Pines fr Aronson, 1988, pp. 97- 111; Shi rt n & M0rch , 1 r~ p. 238). Savicki and Cooley (1987) compared d egree of burnout with work environment and found t he..: those workers who scored highest on burnout i::::.- dexes felt that they had little impact on procedure.: and policy issues, lacked autonomy within the gu ide- lines of the job structure, were unclear about agenc: · objectives, had a high intensity of work assignmenrs over extended periods of time, were highly re stricteC. in how they could deal with clients, and felt generaU.; unappreciated by their coworkers or supervisors. One example is handling client verbal and physical aggres- sion as a major mediating factor in burnout (Gasco= et al. , 2013; Hensel et al. , 2012; Yung, 2013; Ho et aL 2013). Although personal safety is a major concer::::.. when workers feel their safety concerns are not re- sponded to by management then threat level goes u~ (Evans & Petter, 2012) along with the potential fo::- burnout with it.

Above all, the organization's inability to clear1.:- define job roles and functions causes role con fl ic: and role ambiguity, and these are two of the b es;: predictors of the workplace's contribution to b urr.- out (Barber & Iwai, 1996). These findings should no: be construed as representing "gripes" of the resp on- dents. Numerous other studies (Burke & Greenglass. 1995; de Figueiredo et al. , 2014; Duquette et al., 199.ci: Jayaratne , Vinokur-Kaplan, & Chess, 1995; Le e ~­ Ashforth, 1993) have substantiated findings that agen- cies that do not take pains to communicate clear!~­ with and support their staff have high burnout rates.

One of the critical support mechanisms for crisis workers is easy access to consultation, support, a nc: supervision (de Figueiredo et al., 2014; Hand rar:. 2014; Ling et al. , 2014; Salloum et al. , 2015). Crisis intervention should never be done in isolation. and the case example presented in this chapter is

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compass ion Fatigue • 557

an excellent example of why that is so. Yet, as Pearlman and Saakvitne (1995a, p. 359) report, unsupervised trauma therapy seems all too common. Pearlman and Mac Ian (1995) found that less than two-thirds of trauma therapists they interviewed reported getting any kind of supervision, although more than 80% of those who did receive supervision and consultation found it helpful.

In contrast, those agencies that do allow input into the mission of the organization, are flexible in providing instrumental and emotional support to workers, generate support groups, provide consulta- tion, have job clarity, promote managers with social leadership styles, retain realistic expectations for the progress of their clients, and furnish supervi- sion to h elp workers solve problems associated with the high stress of their jobs report workers with lower indexes of burnout (Everly, 1989, pp. 299 - 309; Kahn, 2005; Melchior et al., 1997; Pines & Aronson, 1988, pp. 107- 111; Savicki & Cooley, 1987).

Self-Recognition of Burnout Whatever the degree of burnout, human services workers and their organizations have a notorious blind spot. What they can detect in others and change by therapeutic intervention, they are generally un- aware of in themselves . Furthermore, they have ex- treme difficulty maintaining both the personal and professional objectivity to self-diagnose burnout or muster the discipline and d evo te the ene rgy to inte- grate effective interve ntion st rategies into their own lives (Spicuzza & Devoe, 1982).

When they finally are confronted with the fact that something is terribly wrong in their professional lives, their initial maladaptive response is likely to be "What's wrong with me? " rather than "What can I do to change the situation?" Their typical operat- ing mode is not to change th e situation but rather to increase the amount of effort and consequently in- crease the original problem (Pines & Aronson, 1988, PP· 5-9).

Before delving into intervention, your authors want to be very clear that they agree with Watkins (1983) that no one-and we would go a step further a nd state that absolutely no one-who practices in the human services professions is immune to burnout. Furthermore, it has been our experience that human services workers who, like some of you who are read- ing this passage, think "It'll never happen to me " are invariably the kinds of fellow professionals we end

up treating; or, in the absence of treatment, become those who can no longer stand to ply the trade and quit; or, at the extreme, become substance abusers or suicidal or homicidal. In these circumstances, the outcomes range from bad to worse: bad for the profes- sion and worse for you, the professional.

Intervention Strategies While there is a great deal of literature on Im self-care and balancing other life experiencei'-against work as a buffer against burnout (Ling et al. , 2014; Oerlemans & Bakker, 2014), there have been few pro - tocol and hard data studies to identify specific treat- ments that work with those who are experiencing STS and are burned out (Bercier & Maynard, 2015).

Practitioners on the road to burnout typically are perfectionistic workaholics (Falco et al., 2014) who push relentlessly toward emotional exhaustion, be- coming more inefficient and unhappy as they do so. Note the "aholic" component becaus e our experience is that burning up professionals are much the same as alcoholics in their vehement denial that things are going badly awry until a severe crisis of their own is created such that it finally gets their attention. Thus, when we consider individual crisis intervention with an impaired fellow professional, emphasis in apply- ing the crisis task model in this book will usually fo- cus on the directive end of the continuum because of the depth of the crisis and an "I know more than you do, and I'm not nuts" fellow worker. The crisis interventionist who helps a burned-out human ser- vices worker typically must proceed in a very direc tive manner while confronting th e client's irrational be- liefs, proposing definite alterna tives, and getting the client to commit to specific action steps that will get the person out of the state of immobility. Put in sim- ple terms, fellow human services workers are some of the most stubborn and denial-prone clients there are when they have reached the later stages of burnout.

Intervention for the human services worker suf- fering from burnout may best be considered in three di stinct dimensions: intervention through training, intervention with the organization, and intervention with the individual. Triage assessment of the level of burnout is important in determining the type of intervention to be used. At a trait level, individual therapeutic intervention will clearly be warranted. At a state or activity level, training or organizational intervention may be sufficient. When the organiza- tion itself becomes a client, triage assessment would

558 • PART THREE On the Home Front: Crisis in the Human Services Workplace

clearly include the administering of both burnout and work-setting instruments to all members of the organization and following up that administration with individual interviews.

Assessment Three types of instruments are important in lmI!J determining burnout and compassion fatigue.

Burnout. The first type has to do with determining the degree of burnout in the individual. The most widely used instrument is the Maslach Burnout Inventory- Human Services Survey (MBI-HSS; Maslach & Jackson, 1981a), which is a valid cross-occupational and cross-cultural (Bakker, Demerouti, & Schaufeli, 2002; Gorter et al., 1999) instrument that measures three symptom patterns associated with burnout. The Emotional Exhaustion scale assesses feelings ofbeing emotionally worn out by work. The Personal Accom- plishment scale measures feelings of competence and achievement with work . The Depersonalization scale measures unfeeling and impersonal responses toward clients. The scales can also be combined to produce a total frequency and intensity score for burnout. A variation of the scale for professional burnout in gen- eral (MBI-GS; Maslach, Jackson, & Leiter, 1996) mea- sures exhaustion, cynicism, and reduced personal efficiency, three components that parallel the original MBI-HSS. There is also a Maslach Burnout Inventory for educators (MBI-ES; Maslach, Jackson, & Leiter, 1996), which uses the foregoing components to mea- sure degree of burnout in educators.

Golembiewski, Munzenrider, and Stevenson (1986) used the Maslach Burnout Inventory's three domains to develop a progressive phase model of burnout. In their model, depersonalization is seen as the least potent and initial burnout phase. It must occur prior to any substantial reduction in feelings d-f personal accomplishment, which they see as a sec- ondary response and more potent level of burnout. Emotional exhaustion, the third and most potent in- dicator of burnout (Lee & Ashforrh, 1996; Wright & Bonett, 1997), would follow heightening of the prior two stages.

Lee and associates (2007) have developed the Counselor Burnout Inventory. This instrument mea- sures five burnout dimensions: Exhaustion, Incompe- tence, Negative Work Environment, Devaluing Client, and Deterioration of Personal Life. This instrument attempts to integrate both personal and organiza- tional components of potential burnout factors and

determine how much workplace factors contribme to overall burnout. They have attempted to d eter- mine what particular patterns of these scales bes- classify levels of burnout and pattern clusters (Lee et al. , 2010). Their research, which sampled co u n - selors who worked in a variety of settings, identi fi e · three sets of counselor profiles. A cluster they calle · "Well-Adjusted Counselors" (WACs) had low sco res and flat profiles across all the scales. WACs also re- ported high job satisfaction, good self-esteem, a nc: decent pay. Their MBI scores correlated with their CBI profiles, with low scores on Emotional Exhaus- tion and Depersonalization and high scores on Per- sonal Accomplishment. ,

Lee and his associates (2010) found a seco n d cluster they called "Disconnected Counselors" (D Cs,. who had medium-level scores on Exhaustion, Negati\·e Work Environment, and Deterioration in Personal Life with high Incompetence and Devaluing Cliem scores . DCs' scores on the MBI paralleled their CBI scores, with a very high Depersonalization score, low Personal Accomplishment, and midrange Emotional Exhaustion scores. They reported low job satisfaction. poor self-esteem, and low pay.

A third cluster, which the researcher named "Per- severing Counselors" (PCs), was characterized by high Ex haustion, Negative Work Environment, and Deterioration in Personal Life, but low scores on the Incompetence and Devaluing Client scales. Of t h e three groups , the PCs scored far higher on the M BI Emotional Exhaustion scale, in the midrange on Depersonalization, and high on sense of Person a l Accomplishment. They reported the most counseling experience, highest positive self-esteem, and highest pay of the three groups, even though they reported the most dissatisfaction with their jobs . The PC clus- ter is interesting in that they are still performing well, but all the indicators are there for burnout. As such, it would appear that this instrument could identify no t only workers who were functioning well as opposed to those who were burning or burned out, but those who were moving in that direction.

