Compassion Fatigue: When Listening Hurts

Compassion Fatigue: When Listening Hurts

As the stress of practice intensifies, psychologists have to ask themselves, ‘Am I taking care of myself?’

By Randall Edwards

The psychological and emotional demands placed on the practitioner have never been more intense, clinicians and researchers agree. Psychologists are expected to have the broadest of shoulders, absorbing without complaint the suffering and anxiety of their clients. But who takes care of the caretaker when the stress of a clinical case load becomes too great to bear alone?

Psychologists should look to their own profession for help, practitioners say, but pride and concerns about confidentiality often stand in the way.

In recent years, psychologists have suffered increased stress from the demands of the changing health-care environment, said Daniel Abrahamson, PhD, a clinical psychologist and co-founder of the Traumatic Stress Institute/Center for Adult and Adolescent Psychotherapy, or TSI/CAAP, in South Windsor, Conn. Managed-care organizations and other insurance providers require therapists to document their work with each patient in excruciating detail. That leaves providers feeling they must risk breaking a patient’s confidentiality to collect reimbursement, Abrahamson said.

But psychotherapy has always been challenging, even before managed care, he said. Plumbing the depths of a troubled psyche can be emotionally draining.

“It’s not just dealing with everyday problems like getting motivated, looking for a job, working through relationship problems,” Abrahamson said.

Psychologists who work with patients who have suffered traumatic experiences must learn to balance objectivity and empathy, he said. “You can’t become so hardened that it no longer affects you, because then you can’t be there for the patient,” he said. “On the other hand, you can’t be horrified and outraged to the point of being paralyzed.”

Many psychologists say they have already learned to balance their work and their personal life,. APA President-elect Dorothy Cantor, PsyD, a Westfield, N.J., private practitioner, says she puts her family first, takes time off for lunch every day, exercises, and vacations at what she calls her “country getaway in the city.” The place has an unlisted phone number, no fax and no computer. Anyone who visits is prohibited from bringing work along.

“Psychologists can only reap the rewards and meet the demands of the profession if they find ways to replenish themselves,” Cantor said.

Sharing the trauma

But when the weight of their work uhcauses emotional or psychological problems, psychologists may be experiencing “vicarious traumatization,” say two of Abrahamson’s colleagues, Laurie Anne Pearlman, PhD, and Karen W. Saakvitne, PhD. They recently wrote a book about vicarious traumatization, which they define as “the enduring deleterious effects of trauma therapy on the clinician.”

The phenomenon affects many trauma workers, such as firefighters, criminal defense lawyers and the staff of battered women shelters, the authors write in Trauma and the Therapist. But it is especially challenging to trauma therapists.

“Our clients’ vivid and sometimes graphic descriptions of their brutal victimizations contribute to our vicarious traumatization,” they write. “While it is often essential to their healing for clients to share specific traumatic images, we can carry these with us and they may at times appear to us, unbidden, as clear as our own internal images.”

None of the researchers interviewed for this article could estimate how many psychologists suffer these symptoms, but all agreed it is far more common than published reports suggest.

Psychologists not only become helpless witnesses to a trauma, but must confront the constant possibility of personal tragedy and trauma. The confidentiality of the clinical setting often leaves the provider feeling isolated and alienated as well.

“The cumulative effect of story after story, client after client, day after dayäcan become a chronic condition,” said Pearlman, research director of TSI/CAPP.

Charles Figley, PhD, calls the condition “compassion fatigue” and suggests that the best counselors are its most likely victims. Figley, head of the Psychosocial Stress Research Program at Florida State University, examines the problem in his recently released book, Compassion Fatigue.

His own experiences studying Vietnam veterans in the early 1970s first sparked his interest in the impact of traumatic stress on psychologists. Over a six-year period, he interviewed more than 800 Vietnam veterans, who discussed their traumatic experiences and the role those traumas played in later relationships.

“That experience left an indelible impression on me, and certainly at times, incapacitated me,” Figley said. “There were nightmares. I was obsessed by it. The collective impression was one of anger and frustration about how these men and women were traumatized.”

Figley said positive actions, from publishing the results of his research to establishing a consortium on veterans’ studies, helped him to cope with his stress and his feelings of anger.

Hearing about past trauma can trigger haunting memories from a therapist’s own past, Figley said. One clinician he worked with told of becoming angry with a client who was an adult survivor of childhood sexual abuse. The provider was surprised by those feelings, but as she considered them she realized that the therapy had forced to the surface her own buried anger toward an adult relative who had once fondled her when she was a child.

Based on his experience treating mental health professionals, Figley believes the providers more likely to suffer from compassion fatigue are those who are caring and empathetic. They shouls not be ashamed of these traits, he said.

“I tell them, ‘You are showing your humanity,'” he said. “But we lose some of our best people to this because in some work situations you’re perceived as a wimp if you find you can’t get these images out of your mind.”

Psychologists who find they are carrying this burden should “know that you are normal, recognize that you have been traumatized, and treat yourself like you would treat your patients,” Figley said.

Practice what you preach

Pearlman and Saakvitne are among many psychologists who believe that all members of the profession should have had some therapy themselves. But therapists don’t always practice what they prescribe.

“Caregivers sometimes have a hard time knowing when they should be taken care of,” said Lynne Hornyak, PhD, a Washington, D.C., clinical psychologist. “We all need to have people in our lives who we can count on.”

Hornyak said her work with therapists’ children has also revealed the extent of stress in a psychologist’s life.

“Children of therapists tell me that their parents are giving, supportive people, but they were not giving to them and they were not there for them,” she explained.

Practitioners often schedule their time to the minute, are exhausted by the stress of their work and don’t always set themselves-or their families-as priorities.

Hornyak advises psychologists who seek treatment to carefully lay ground rules with their own counselor, discussing confidentiality, expectations and how to act when they meet in professional settings.

Coping strategies

Aside from personal psychotherapy, Saakvitne suggests other ways to help psychologists cope with vicarious treatment, compassion fatigue or burnout.

“It is our clinical responsibility to make sure we are not harmed by our work,” said Saakvitne. “If we don’t take care of ourselves, we can’t take care of our clients.”

Not surprisingly, many of her recommendations are ones psychologists have advocated for years to their own patients:

Always work under supervision, either in a group practice, through hired supervision, or by a peer supervision arrangement where psychologists discuss one another’s cases and exchange recommendations.

Take time for relaxation and for lunch, and take at least two consecutive weeks for vacation.

- Take care of your body, through diet and exercise.
- Set boundaries between home and work: Don’t play therapist in personal relationships.
- To avoid isolation, get involved in professional organizations where psychologists can meet and discuss events and mutual problems.
“Balance is the key, not only in caseloads but in the rhythm of the day, in the clients we see and in our other activities as professionals,” Saakvitne said.

Hornyak, however, said she thinks balance is impossible.

“A much better metaphor is juggling,” she said. “You’re going to have a lot of balls in the air and sometimes, balls drop. You need to make sure that the ones that drop are sturdy enough not to shatter.”

Randall Edwards is a reporter with The Ohio Dispatch.

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