Compassion Fatigue and Compassion Satisfaction. Newer tests that specifically target different facets of secondary stress include the Compassion Fatigue Self.Test (Figley, 1995). From Wee and Myers's (200 3) preliminary work with this test, it appears that sat- isfaction with doing crisis intervention work is in- deed a counterbalance to compassion fatigue. What they found was that although approximately half the

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 559

workers sampled had high compassion fatigue scores, almost 90% had high satisfaction scores and low burnout scores. The belief is that compassion satis- faction can act as a protective buffer against compas- sion fatigue and burnout (Collins & Long, 2003).

The Professional Quality of Life Scale (ProQOL; Stamm, 2002, 2005, 2010) measures compassion satisfaction, compassion fatigue , and burnout. It is a test for workers in the human services field but is particularly designed for first responders such as po- lice, EMTs, firefighters, and ER personnel. The Com- passion Satisfaction and Fatigue Test is of particular interest because it factors in the worker's satisfaction and therapeutic fatigue with clients. Certainly not all crisis workers manifest STSD; many workers are resil- ient, hardy, and continuously involved in crisis work over long terms with no ill effects. Stamm (2002) hy- pothesizes that it is because their satisfaction with doing the job counterweights and compensates for the heavy fatigue factors they experience. Therefore, this test gives scores for compassion satisfaction (CS), compassion fatigue (CF), and burnout (BO). Research indicates that indeed compassion satisfaction is an ameliorating factor in both compassion fatigue and burnout.

Work Environment. The third type of instrument measures the work setting. Typical of this type of as sessment device is the Work Environment Scale (Moos, 1981), which measures 10 different dimen- sions of an organizational component named "social climate." These dimensions are job commitment, support from coworkers, management support, in- dependence in decision making, efficient and plan- ful approaches to tasks , performance pressure, role clarity, degree of control by management, variety and change in job, and physical comfort. Taken together, these various instruments provide a way of examin- ing the degree of burnout in relation to environ- mental factors within the organization, yield a fairly comprehensive picture of how burned out the worker is , and indicate the degree of intervention necessary (Savicki & Cooley, 1987).

Intervention Through Training Early in a human services worker's training, and on an ongoing basis when in practice, emphasis needs to be placed on correcting worker attitudes that lead to over involvement (Koeske & Kelly, 1995). Although Saakvitne and Pearlman (1996, pp. 25-26) argue that th e deep empathy needed for trauma work inevitably

begets countertransference and the possibility of vi- carious traumatization, at least a part of training should focus on increasing therapeutic detachment and moderating idealism (Warnath & Shelton, 1976). A delicate balance exists between providing empathy and manifesting sympathy for a client. To that end, trauma-informed worker development training has been found to be a strong predictor against burnout (Handran, 2014; Salloum et al. , 2015) .

Beginning human services practitioners need to have their rose-colored glasses gently removed, so they can see that their good intentions are doing nei- ther themselves nor their clients much good (Pines & Aronson, 1988, p. 194). Most particularly, students need to examine their limited insight into their own unresolved issues and conflicts and how those inter- act with those of their clients, particularly when they are dealing with the often horrific material that is a hallmark of crisis intervention and trauma work (Dahlenberg, 2000; Pearlman & Saakvitne, 1995a, pp. 359-380; Watkins, 1983).

Not all students in the hum an services field are psychologically equipped to go into crisis work. Al- though this work is absolutely some of the most grat- ifying and reinforcing there is in the human services field, it is also some of the most gut-wrenching and heartbreaking. Students who are not exposed to re- alistic field experiences and good supervision may go blindly into one of the most stressful occupational fields known.

Intervention with the Organization Much of the literature shows burnout to be situation based (Barber & Iwai, 1996; Kesler, 1990; Melchior et al., 1997; Schaufeli, 2006). Thus, the organization can also be considered as client. When an organization is in danger of burnout, all those who work in the or- ganization should be involved in restructuring work- ing conditions . Indeed, one of the major criticisms of burnout intervention has been the lack of change in the total system (Carroll & White, 1982, p. 56). What makes the major difference in obtaining peak perfor- mance from workers as opposed to having them burn out is whether the work environment is supportive or stressful (Pines & Aronson, 1988, p. 48).

Lack of positive reinforcement by the institution is not at all uncommon and fits neatly into an aver- sive management policy: "There is no such thing as burnout, only staff who don't work and have mali- cious motives toward the organization." As staff be- come inc reasingly burned out, they tend to fulfill

560 • PART THREE On the Home Front: Crisis in the Human Services Workplace

management's negative predictions about th em (Carroll & White, 1982, pp. 53-54). Although much is mentioned in the burnout literature about eradicat- ing the negative aspects of the work environment, research indicates that a lack of positive features is significantly correlated with burnout independent of the presence of negative work features (Pines & Aronson, 1988, p. 48).

Human services organizations are notorious for having to live continuously on the edge of financial exigency: Lack of physical, human, and financial re- sources militates against comprehensive service pro- vision and long-term planning. Organizations that face crises such as funding and human resource cut- backs often cope with problems by unwittingly adopt- ing crisis characteristics and operating in a state of disequilibrium and immobility. Just letting the crisis "run its course" is no more appropriate for organiza- tions than for individuals in crisis (Devine, 1984).

Therefore, from an ecological standpoint, the or- ganization needs to move away from piecemeal in- terventions and apply techniques that have general inputs to the total organization rather than just in- puts focused on individuals (Paine, 1982, p. 25). Ide- ally, interventions should be multifaceted and take into consideration both individual and environmen- tal issues in a balanced and sensitive fashion (Carroll & White, 1982, p. 53). As a start, the administration can take the time to articulate clearly the organiza- tion's mission. Cherniss and Krantz (1983) found that organizations that have a clear ideology of purpose have reduced burnout in staff because they minimize ambiguity and doubt about what kind of action is to be taken. Time should be devoted both to establish- ing positive coworker and supervisory relationships and to reducing the rules , regulations, and paperwork that line staff face as they attempt to provide service to their clients (Savicki & Cooley, 1987). Improved job design , flexible hours, continuous supervision and training, intrinsic and extrinsic reinforcement, and emotional support are a few of many changes that will go a long way toward reducing burnout (Shinn & M0rch, 1983, p. 238).

Most attempts to deal with the organization by people who are burned out are typified by passively hostile actions that include physical, emotional, and mental withdrawal from problems the organization faces (Pines & Aronson, 1988, pp. 91-93). However, effective organizational change rarely is generated solely by the administration or by the individual. Both parties must decide that stopping burnout in its

tracks is a good thing to do. To effect change in t he organization, each individual must recognize t h a: there is an institutional problem and be responsible for doing something about it. Likewise, administra- tors and boards of directors must be constantly vigi- lant and not deny these kinds of problems exist in t he organization. Beginning to take responsibility for ef- fecting change in a difficult situation is therape utic in and of itself simply because it reduces the debilitat- ing effects of the feeling of helplessness.

Yet workers who believe that everything about an organization is wrong and should be changed are t he most likely to be burnouts, and administrators an · boards of directors who believe th~ same about t heir workers are likely to go out of business. Some asp ec r:s of the bureaucracy cannot be changed short of d e- stroying it. Thus workers need to develop the ab ilir;· to distinguish between those aspects of the organ i- zation that can be changed and those that cannot (Pines & Aronson, 1988, p. 29).

Burnout-Proofing an Agency. Probably one of the very best organizations at preventing burnout your au - thors are aware of is the Exchange Club - Carl Perki ns Center for the Prevention of Child Abuse in Jackson . Tennessee, which is used as an example of an exem - plary child abuse treatment program in Chapter 9. Sexual Assault. One of the reasons for Carl Perk ins Center's excellence is that its directors attempt, to t he best of their ability, to burnout-proof the agency anci. the people in it. As described by East, James, and Kei rr: (2001), they use several strategies to prevent burnout. STS/ VT, and CF that are recommended by many o: the researchers in this chapter. They are:

1. Nobody works more than a 40-hour week. Al- though emergencies may arise, workers will im- mediately take comp time off after the emergency has passed. Nobody works through lunch. Lunch is downtime and is expected to be taken.

2. The center takes quality time to promote inservice education as a way of continuously updating staff on the most effective and innovative practices available in the field. Quarterly inservices combine staff development, organizational issues, and fun events on skill building.

3. Supervision is continuous and supportive. T h e supervisor-to-worker ratio is 1:6. Each worker has a weekly session with a supervisor. The role of t he supervisor is to listen, provide empathic supporL consult, and plan cases.

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 561

4. The center expedites logistical problems. Work areas are clean, well lit, with cheerfully decorated offices and meeting rooms. Therapy rooms have brightly colored carpets and colorful children's murals on the walls. There is a well-stocked re- source center with videos, instructional programs, reference books, and a complete, full-sized, Kids on the Block puppet set. There is adequate office and clerical help for all workers, so they do not drown in paperwork. Supplies are adequate and readily available.

5. Case staffings are carefully constructed in a com- prehensive manner with team inputs. A clear treatment plan is laid out. There is little confusion about what mission goals are. There is a definite feeling of "we" between the administration and the staff. All supervisors have worked their way up through the organi zation, so they are acutely aware of the problems and issues staff face.

6. There is a clear delineation between work and home. Home and family are an overriding priority, and the directors of the center are adamant that families come first and work comes second.

7. Faith-based renewal and spiritual growth are en - couraged. As one worker stated, "I can' t do this alone . I have to give it over to God." This approach is encouraged without regard to denomination. Prayer is a powerful tool for these people, and they use it. There is a saying in war that there are few atheists in foxholes. A parallel can be made to the trauma and crisis business. Finding a sacrosanct spiritual center that one can believe in and retreat to is paramount, given the often heinous nature of crisis work (Collins, 2005; Kennedy, 2006). Be- cause Jackson, Tennessee, is in the "Bible Belt" you may suppose that the staff's deep reliance on faith is a southern cultural artifact. You would be wrong. A good deal of research (Harrison & Westwood, 2009; Lawson & Myers, 2011; Reese, 2009; Simpson, 2006) demonstrates that spiri- tuality is a key component in keeping the nastiness in this chapter out of your life. Short of prose- lytizing, your authors believe that anybody in this business needs to find some spiritual rock to anchor them . Go to a church, synagogue, mosque. Hug a cypress tree if you are green. Meditate, read theology, worship the Great Spirit, Buddha, God, but get a spiritual foundation in your life. You'll need it if you do this work.

8. Debriefing is used continuously. Whenever a tragedy occurs, such as a child's death or other

traumatic event, workers are debriefed, and it is done as expeditiously as possible.

9. The center does not work on an assembly-line ba- sis with repetitious, day-in-day-out work assign- ments that grind staff down. Workers are expected to schedule variety into their days.

10. The center provides technical support. All of the staff have offices, computers, cell phones, VCRs, and other equipment necessary for optimal performance. '\.

11. The center is well maintained. It is a pleasant place to work with bright colors, nice furniture, individ- ual spacious offices, and conference and therapy rooms that are well lit with good AV and IT facili- ties and equipment.

12. Workers use a team approach. No one is above get- ting her or his hands "dirty," and everyone pitches in when something needs to be done. It is not frowned upon to ask for assistance . The center does not deify go-it-alone, heroic martyrs .

13. Safety is the most important product of the cen- ter, for both its clients and staff. Clear-cut safety procedures are constantly taught and reinforced to ensure the workers' well-being both at the cen- ter and during home visits.

14. The workload is "doable." Over the years, the cen- ter has lightened workers' caseloads. As the total number of caseloads rises, more workers are hired. The center has been able to increase staff because its administration is very adept at convincing its constituency that it is doing a great job and should be given the financial support to continue to do so. The administration works very closely with its board and continuously educates it regarding the financial and staffing needs of the center.

15. The center does an excellent job of networking. It serves a large geographic area and therefore has established relationships with other social services agencies (such as schools, police departments, and state welfare agencies) in outlying counties. The center also goes out of its way to provide support for other agencies within its service area. This not only increases the center's credibility with the agen- cies and institutions, but it also allows for reciprocal perquisites: center employees can utilize office space and the support of staff in other agencies when the employees are far away from their home office.

16. The administration is very thorough in its hir- ing selection. Candidates are carefully screened to determine how well they will fit into the overall scheme of things.

562 • PART THREE On the Home Front: Crisis in the Human Services Workplace

17. Staff are positively reinforced both intrinsically and extrinsically on a consistent basis. Workers are told they are doing a good job in specific behavioral terms, and they are told often. After a particularly horrific incident in which three sexually abused children all died in a house fire at a foster home, the associate director went to the field office and picked up the workers who had been engaged nonstop in dealing with this tragedy. She piled them into her van and, without a word, took them to a local spa, where they spent the day getting makeovers, massages, aromatherapy, yoga lessons, and a nice lunch. While a day trip to a spa can in no way assuage the grief and stress these workers felt, it does say very clearly, "We care about you!" and that message comes across loud and clear to all of the staff.

The Carl Perkins Center sees its workers as its most important asset and understands the perils of the kind of work it does. The outcomes are proof positive that a proactive program to prevent burnout works. The attrition rate is extremely low. Because this is a fairly young and rapidly expanding agency, many of the workers are young. Research indicates (Meyers & Cornille, 2002) that the demographics and job role of this group would cause them to be at high risk for burnout or STSD. They are not!

The following tests were administered to the Carl Perkins staff: the Los Angeles Symptom Checklist (LASC; King et al., 1995) to m easure PTSD symptoms, the Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979) to measure subjective perceptions of stress experienced by human services workers as a re- sult of working with their clients, and the Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981a) to measure burnout. While the IES indicated that traumatic events have had a high impact on work- ers,~he LASC and MBI scores were very low, indicat- ing that these workers do not have PTSD symptoms and they are not burned out. Particularly noteworthy were their extremely high "personal accomplishment" scores on the MBI (East, James, & Keim, 2001).

In conclusion, the administrative staff at Carl Per- kins understand the effects that vicarious traumati- zation, compassion fatigue, and burnout can have on their organization and set aside time and resources to deal with it. In providing support to staff, the Carl Perkins Center follows very closely the six points pro- posed by Pines (1983) , listed and described in the next section. It would thus appear that even in one of the most stressful of all types of crisis agencies-one that

works with traumatized children (Meyers & Co rm' 2002)-the institution can stop burnout dead in • tracks if it has the will to do so.

Social Support Systems. Social support systems a._-: as buffers for the individual and help maintain pS'" - chological and physical well-being over time (L'-~ et al., 2014; Oerlemans & Bakker, 2014; Pines, 19S.: p . 157). They are just as critical to avoiding burnoi.:: whether at home or in the workplace (Distler, 199C Greenglass, Fiksenbaum, & Burke, 1996; Halbeslebe- 2006; Kesler, 1990; Pines & Aronson, 1988; Sulliva:::.. 2004). Family systems are major sources of suppo~ (Killian, 2008; Lawson & My~rs, 2011; Sulliva::.. 2004) and can help insulate workers against burnoc: (Bakker, Demerouti, & Schaufeli, 2005; Halbeslebe=. 2006; Maslach &Jackson, 1981b). However, it is imp os- sible for one's spouse, partner, family, or fri enC.S to fulfill all the support tasks a crisis wo rke- who engages specifically in trauma work will n ee.: (Pines, 1983, p. 172). Clearly, the worker needs to h a\ functioning support systems at the job site (Handrau.. 2014; Li et al., 2014). How, then, might this occur ifi: does not happen spontaneously?

In that regard, Golembiewski, Munzenrider, a nc: Stevenson (1986) propose that both instrumema... support to achieve an end, such as material as sis- tance, and expressive support to provide a sens e o: belonging and caring are needed in the workplace (p . 52). They found that employee concern and com- mitment to the job, peer friendliness and support fo~ one another, and management's support and enco u r- agement of employees all characterized low-burnou - groups (p. 189).

Social support systems have six basic functio n s: listening, technical support, technical challenge. emotional support, emotional challenge, and sharin,, social reality (Pines , 1983).

1. Listening. Periodically, all workers need someone to listen actively to them in an empathic manner without giving advice or making judgmems (p. 158).

2. Technical support. When confronted with complex client problems, all workers need someone wh o can affirm confidence in their endeavors. Such a person must have the expertise to understand the complexities of the job and be able to give t h e worker honest feedback (p. 158).

3. Technical challenge. If workers are not intellectually challenged, they will stagnate. Intellectual contact

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 5 63

with significant others stretches the worker in a positive way. Such challenges can come only from people who do not intend to humiliate or gain an advantage and who have professional expertise equivalent to that of the worker (p . 158).

4. Emotional support. Workers need someone to be on their side in difficult situations, even if the signifi- cant others do not necessarily agree totally with the workers. Professional expertise is not neces- sary for this function (pp. 158- 159).

5. Emotional challenge. It is comforting for workers to believe that they have explored all avenues in attempting to resolve their problems. Support persons serve a valuable function when they ques- tion such assumptions and confront the worker's excuses. This function should be used sparingly; otherwise it may be construed as nagging (p. 159).

6. Sharing social reality. When workers become unsure of the reliability of their own perceptions about the reality of the situation, they need external validation. This function is especially important when workers feel that they are losing the ability to evaluate what is happening with their clients and with the organization (p. 159).

Support Groups. Within the organizational struc- ture, time should be set aside for formal, structured support groups. Structurally, a support group resem- bles a problem-solving discussion group. The goal of such a group is to build a sense of competence and help workers feel that they can deal with the stresses they encounter in their work situation. A support group is a safe place for workers to disagree and chal- lenge feel ings of helplessness.

The group s,erves as a cathartic agent for releasing pent-up emotions related to the job. Once catharsis occurs, members can realistically examine feelings associated with job stressors. By providing feedback, the support group validates for members that they are not alone in their feelings and reassures them that they are not abnormal in their response to the situa- tion (Sculley, 1983, pp. 188 - 191).

To do this effectively, a support group not only needs the support of the administration but a lso must have a consultant/ facilitator who is sensitive to the issues involved and can walk a tightwire between allowing the group to vent feelings and keeping the group in a problem-solving model. The buffering ef- fect of a third party consultant/ facilitator can help re- duce conflict stressors (Giebels & Janssen, 2005). The consultant/ facilitator also needs to be in a position

to provide the administration with information from the group that will allow for effective organizational change without becoming a "snitch" in the process (Sculley, 1983, pp. 193-194).

Finally, for those members suffering from vicari- ous traumatization, compassion fatigue , and the later stages of burnout, referring them for personal counseling should be done with the understanding that these outcomes are indeed occupational hazards no different from carpal tunnel syndrome for key- board operators or arthritis for concrete fini aj'iers. In that regard, organizations must be careful not to sec- ondarily victimiz e such people as being of weak char- acter or lacking in the "right stuff."

The Individual and the Organization. Vocationally, there are four major maladaptive responses to the onset of burnout. As the level of burnout increases, so does escape avoidance behavior (Thornton, 1992). Workers may attempt horizontal job mobility. They continuously lo ok for the "right" boss or organiza- tion when it is the job they are in that is causing their unhappiness.

Others tire of the constant interaction with cli- ents and decide to move vertically up the job ladder into administrative positions. What they fail to real- ize is that their cynical and jaundiced view of the sys - tem will not be left behind but will be carried with them into a whole new set of stresses. It is an under- statement to say that these people do not make very good bosses.

There are also people who become what Pines and Aronson (1988 , p. 18) call "deadwood." These people have long ago decided that their best bet is to not "rock the boat" so they can make it to retirement. If you have ever read the comic strip Dilbert, Wally best represents these individuals. When asked to do something, they politely indicate they are too busy, or agree with every idea put forth but venture none of their own, or contribute only what is minimally nec- essary to escape notice or censure, or turn the tables and cast incompetence on others to cover up their own failings .

Finally, some people quit their job and the voca- tion, and in some instances this may be the wisest choice of all.

At this stage of frustration, choices may seem to be limited to job change or job stagnation, but the individual does have other options. First, clearly de- fining one's role within the organization is a high priority (Kesler, 1990). The worker should conduct a

5 64 • PART THREE On the Home Front: Crisis in the Human Services Workplace

job analysis and determine which tasks are necessary, which are self-imposed, and which contribute to role overload (Pines & Aronson, 1988, p. 109). Through assertive negotiation with the administration, the worker needs to define a reasonable work level and commensurate financial or other rewards for the work performed. Clients should be clearly apprised of the limits of service in regard to time as well as the amount and kind of service to be provided. Although service to clients needs to be a high priority, other tasks should be clearly prioritized. If chores that do not have a high priority cannot be delegated, then se- rious consideration should be given to dropping them (Leiter & Maslach, 2005).

Finally, if it is apparent that the organization is so entrenched and regressive that little change in poli- cies and programs can be effected, it is probably time to look for greener occupational pastures. It would behoove a worker who is in the frustration stage to consider what a near-future job change entails and start planning for it before reaching the apathy stage. Knowing company severance policies and state unem- ployment benefits, updating a resume, saving money, and commencing a job search are examples of pru- dent measures workers may take before they are so mentally, physically, and emotionally exhausted that there is little energy left for a major shift in one's life.

Self-Care As we have said, burnout is a two-way street with both individual and organizational culpability. There are literally volumes of research that find self-care as the critical ingredient for the crisis worker (Alkema, Linton, & Davies, 2008; Eastwood, 2007; Harrison & Westwood, 2009; Killian, 2008; Lawson, 2009; Lawson & Myers, 2011; Ling et al. , 2014; Morkides, 2009; Oerlemans & Bakker, 2014; Rupert et al., 2015; Ringenbach, 2009; Thomas, 2007) . We have already sp"eken to the significance of support systems and spirituality. What follows sounds a lot like what your mother lectured you on: eating right, sleeping right, getting exercise, taking care of your general hygiene, and after all of those things are done, not forgetting to have fun! One of the toughest parts of this busi- ness is doing that.

In William Glasser's reality therapy/ control the- ory (1985), one of the central axes on which his theory revolves is engaging in positive addicting behaviors, and central to those positive addicting behaviors is having fun. The whole notion of Glasser's theory is that when you engage in these positive addicting

behaviors your personal world grows much large:-. and so does your social world as you interact with iL

Nobody can make you get out of your rut, and i : is ex tremely easy to stay in it, as in the case of one o~ your authors who right now has been word processinc 12 days in a row on this $! %#@$ %#! book and not get- ting his workouts in and feeling very guilty and ever:. physically edgy about missing his positive addiction. The word recreate makes a lot more sense when ym:: break it down into re-create. So meditate, play rugby. work up your fantasy football team, make a quilt, ru~ a marathon, shoot some pool, play bridge or poker. kill all the video game aliens , go fishing, see a ball- game, weed your flower garden-any of those will do as long as you are having fun, enjoying it, and it h as absolutely nothing to do with anything in this bo ok. Hey! You cannot use that as an excuse to your profes- sor that you needed to go recreate and didn't fin ish this chapter so flunked the exam because you were afraid of burning out!

Private Practitioners and Burnout The occupational dream of many of our students is to start their own private practice. They fantasize tha t they could do the kind of therapy they wanted with the clients they selected, be rid of overbearing supe r- visors and be their own boss, not be bothered with bureaucratic hassles and avalanches of paperwork, set their own hours , and make lots of money! Yet t he private practitioner has the potential for even greater problems.

Generally, private practitioners are type A perso n - alities who tend to invest a great deal of time in the job as a means of finding a sense of fulfillment and identity. Competition and achievement serve as guid- ing values that correlate highly with the need to be seen as worthy and capable (Everly, 1989, p. 105; Pines & Aronson, 1988, pp. 6-9). In a word, they are "driven' workaholics (Falco et al. , 2014).

Although the aloneness that pervades a private practice is not the same as the isolation that agency workers sometimes impose on themselves when placed in high-stress situations, it can be more com- plete. Fenced off from other professionals by ethical and ecological boundaries, the private practitioner has few others with whom to discuss client problems. More important, there are few other individuals with whom they can discuss their own personal problems.

Private practice is clearly a business. As such, it promotes the continuing fear that there will be no

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization , and Compassion Fatigue • 5 65

clients or that there will never be enough no matter how successfully the business is going (Mitchell, 1977, pp. 145-146). Every client termination raises ques- tions: "Will there be someone to take her place?" "Will he pass the word along that I did him some good?" The private practitioner who is moving toward crisis invariably answers these questions negatively and re- doubles his or her efforts to increase client loads and effect cures.

Starting and maintaining a private practice also call for maintaining a public presence. Whether such a presence involves making speeches to the Rotary Club on stress and the businessperson, consulting with the oncology staff on death and dying at the lo- cal hospital, or giving a workshop on discipline for Parents Without Partners, the continuous pressure of needing to be seen as active, abreast of current devel- opments, and visible is part of a sales program that must constantly be maintained and upgraded.

Although the private practitioner is his or her own boss , being an independent businessperson also means being completely responsible for maintaining the practice. Long hours and difficult work periods are the rule rather than the exception. Because most clients work regular hours, private practitioners de- vote many evenings and weekends to their work . Usu- ally there is no one to pick up caseloads, so vacations or even short respites are few and far between. Cer- tainly not all private practitioners suffer from burn- out. However, when burnout does occur with human services workers who are in private practice, it is accel- erated by the foregoing problems and issues.

Intervention with the Individual: A Case Study Direct action, in which the worker tries to master the environmental stressors, and palliative action, in which the worker tries to reduce disturbances when unable to manage the environment, are the two posi- tive ways to cope with stress (Pines & Aronson, 1988, p. 144). Direct action is applied externally to the situ- ational stressor in the environment, whereas pallia- tive action is applied internally to one's cognitions and emotions about the stressor. Social support groups, workshops, assertiveness training, flextime, taking time off, salary increase, and role shifts are all examples of direct action. Meditation, relaxation techniques, biofeedback, physical exercise with no ego involvement, adopting positive cognitions, engag- ing in leisure-time pursuits, adopting better eating

habits, reducing addictive substance intake, and add- ing more humor and joy to one's life are all palliative "decompensation activities" that allow the worker to put stressors aside (Hoeksma et al., 1993; Melamed, Meir, & Samson, 1995; Oerlemans & Bakker, 2014; Pines & Aronson, 1988, p. 152; Rupert et al., 2015; Saakvitne & Pearlman, 1996, pp. 78-87; Stark, 1994).

Whereas workers who are at the frustration stage may well be helped by being involved in self-initiated directive and palliative actions , those at the more seri- ous stage of apathy will not be (Edelwich & Brodsky, 1982, p. 137). In such cases, individual coun'seling is more appropriate (Baron & Cohen, 1982). Kesler (1990) proposed using Arnold Lazarus's (1976) BASIC ID (behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs/ biology) par- adigm as a treatment approach to burnout. To this formulation Kesler adds an S for setting. Given the in- teractive effects of burnout across multiple facets of the individual, the BASIC IDS approach seems valid for attacking burnout in a comprehensive way.

The following case illustrates the crisis worker using combinations of direct and palliative actions in an abbreviated BASIC IDS approach. It should be clearly understood that neither symptoms nor intervention procedures are all-inclusive. For exam- ple, Tubesing and Tubesing (1982, p. 161) listed 36 possible intervention strategies that cover physical, intellectual, social, emotional, spiritual, and envi- ronmental components ofburnout, and those are not comprehensive by any means . If the client is identi- fied as having more compassion fatigue or vicarious traumatization, a more specific program that focuses on STSD symptoms may be used, such as the Acceler- ated Recovery Program (ARP; Gentry, Baranowsky, & Dunning, 2002). The cas e presented is that of a pro- fessional with a doctorate and many years of experi- ence, but neophytes should understand that Dr. Jane Lee is genotypical of any human services worker. Her case clearly points out that no worker is immune to burnout, no matter how much experience or expertise that worker may have.

The Client. Dr. Jane Lee is a striking, raven-haired, 43 -year-old woman with aquiline features , a low, melodious voice, aquamarine eyes that twinkle, and a smile that could serve as a toothpaste commercial. She is ex tremely witty and incisive of intellect, is widely read, and can talk as easily with truck drivers as she can with lawyers. At any social function people gravitate toward her. She seems to have been born

566 • PART THREE On the Home Front: Crisis in the Human Services Workplace

with the natural empathy and easy familiarity that many people consciously work their whole lives for, yet never quite attain. Divorced for 10 years, Jane has raised her only son while carrying on an exceedingly successful professional life.

Jane has a thriving practice in marriage and fam- ily therapy. She has a heavy client load and is clear- ing approximately $150,000 a year. She is seen by her peers as extremely capable, and her clients speak highly of her. Jane has been in private practice for 8 years'. Prior to entering private practice she worked in a community mental health facility. She was so skillful at therapy there that she rose to the directorship of the clinical program.

Jane graduated from a major university with a doctorate in counseling psychology and completed her internship in a VA hospital. She then successfully completed an American Association of Marriage and Family Therapists internship at a private clinic. She has written and published many articles on therapy for anorexics and the families of individuals suffering from catastrophic illnesses. She has also given many inservice programs and presentations at national hu- man services conferences.

By any criteria imaginable, Jane appears to be a highly competent, successful therapist and an ex- ceptionally endowed woman overall. Her ability and demeanor have made her a role model that many in her community aspire to emulate. As Jane sits down with the crisis worker, she is seriously considering drinking a good deal of wine, closing her garage door, climbing into her new Lexus, turning on the ignition, and killing herself

Jane: I came here today because of what you said to me the other night when we were having a drink. You pretty much have me pegged. I'm burned out even more than what you think, more than what

'\. I like to admit. Today I had a decision to make, whether to kill myself or come here. I came here, but I'm not sure it's the right decision . If I killed myself, it seems like it would just be over and done with. I've taken care of everything concern- ing Bobby, my son. He 's practically through with college, and even though we're very close, I really think it'd be better for him ifI were gone.

He wouldn't have to put up with my lousy be- havior, and believe me, it's lousy right now. There's enough insurance to get him finished up in school, and he could sell the house. He's the only one that re- ally matters besides my clients, and right now I'm not

doing worth a damn with them. I'm probably hurtin~ more than I help, and I'm just not up to it anymore. So much pain and so damn little I can do about i The only thing I can think about now when I go imo a cancer ward is how bad the patients smell. Whoen~::­ said "You don't have to smell them. All you gotta do is help them!" sure wasn't in this end of the business. I'm also starting to behave like those screwed-up a n - orex ics I work with too . It's starting to seem prerry reasonable to me that they aren't eating. Why the he[ should they? Why the hell should I? Just sort of fa de away and look thin while you're doing it. At least I' · make a great-looking corpse. Anyway, the main rea- son I came over today was to see if you'd be willing to take my clients. I've thought this' over, and you've got what it takes. I think you could help them, and if yo11 agree, I'll start talking to them about coming over m your practice.

CW: What you just said scares the living hell out oi me. There's a part of me that wants to run right our of here, because what you're saying is really hittin 0 home with the way I feel at times. There's another part of me that wants to tie you up in log chains until you come to your senses. Finally, there's a n - other part of me that cares for you so much th at I'm angry that you've let yourself get into this pre- dicament. Most of all, though, I'm glad I made that reflection the other night and that it fina lly sank in. I've seen you going downhill for quite a while now. My guess is that you didn't even know it was happening or just laid another piece of a r- mor plate over yourself and said something like "I've got to gut this through" or some of that other irrational garbage I hear you unload on yoursel f. First of all, I won't even consider what you said about the clients until we agree on one thing, and that is you don't do any harm to yourself until we talk this through . So I want an agreement both as your therapist and as your friend that we shake on that before anything else happens. I won't take n o for an answer. If that's not acceptable, we'll negoti- ate it. No matter what, we're now in this together.

Ethical Issues. The crisis worker is in a difficult p o - sition as the client's friend, fellow professional, and now as a therapist dealing with another human being in crisis. When a human services professional who is a colleague becomes impaired, it is the ethical duty of the fellow professional to do something to pre- vent harm to clients (Harrison & Westwood, 2009;

CHAPTER SIXTEEN Hum an Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 567

Thomas & Levitt, 2010), and there is research that impaired therapists can hurt clients (Lawson et al., 2007) . The overall principle of nonmaleficence (do no harm) comes into play. It is simpler if impairment is due to drugs or alcohol abuse that can be readily ob- served, or if the professional works in a setting where other professionals can observe the behavior, but it becomes much more difficult when the professional is in private practice or the impairment is burnout, which cannot be smelled or seen in slurred speech or unsteady walking.

Oftentimes close friends and colleagues of burned-out professionals are the first to notice the impairment. Clearly, there are many personal and so- cial dilemmas about "snitching" out one's colleague. The question then becomes: Should colleagues report the impaired professional to the state licensing board or attempt to intervene and help the person by them- selves? It is a slippery slope and, as with many ethics questions, there is no clear answer.

Although there are ethical issues in treating a friend and a colleague, when a client is in crisis and lethality is involved, the primary concern is keeping the client safe and returning the individual to a state of equilibrium. Depending on what comes of this cri- sis intervention, if Jane can regain her psychological equilibrium and manage her own self-care, the cri- sis worker may do nothing more. If Jane doesn' t, the worker is ethically bound to notify a licensing board although that might well spell the end of the friend- ship (Thomas & Levitt, 2010).

The nuances of this ethical dilemma can be ar- gued after the fact, but right now the crisis worker needs to act. Particularly in small towns where there are essentially no other professionals with the neces- sary expertise t o provide immediate assistance, the appropriate ethical response would be to provide the best level of care as quickly as possible. In that regard, it is most likely that the crisis worker will have some personal or professional relationship with the client.

Because the crisis worker knows the client, she feels free to make some initial owning statements that let the client know exactly how she feels about the situation without becoming sympathetic in the bargain, which she could easily do because she has felt much the same way at prior times in her professional life (countertransference). The crisis worker also makes an initial assessment of the lethality level of the client. Her reflective statement to the client a few evenings earlier was not idle conversation. The crisis worker has seen a slow but steady change coming over

Jane in the last 3 months, and as she thinks about it she sees that it was coming a good while before that. Jane has been keeping a stiff upper lip, but there have been indicators that all has not been well lately. She has been rather cynical about clients, as evidenced by her comment about how they smell. She has been suf- fering a variety of physical maladies that have ranged from unending colds to some severe gastrointestinal problems ominous enough to indicate that surgery might be needed in the near future.

As the crisis worker continues to assess the situa- tion, she further realizes that Jane has trunc1tted re- lationships with most of her acquaintances and has done this lately with the crisis worker on at least two occasions. Their relationship had been characterized by an easy rivalry, good comradeship, and just gen- erally a lot of good times together without ever en- gaging in one-upmanship. Lately, though, the crisis worker has had the feeling that Jane has treated her more as a client than as a friend and has attributed some deeper psychological meaning to even the most innocent conversation.

Assessment. Behaviorally, Jane is in serious trouble. Her performance of daily tasks has become seriously compromised. Her uncharacteristic behavior coupled with her suicidal thoughts places her at a triage level of7 to 8 on behavior. The only positive behavior she is currently exhibiting is seeking out her colleague. Even though she says she is doing that only to transfer cli- ents, dynamically she is making a clear call for help.

The rather detached, mechanistic way that Jane has reported all this and her blank, hollow look are completely at odds with Jane's usual sparkle, which has been absent the past few months . Performing a quick synthesis of all this background knowledge, what Jane is saying, and the depressed way she is look- ing and behaving, the crisis worker makes the assess- ment that Jane is not kidding about killing herself and that the threat must be taken seriously. The cri- sis worker immediately goes into a suicide prevention mode and institutes a verbal contract with Jane not to kill herself. Even though Jane is a practicing therapist, she is no different from any other client in this regard.

Besides the threat of suicide, a triage assessment of Jane by a worker unfamiliar with burnout might cur- sorily dismiss her problem as typical whining about one's work. However, the difficult clients she deals with, the amount of time that she has done so, the isolation she has imposed on herself, and the absence of social support systems in her work and at home all

568 • PART THREE On the Home Front: Crisis in the Human Services Workplace

lead to a hypothesis of vicarious trauma/ compassion fatigue that is rippling out into every component of her life (Figley, 2002, p. 7). Research clearly indicates that the more traumatic clients are and the more of- ten they are seen, the more likely it is that the therapist will experience compassion fatigue, vicarious trauma- tization, and burnout (Simpson, 2006). In short, Jane is fitting many of the behavioral, attitudinal, emo- tional, and interpersonal descriptors mentioned ear- lier in this chapter regarding symptoms of burnout.

Triage assessment for affect is 7 to 8 . Although her outward demeanor is calm and collected, her af- fective responses are uncharacteristically angry and hostile for someone in the helping professions. Jane is using considerable effort to control her feelings. Cou- pled with the emotional exhaustion that is the most salient factor of burnout, she is close to being acutely depressed. This should come as no surprise, because depression and burnout often go hand in hand (Lawson, 2009; McKnight & Glass, 1995).

Cognitively, Jane is operating at a triage level of 6 to 7. Although Jane is thinking in a linear manner, her logic is twisted, and her belief system is severely com- promised by obsessional self-doubt. She is manifesting a great deal of Ellis's (1973) "musturbatory" thinking and demonstrating another hallmark of burnout: a se- vere decline in her belief in her personal competence, along with depersonalization of her clients. Her com- plaints go beyond her job and indicate problems with social relationships, physical health, personal integrity, professional identity, belief system, and her total envi- ronment. Jane's total triage assessment scale score of 20 to 23 places her in the low to moderate marked im- pairment range. She is currently functioning between the frustration and apathy stage of burnout and is at a trait level where burnout has become pervasive across her environments. Without intervention, she is likely to move quickly into severe and lethal impairment.

Jane has done one thing right. She has gone to a significant other and is using that trusted other to self-disclose in a very intimate way some of her most troubled feelings (Maslach, 1976; Watkins, 1983). Because Jane's problems have spread out across her environment, the crisis worker will do exploratory counseling across BASIC IDS (Lazarus , 1976) compo - nents with the idea that no component ofJane's life is immune to the burnout currently assailing her.

Jane: All right, I can agree to a no-suicide contract. I know that's part of the procedure. Hell, I guess I knew you'd do that when I came in here. Maybe

I'm only kidding myself about all this anyway,jus: a bit of the blues, feeling sorry for myself, and ~ that crap.

CW: I'm glad you came here, for whatever reason. and I'm also glad you agree to our contract even though you know it's part of the program. I also don't believe that about having the blues, either. I think it's much more than that. I believe righ[ now you're hurting quite a bit. But first I'd like to hear what you think and feel is going on in your life right now.

Intervention . While the crisis worker is acknowledg- ing her regard for Jane, she is also doing quite a bit more . First, she has decided to take a pretty directive stance with Jane for the time being. The worker b al- ances between making emotional challenges to t h e client and listening closely and accurately to Jane's problems. She also knows Jane is extremely astute at the business they are engaged in, as evidenced by h er comment about the contract. She is not going to let Jane play the game ahead of her. Her analysis is th at Jane is out of control right now. The crisis worker is therefore going to take control of the situation and will not sit back in a passive mode.

Jane: I don't know. I've dealt with all kinds of prob- lems in my life, and right now there's nothing I can really put my finger on. In comparison to what is going on now, I can tell you that going through the divorce with Jeff, taking off on my own to finish up the doctorate, fighting my way up the ladder in the agency, and then finally mak- ing a decision to go out on my own while raising Bobby make what's happening to me now seem like peanuts.

CW: Right! Those were really tough times, and you went through those like Superwoman. But that was then, and we're right here, right now, and from the looks of it you don't much feel like you're Superwoman, and what's happening in your life surely isn't peanuts, or we wouldn't be having thi s talk right now. So what do you feel like right now?

The crisis worker acknowledges how tough the cli- ent has been, but will not let her get stuck in the past. The crisis worker wants to find out what is happening right now. What is more important about this now than it was a year ago? Furthermore, the crisis worker will not let the client discount the problem. It is inter- esting that ifJane were the counselor here, she would

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicar ious Traumatization, and Compassion Fatigue • 5 69

probably ferret out what she has just done-retreating into the past-in a second. The difference is thatJane has really become a client, and she is as blind to the way she talks, thinks , and behaves as any other client. Jane's being a therapist gives her no edge in dealing with her own problems. In fact, her own expertise may militate heavily against her (Kesler, 1990).

Jane: All I can tell you is I'm washed out. Like I get dates and appointments all mixed up. Last week topped that all off. I saw 44 clients last week. I think I got about a dozen appointments mixed up. My appointment book was really screwed up. It was a madhouse, and some of the people got agi- tated. Nothing like that ever happened before.

CW: Never?

Jane: Well, to a far lesser extent. I've been strung out before, but I could always get it straightened out.

CW: How?

Jane: About every 3 months things would start to get out of hand. I'd just sit back and say, "Janie, old girl, you've got to get out of here for a while." I'd just hop in the car and take off for a weekend in Chicago. Check into a hotel, take in a show, eat some really special meals, and use about half the hotel's hot water washing the clients off of me. Seems like that would clear the cobwebs out of my head.

CW: When was the last time you did that?

Jane: (wistfully) About 9 months ago.

CW: Why so long?

Jane: Well, I bought that new office and went in and remodeled the whole thing. I cut the contractor a deal. If I could work on it too, he'd reduce the pnce .

CW: So being the omnipotent individual you are, you threw out at least one thing that keeps you on an even keel. In fact , rather than getting away from the office, you've been spending almost all your time there. Let's see, we've got a couple of char- acters running around inside of Jane-Dr. Jane, healer to the world, andJane the carpenter. Won- der who else is inside there?

The crisis worker is looking for a link between the past and the present. If Jane had some coping mecha- nisms in the past, what were they? She is specifically looking for coping mechanisms in the past that can be linked to the present and what is happening in the present to keep those coping mechanisms from

being put into place. She is also beginning to build a character repertoire with Jane in the hope that Jane can start to see all the various aspects of herself that are now motivating her to do some of the things she does (Butts, 1996). To set the stage for the client's re- gaining control of her life, the crisis worker proposes a positive character in Jane.

CW: I also heard a character that I'd call Janice, a per- son who knows when her stress bucket is full and is practical and smart enough to get away from the crap that goes on at that office. Where have you stuck her?

Jane: Back up on the shelf with Janie?

CW: Who'sJanie?

Jane: She's the gal who's a little crazy, who can joke with her clients and get up in the middle of the night and go out and start seeding her lawn and sing Chuck Berry songs while she's doing it. (em - barrassed) There's just no time for them right now. It's not just the new office, but I also needed an- other car, and since Bobby has changed schools there were a lot of added expenses in that. So I re- ally needed to devote my time to building my case- load up. IfI can get through the next 2 years, I can breathe easier.

CW: Well, I'm sure glad to hear you're planning on being around for the next 2 years, anyway. But that's not the question now, is it, because right now it sounds to me as if you're wrung out. You don't have any more energy to give, and you've set up on the wall a couple of people who are pretty important in recharging your batteries. Do you see how important they are and what it's cost you to do that?

The crisis worker is not yet making direct sugges- tions as to what Jane needs to do; however, she is hop- ing to raise Jane's consciousness to the f~ct that she has unconsciously changed her operating method. The crisis worker attempts to get her to recognize this by describing what these very positive characters have done for her. By doing so, the crisis worker is attempt- ing to reintroduce some very healthy defense mecha- nisms that have previously helped Jane cope well with the stressful life she leads. Three major pathways that keep Jane in equilibrium are currently missing from her life: resiliency, self-management and self-care, and connection with others (Gentry, Baranowsky, & Dun- ning, 2002). The crisis worker will attempt to reinte- grate those into Jane's life.

570 • PART THREE On the Home Front: Crisis in the Human Services Workplace

Jane: I guess so, but I don't know how to get out of it.

CW: What will happen if you don't work on the office this next weekend?

Jane: The new plumbing isn't in. Clients wouldn't be able to use the bathroom. I'd also feel guilty for not working on it.

CW: (laughing) Well, the first part of that problem is pretty easily handled. Call the Porta-Potty people. I can imagine a sign that says, "The crap stops here," hanging from the door as clients walk in. Uane starts to smile and giggle for the first time since walking in the door.) The other part of that is, who's the character laying a guilt trip on you? Tell me some more about her.

The crisis worker takes a little bit of a well-gauged risk here by injecting some humor into the situa- tion (Moran, 2002). She does this because humor has been important in Jane's life, is helpful to her in cop- ing, and turns her away from some of the cynicism she feels toward her clients and starts to allow her to laugh at herself a little . The ability to laugh at one's own foibles and some of the bizarre and ridiculously funny things that happen in our clients' lives can- not be overemphasized (Pines & Aronson , 1988, p. 154). Van Auken (1979) extols the judicious use of hu- mor even in the most pathetic of situations. Getting a smile or a laugh from clients is a direct intrusion into the depressive thought processes and behaviors in which they are mired.

The crisis worker also starts to hammer a bit on Jane's guilt. Generally the crisis worker sees guilt as a pretty useless emotion, consumptive of energy that could be used in other, more positive ways. Guilt is in- variably an emotion of the past, and whatever was done can never again be retrieved. It is one thing to learn from one's past mistakes and quite another to carry past). unfinished business into the present, particularly when one is feeling guilty about not measuring up.

Jane: That's Mother Superior. I get all kinds oflectures from her. (bitterly) She's just like Sister Angeline at St. Mary's, where I went to school. "Say your Hail Mary's and Our Father's. Get your homework done. God doesn't like a shirker. Watch how you dress ." Jesus, I hated that!

CW: You hate it, but it sure sounds like you're living it. Small wonder you're feeling so lousy.

The crisis worker starts hooking up feelings with thoughts and actions. The response the crisis worker

gets indicates that the burnout has spread out inL the client's family life.

Jane: You know, I think that's maybe why Bobby a nci.: are having problems right now. I really sound an.:: act like a Mother Superior to him. My Lord! He·s 21 years old, and I've started treating him like h was a 6-year-old. He's about like some of thos e cli - ents I have to lead around by the nose .

CW: Did you hear what you just said? "He's ab oc: like some of those clients I lead around." Fir.st o: all, I didn't know that was the business you were in. Sounds like Jane the handywoman. Fix 'em up the way you do your office. Second, I wonder h ow many people outside the offic~ you've decided to fix up and look out for. I have to tell you that's one of the kinds of feelings I've had around you lately.

With this information, the client gives the crisis worker a chance to plunge into some core issues tha have definable behavioral outcomes. By stating h ow she deals with Bobby, Jane is manifesting anoth er of the typical signs of burnout: trying to treat sig- nificant others in her life as if they were in the thera- peutic situation (Van Auken, 1979). Her relations h ip with Bobby is extremely important because one way of decreasing burnout is to have a satisfying fam ily life, especially with one's children (Forney, Wallace- Schutzman, & Wiggers , 1982). Worse yet is that she has become autocratic in the therapeutic situation. so it is not surprising that a major component of h er life that has been highly reinforcing to her is no lon- ger so and, in fact, has taken on some very negative connotations.

The crisis worker lays that squarely on her. She is mixing up her characters and has replaced Dr. Jane with Jane the handywoman. This state of events is n m so surprising since both characters are working in t h e same office. Jane needs a break in her day-to-day ac- tivities and needs to get away from the office to do it (Forney, Wallace-Schutzman, & Wiggers, 1982).

Finally, the crisis worker relates and owns her own experience of having been treated the same way by Jane . She tries to makeJane aware that, like rings on a pond, the ripple effect from her burnout goes far b e- yond her immediate line of sight (Kesler, 1990).

CW: Indeed, I wonder about your relationships other than those with Bobby, myself, and your clients. Anyone else you're trying to control right now?

Jane: (frostily) If you mean men, absolutely no. When I get home at night, I'm so bushed all I want to do is

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 571

fall asleep, but then all those clients go tumbling around in my head, and I start thinking about car payments, mortgage payments, how to straighten things out with Bobby, and I wind up getting about 2 or 3 hours of sleep a night.

CW: So right now you're so exhausted that you'd just rather be alone .

Jane: That's right, but I feel like I ought to be out min- gling with people. I'm so damned isolated anyway.

CW: OK! I can understand that, and I'd agree with you, but let's look at right now. Seems as if you re- ally need some time to just curl up in the fetal po- sition, turn the electric blanket up to nine, and get your batteries recharged. Could you just go home and go to bed, put the answering service on until Monday, and not get up for the whole weekend?

Jane: I suppose.

CW: No supposes. If you don't want to do that, we'll look at something else. But right now you look like The Grapes ofWrath and just seem to really need to rest before you think about doing anything else. Are you willing to call the contractor up and tell him you won't be there Saturday and Sunday without feeling guilty about it?

Jane: I could use the rest. All right! I'll give it this weekend.

CW: Fine. But there's one more thing. If you really get to feeling blue, plug the phone in and call me at home. I also want a report next week, so what time do you want to come in?

Jane: Sounds like I'm a client.

CW: Sounds like you're right. (laughs)

The crisis ' worker is basically assisting Jane to make a simple commitment to do one thing-get some rest. A critical component in treating burnout is revitalization (Tubesing & Tubesing, 1982, p. 160). Jane is physically fatigued , and the first order of busi- ness is to get her physical batteries recharged. A num- ber of other options are available at this juncture, but the crisis worker follows Tubesing and Strosahl's (1976) advice to let the client make the choice of what treatment is appropriate. Keying on the client's own words about needing sleep, the crisis worker follows up and gains commitment to a specific behavior that the client will engage in over the short term. This is not a dramatic first step, but considering the least dramatic steps first is probably the way to go (Van Auken, 1979). The most important objective of this

initial encounter is finding some short-term interven- tion techniques the client is able and willing to use (Freudenberger & Robbins, 1979).

A particular behavior the crisis worker touches on is the use of the telephone. Private practitioners are notorious for taking phone calls from clients at all hours of the night and on weekends. Van Auken (1979) urges human services workers not to let clients run- or, for that matter, ruin-their personal lives. The cri- sis worker makes sure that Jane follows this dictum, even though the crisis worker herself doesn't> practice what she preaches, which leads one to wonder whom the crisis worker may soon need to be talking to about burnout. Finally, the worker provides emotional sup- port, but once Jane is able to ventilate her feelings, the worker moves into a problem-solving mode.

The Next Week

Jane: I'll have to admit I do feel better. Couldn't sleep at all Friday night, but I got 10 hours in Saturday. I can't believe it! I woke up, and I was all curled up in the fetal position. The clients looked somewhat better this week. I can't say it was wonderful, but at least I wasn't an ogre to them. I guess what bothers me most about that is that I've lost all my creativity.

CW: OK! Let's talk about that a bit. You haven't been paying very much attention to the right side of your brain, so what do you expect? What could you do creatively that isn't client involved that'd get the right side of your head going again?

Jane: I've got a couple of articles I've been putting off-how about that?

CW: Got anything to do with clients?

Jane: Yes.

CW: Is that going to help you out?

Jane: I don't guess so, the same old stuff, only I'm writing about it.

CW: What else, then?

Forney, Wallace-Schutzman, and Wiggers (1982) propose that a variety of professional activities may be an excellent coping mechanism; nevertheless, the crisis worker confronts Jane about this suggested al- ternative . The crisis worker is fairly sure that the cli- ent's stress bucket is full to the brim professionally. Jane needs to become less, not more, involved in her professional life.

Jane: Well, there is something else. I bought this sail- boat for Bobby and me. The Coast Guard Auxiliary

572 • PART THREE On the Home Front: Crisis in the Human Services Workplace

is putting on a sailing class. It would sure surprise Bobby if the next time he came home I could han- dle that Y-Flyer.

CW: Is that something you want to do? Would like to do it, not need to do it?

Jane: Yes!

CW: And not pile it on top of everything else. Really reserve some time for yourself to enjoy it.

Jane: You sure drive a hard bargain, but I can do it.

This is a wedge in the behavioral repertoire of the client that the crisis worker has been looking to find. Writer after writer in the burnout literature has promoted the use of leisure, particularly physical exercise, as a way of breaking up the dogmatic, work- brittle behavior of just going through the motions that often characterize the burned-out human services worker (Hoeksma et al., 1993; Melamed, Meir, & Samson, 1995; Oerlemans & Bakker, 2014; Savicki & Cooley, 1982).

By proposing for the client a combination of lei- sure, physical exercise, and quality time with her son, the crisis worker has neatly integrated a number of positive interventions. The crisis worker is moving methodically around Myers , Sweeney, and Witmer's Wellness Wheel (Myers , Sweeney, & Witmer, 2000; Myers & Sweeney, 2005), which has at its center spiri- tual self-direction, and which Dr. Jane is now mostly without. Specific spokes that radiate out from that wheel that the worker is attempting to put back in place in the client's life are nutrition, exercise, self. care, stress management, a sense of control, realis- tic beliefs, a sense of humor, renewed creativity, and awareness and coping across her entire ecosystem. With that many spokes missing, it is no surprise that Dr. Jane 's psychological vehicle has about lost its spiritual axle as it careens down a crisis cliff that has become a burnout landslide of behavioral, physical, int{ rpersonal, and attitudinal problems.

The crisis worker now takes on the main issue of the client's private practice.

CW: Fine. Let's talk about your practice for a while.

Jane: You know as well as I do about that. Sure, I've got a great caseload now. But who knows, it might dry up next week, and then where would I be?

CW: Has it ever dried up? Even in the last recession?

Jane: No, it hasn't, but I keep expecting the worst.

CW: You've been in private practice 8 years now, right? Has it ever been such that you didn't have enough clients to keep the wolves away from your door?

Jane: No. I guess there's something else. I feel a lit de foolish saying this, but it's almost like if I don 't live up to my reputation and take on those really tough cases, I start feeling like I'm not the que en of the mountain. I mean, in the past I've been real proud of that, but now I don't seem to feel a ny- thing but that there's an albatross around my neck.

CW: Sounds like Superwoman again. I frankly admire you for dealing with those terminals' famil ies. and you're right! Not many could do that. But if there's no intrinsic payoff, why are you fool in6 yourself into thinking you can heal the whole world? See the trap you've put yourself into?

Jane: Well, no! I guess I don't.

CW: OK! I want to try something. Maybe you've u se it on some of your clients before. It's a game ot "Who Told You?" I want you to move over to my chair and ask that empty chair, which will rep re- sent Jane, some questions. I'm going to stand aside and process as we go along, but it'll mostly be u p to you. I want you to use all your insight as a the ra- pist and really bore in and go to work on Jane's fictional goals, those crazy things she tells hers elf that have no counterpart in reality.

Jane as CW: (shifts chairs and gets a glitter in her eyes) OK. toots! Who told you you had to be Superwoman?

CW: Now shift back.

Jane: Nobody,really, I'vejustgotalotofresponsibilities.

Jane as CW: Responsibilities, my foot! You've been go- ing up that success ladder so fast you've scorched the rungs. Always got to show them. Be number one. My God! You little twerp. You're 43 years old. and you still think you're back on the VA ward. Got to show them you're better than any man. Volunteer for the worst cases. Scared to death you won't succeed. And when you did, you were scared you wouldn't succeed the second time. Who told you that?

Jane: Nobody! It was reality. I had to be better than the men there.

Jane as CW: That was 20 years ago, nerd! The only men you deal with now are your clients. And that's another thing. Is that why you're so afraid of go - ing out with any other man? And don't give m e that stuff about getting burned again. You know why that divorce happened, and it sure doesn't have anything to do with having good social rel a- tionships now.

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 573

Jane: It's just that with the financial obligations for Bobby, I really don't have the time.

Jane as CW: (really angry and shouting) I won't have that! How long will you be responsible for him? He's 21 years old. Who supported you when you were 21? I'll tell you who. You did! You just use that as an excuse. Just like you use all those clients as an excuse. You don't fool me, you little martyr. Oh, sure! You get those strokes. (dripping sarcasm) Just like Annette here said, "I really admire you, Jane." You go around fooling everybody, but worst of all you fool yourself. Look at you. Sitting here the pa- thetic little wretch. You don't fool me. You're not little Miss Goody Two-Shoes. Behind all that de- pression is a really angry, bitter bitch who's always going around being everybody's servant. So just who told you you had to be that?

Jane: (Breaks and sobs. The CW goes to Jane, gathers her into her arms, and hugs her for dear life. Five minutes elapse.) Good Lord! I didn't realize that was all in there. I really got on a roll.

CW: Neither did I, but I figured if anybody could get it out, you could. What have you got out of that?

Jane: Besides spilling my guts, which I haven't done in 25 years, I see now how I got into this. I really set myself up.

CW: What do you want to do?

Jane: Well, I'm not going to kill myself, literally or fig- uratively. I've got some living to do, and although I'm not going to quit the practice, there sure are going to be some limits put on it.

The "Who Told You?" technique is a combination of Adlerian, rational-emotive behavior, and Gestalt therapy that is 'extremely powerful. Given a person with the kind of insight Jane has, it often has dramatic results in pointing out the way clients delude them- selves. By using Jane as her own therapist, the crisis worker provides no one for the client to rationalize to, attack, manipulate, or otherwise attempt to fool but herself. For a person with Jane's abilities and insight, that seldom happens for very long. Underneath most depression lies anger. If that anger can be mobilized, then the client has taken a major step toward getting back into control of the situation. By putting Jane in a position to view her behavior from outside herself and also giving her a stimulus to attack her irratio- nal ideas by the "Who Told You?" technique, the crisis worker provides an arena in which Jane can combat the apathy she is experiencing.

Such a dramatic shift to being mobile is uncom- mon among the general populace, and Jane's case is a condensed version of what may generally happen. The crisis worker often must provide the stimulus state- ments that are the core of clients' irrational ideas be- cause of clients' poor cognition of their own negative self-talk. However, in dealing with highly trained pro- fessionals, it is not uncommon for such rapid shifts to occur.

Given the initial stimulus, they may pick up on the technique and provide their own dialog<\;)-e with little or no help from the crisis worker. When emo- tional catharsis occurs, the crisis worker then takes a nondirective stance and serves as little more than a sounding board as their fellow professionals put reasonable parameters back into their lives. At that point, human services workers as clients tend to be able to make good decisions quickly about the behav- ioral, emotional, and cognitive aspects of their lives.

Indeed, if burnout syndrome is successfully over- come, it is not unreasonable to expect that human services workers will come back to their profession with hardier personalities, stronger commitments to self and profession, better self-temperance, a greater sense of meaningfulness, and increased vigor toward their environment (Kobasa, 1979). Furthermore, new coping styles that include greater self-awareness, in- creased self-insight, and a more direct approach to problem solving are likely to result for those who suc- cessfully navigate these treacherous waters (Cooley & Keesey, 1981). Finally, it is our own observation that human services professionals who have successfully conquered burnout respond not only to their work but also to their daily living with calmer and wiser choices, behaviors, and work style.

Summary. In this vignette the crisis worker uses the BASIC IDS model to deal with multiple, overlapping issues in the client's life (Kesler, 1990).Jane's workload affects her relationship with her family and friends. Her role as mother affects her image of herself. Her image of herself affects her beliefs about her abilities as therapist and mother and finally affects her coping behaviors across the board. The crisis worker links all of these dimensions into a unified whole because each modality interacts with other modalities and should not be treated in isolation (Cormier & Cormier, 1985, p. 153). Jane's sailing expeditions not only will pro- vide her with fun, relaxation, and togetherness with her son, but also are as necessary to her therapeu- tic functioning as her doctoral training. Achieving

574 • PART THR EE On the Home Front: Cr isis in the Human Services Workplace

balance among the various parts of her life and com- partmentalizing them to the ex tent that they do not start to run into or over one another allow Dr. Jane Lee to be fully functioning in all of them and at the same time limit the stresses inherent in each (Pines & Aronson, 1988, p. 152). Oerlemans and Bakker (2014) have conducted a one-day-at-a-time plan that focused on physical vigor and cognitive liveliness through low-effort social and physical activities and got posi- tive results on burnout reduction indicators. In other words, don't take your work home with you and fol- low Glasser's theory (1985) and have some fun!

Webb (2007) has listed the following points that can help crisis workers who deal with traumatized children stave off vicarious traumatization, compas- sion fatigue, and ultimately burnout.

1. Pursue training and professional acnvmes that promote learning. Keeping up in this business is important not only for the knowledge gained and skills learned but for meeting other professionals and continuing to build a professional support system.

2. Work with a variety of clients and limit exposure to trauma in general. It is tempting to specialize in trauma work. Many crisis workers take pride in doing work not everyone can do. It is also an adrenal rush and addictive. However, the old say- ing "Pride goeth before a fall" is true here. Varied client issues are not only a good way to keep the worker on his or her game but also provide relief from the constant grit and grind of trauma work. One of your authors startled a student he was doing some career counseling with after having worked with five suicidal/ homicidal students in a row. His statement, "Thanks for coming in, you' re the first normal student I've met today," probably made her wonder just exactly who was enrolling

'\. in the university. 3. Create boundaries between work and home, and

maintain a personal identity. One of your authors is married to a middle school counselor. Do we talk about our work? Yes! Do we talk about it all the time? Absolutely not! We leave most of it at the door. "It'll be there tomorrow" are words to live by.

4. Find professional friends who understand the stress of this business. You can't have too many professional friends and colleagues. One of your authors makes regular dates to watch baseball games with a psychologist who works at a VA hospital. We talk about psychology, but we also

discuss theology and politics, watch baseball, ea;: peanuts, and sing "Take Me Out to the Ballgame- during the seventh inning stretch.

5. Spend time with people who have not been vic- timized to maintain a balanced perspective th a t not all people have pathology. That's why it is important to get into a church, civic organization, fitness center, bridge club, model train club, or benevolent organization where there are just "regu- lar" folks engaged in just "regular" activities.

6. Confront intrusive images and work through them. After reading this chapter, you should u n- derstand full well that if you start having pop-ups in your mind of the bad s tuff you deal with or have nightmares about the' stuff, don't punch it back as part of the job. Go get help.

7. Engage in activities that promote a sense of effi- cacy and empowerment. You may not decide to run for U.S. Senator, but getting involved in a commu- nity action program or government committee is an excellent way of feeling empowered and helping promote causes that give you a sense of self-esteem.

8. Engage in your own psychotherapy. While we do not advocate becoming your own "shrink," what is meant by this point is knowing yourself If yo u saw Crazy walking down the other side of the street, would you run over and go lay a body wrap on it? Knowing yourself as to your psychological strengths and weak points is critical in this work. Practicing mindfulness techniques by increasing awareness and acceptance of feeling and body states and gently letting go allows one to preempt stress as it starts to arise and ameliorate when it's present. Research (Decker et al. , 2015; Felton et al., 2015; Thieleman & Cacciatore, 2014; Thompson et al. , 2014) has shown that practicing mindfulness has positive effects on decreasing CF and increasing CS.

9. Get supervision from somebody who knows his or her business about trauma work. Your bartender, hairdresser, minister, golfing buddies, or book club members are fine to talk with, but they are "regular" folks up in point 5. You do need somebody who knows this business and how to effectively supervise you as you do it.

Epilogue: Cross-Cultural Comparisons This chapter is not just for human services lmll workers in the United States . If you are reading this book in Germany, Scotland, Australia, Poland,

CHAPTER SIXTEEN Human Services Workers in Crisis: Burnout, Vicarious Traumatization, and Compassion Fatigue • 575

Austria, Canada, Denmark, China, Korea, Israel, Japan, or some other country, this chapter is also for you. Victor Savicki (2002) conducted a land- mark study of child care workers, culture, work envi- ronment, and burnout across the United States, Australia, a number of European countries, and Israel and compared them on Maslach Burnout Inventory subscales (Maslach & Jackson, 1981a). What Savicki found when he compared 13 different cultures was that all of you out there don't do well and tend to burn out when there are heavy workloads, unsupportive middle-level managers , an atmosphere in which new ideas and practices are restricted, and inefficiently organized work. Conversely, when the work environ- ment offers encouragement for new ideas, a team of coworkers lends support, and managers set the stage for positive feelings of goal attainment, low burnout scores are the result (Savicki, 2002, pp. 80- 87).

However, when culture is facrored in, Maslach's three components of burnout change dramatically. For example, Danish and both French Canadian and English Canadian workers have low emotional ex- haustion, low depersonalization, and high sense of personal accomplishment scores. Child care work- ers in what was formerly West Germany have high burnout profiles with a low sense of personal ac- complishment and high emotional exhaustion and depersonalization scores. Interestingly, in what was formerly East Germany respondents had very little sense of personal accomplishment, yet they were not emotionally exhausted nor did they feel much deper- sonalization. Clearly, even though those are both German populations, the political cultural artifacts left over from what was formerly a communist co untry seem to play a role in how child care workers operate and what their culture expects from them, in contrast to the democracy of the former West Germany. Now compare the German scores to those of the Israelis, who had very low depersonalization, very high sense

Burnout is not simply a sympathy-eliciting term to use when one has had a hard day at the office. It is a very real malady that strikes people and can have extremely severe consequences. It is prevalent in the human services professions because of the kinds of clients, environments, working conditions, and

of personal accomplishment, but were at the median on emotional exhaustion. Then look at the United States, whose workers scored extremely high in sense of personal accomplishment, but unhappily also had high emotional exhaustion and high depersonaliza- tion scores (Savicki, 2002, pp. 78 - 79).

Both general environmental work measures and individual cultural conformity measures showed signific ant relationships to the burnout subscales (Savicki, 2002, pp. 88-89). For example, the concept of power distance means the amount of control that bosses feel th ey have over workers and ice versa. High power distances mean that bosses believe they can dictate the behavior of their subordinates. It should come as no surprise that high power distances lead to burn out. Likewise, the uncertainty avoidance principle is the degree to which cultures establish rules, procedures, and rituals to compensate for uncertainty and chaos (Savicki, 2002, pp. 38-41) . Again it should be no surprise that those cultures with high uncertainty avoidance and many rules to guide the bureaucracy tend to have high burnout scores.

The implications of Savicki's (2002) work would seem to be that not only are the individual worker and the work setting complicit in whether burnout poten- tial is high or low, but also that the overall culture may be a factor as well. If that is true, changing the cultural factor is a tall order indeed! Savicki's (2002) study ex- amines countries whose cultures are generally seen to be more individualist as opposed to collectivist, al- though arguments could certainly be made for a more collectivist Gestalt in what used to be East Germany and other former Soviet bloc countries of Eastern Europe. It would be interesting to see how child care workers from Middle Eastern, African, and Asian cul- tures that tend to operate more on the collectivist end of the cultural continuum would fare on the Burnout Inventory. Much like avian flu , burnout circles the globe, and you can catch it pretty much anywhere.

resultant stresses that are operational there . Because of the intense and stressful nature of crisis interven- tion, a major contributor to burnout is constant ex- posure to clients who have had horrific experiences.

Prolonged exposure can induce what is variously called vicarious traumatization, compassion fatigue, or

576 • PART THREE On the Home Front: Crisis in the Human Services Workplace

secondary traumatization in the crisis worker. No one particular individual is more prone to experience burnout than another. However, by their very nature, most human services workers tend to be highly com- mitted to their profession, and such commitment is a necessary precursor to burnout. Private practitioners may experience burnout even more severely than their counterparts in organizations because of their profes- sional isolation. All human services workers, public or private, tend to be unable to identify the problem when it ts their own. No one is immune to its effects .

Burnout moves through stages of enthusiasm, stagnation, frustration , and apathy. In its end stage, burnout is a crisis situation. The crisis takes many forms. It can be manifested behaviorally, physically, interpersonally, and attitudinally. It pervades the professional's life and can have effects on clients, co- workers, family, friends, and the organization itself.

Recognition of the beginning symptoms of burn- out can alleviate its personal and organizational ramifications. Raising consciousness levels in regard

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to the dynamics of burnout in trammg programs and conducting on-the-job workshops are important ways of halting and ameliorating its effects. Support groups within the organization that provide instru- mental and emotional resources to victims are im - portant. In the past, burnout has been regarded as a malady that resides only within the individual. Th ar view is archaic. Burnout should also be viewed in a systems perspective and as an organizational and cultural problem. At its end stage, burnout is a crisis situation that calls for immediate, direct, and reality- oriented therapeutic intervention. Given corrective remediation, victims of burnout can return to the job and again become productive.

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