By: Tracy C. Wharton, M.Ed., MFT
Socialworker – When I was a young counselor just out of school, I took a job at an alternative school. I provided crisis intervention and behavioral therapy to children who were unable to succeed in normal educational environments. One of my clients was a six-year-old girl who had been repeatedly sexually abused and had been bounced around foster homes with her aggressive outbursts. After one particularly bad day of her active flashbacks, I found myself sitting in my clinical supervisor’s office in tears.
“How do you do it?” I asked. “I can’t sleep without thinking about her, about all of them. How do you deal with it?” He turned around and slammed his briefcase shut. “Like that,” he said, latching the locks shut. “You just have to learn to walk away. If you can’t do it, maybe you’re in the wrong field.” I hated him at that moment, and suddenly I felt as if all my teachers had betrayed me for not letting me in on this little secret. Why hadn’t anyone told me that this job would hurt so much sometimes?
The truth is that he was wrong. He may be able to shut it all off at the end of each day, but research tells us that most of us cannot and do not. In fact, about 48% of the total social work workforce in the United States experiences high levels of personal distress as a result of their work (Strozier & Evans, 1998).
Personal distress can look like a lot of things, such as relationship problems at home, feelings of no longer being effective at work, depression, or more noticeable things like nightmares or hypervigilance. Researchers make the case that there is a strong connection between the helping professions and what they call Secondary Traumatic Stress (STS). There is a lot of literature out there that talks about the high incidence of suicide rates in social workers, high turnover rates in employment, high rates of burnout, and disruptive symptoms to personal lives resulting from traumatic stress (Figley, 2002; McCann & Pearlman, 1990; Meyers & Cornille, 2002; Pryce, Shackleford, & Pryce, 2007; Valent, 2002). We often are willing to write it all off as fatigue, or tell ourselves (or others) to “buck up,” or “learn to deal,” or even worse—to get out of the profession, as my supervisor had done with me. Can you imagine what would happen if every young social worker took such advice? There’d be no one left to help our clients. It took me less than six months to learn about the strains of the job, but it would be nearly a decade before I would find out that reactions like mine are common, and more importantly—normal.
Exposure to stressors is not necessarily a guarantee that there will be development of clinically significant symptoms. Job satisfaction and personal gratification protect us (this is that notion that we love what we do, even if it’s very rough some days). We know that these things are true for our clients. What makes us think that our training makes us something other than human?
Burnout, Trauma, and Compassion Satisfaction
Burnout, secondary trauma, and compassion fatigue are not exactly the same things, and it’s helpful to be able to distinguish among them. Secondary trauma is the reaction to dealing with other people’s situations, such as my reaction to my six-year-old client. Burnout is related to the job environments in which we work, and the stresses attached to those jobs and requirements, like paperwork or poor supervision or support. When burnout and STS are both present, an individual is said to be experiencing compassion fatigue (CF). There is also a third factor in CF—something called compassion satisfaction (CS). Stamm explains this phenomenon as “being satisfied with doing the work of caring” (2002, p. 110). In other words, the gratification of helping others makes the strains of the work worth it. It is not uncommon to see social workers continue in their jobs after physical or psychological injury, or to find them reluctant to leave the field despite personal stress. The caring that we give to the world is both the greatest risk and the greatest protective factor from long-term trauma (Figley, 2002; Saakvitne & Pearlman, 1996; Stamm, 2002).
Ethical Considerations
The truth about compassion fatigue is that not only was my supervisor’s advice very bad and uninformed, but it was completely ignorant of the ethical obligations that we have on this subject. There are several sections of the Code of Ethics of the social work profession that apply directly to this topic. The first point of note deals with impairment:
4.05 Impairment
(a) Social workers should not allow their own personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties to interfere with their professional judgment and performance or to jeopardize the best interests of people for whom they have a professional responsibility.
(b) Social workers whose personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties interfere with their professional judgment and performance should immediately seek consultation and take appropriate remedial action by seeking professional help, making adjustments in workload, terminating practice, or taking any other steps necessary to protect clients and others (NASW, 2006).
According to this section of the Code, when a social worker becomes aware of impairment of any kind, including psychological distress related to job function or experience, it is that person’s responsibility to seek help. It is not ethically sound to allow personal distress to interfere with job performance, and doing so may put clients at risk.
Imagine for a moment that a woman comes to you for help. She does not mention any trauma. She talks about how jumpy she is all the time, her inability to concentrate or sleep, and intrusive thoughts that constantly distract her. You notice her pressured speech. Now imagine that you are worn out, tired, and emotionally drained. Without getting the full story, this client could easily be misdiagnosed. The presenting symptoms could have a number of axial diagnoses, but it may take some effort to get to the right story of trauma. What would happen if this client, who really is suffering from PTSD, is mistakenly labeled with a personality disorder because the therapist is unable to see the situation clearly, and only reacts to the behaviors? That client could be injured for life with such a label, and run the risk of never receiving appropriate care!
It is a difficult line to walk to determine when personal distress begins to interfere with job performance, and it is often friends and family who point out the problem. When Hurricane Katrina came through the south, many first responders struggled with compassion fatigue. When a friend of mine found herself unable to sleep because of the images from stories that she had heard from evacuees, it took a great deal of prompting to convince her to get some help. Eventually, she realized that her health, not to mention her concentration and attention span, was going down the tubes and went to talk to someone. By the time she got help, she had begun to feel jaded about her clients’ stories. Thankfully, she realized that getting help was not only the best choice for her, personally, but also the ethical thing to do as a professional.
Not only are social workers ethically bound to self-monitoring, but the Code of Ethics explicitly states that we should watch out for our colleagues:
2.09 Impairment of Colleagues
(a) Social workers who have direct knowledge of a social work colleague’s impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.
(b) Social workers who believe that a social work colleague’s impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations (NASW, 2006).
Not only does the Code direct us to assist colleagues experiencing distress, but provisions are made for colleagues who do not take adequate remedial measures. Clearly, this is considered quite a serious matter! Pushing my friend to go talk to someone was not only the right thing to do—it was mandated by the Code of Ethics. When my first supervisor—the one who told me to get out of the field—walked away from my tears and told me to “learn to deal,” he ignored these important mandates. The ethical response would have been to hear me out and determine whether my judgment was impaired and whether I needed further support.
It is important that supervisory-level social workers are able to provide this information to professionals in the field. Research suggests that education and support resources help to protect social workers from risk. Given this information, the Code of Ethics again provides guidance:
3.07 Administration
(c) Social workers who are administrators should take reasonable steps to ensure that adequate agency or organizational resources are available to provide appropriate staff supervision.
3.08 Continuing Education and Staff Development
Social work administrators and supervisors should take reasonable steps to provide or arrange for continuing education and staff development for all staff for whom they are responsible. Continuing education and staff development should address current knowledge and emerging developments related to social work practice and ethics (NASW, 2006).
Some years into my practice, I again faced a young client who had been sexually victimized. Filled with doubt, I wondered if I would be able to be effective in helping her. This time, though, I had a wonderful supervisor. Together, we talked about the course of treatment, along with my hesitations and fears, and she was able to support me through my moments of doubt. She also asked me, point-blank, if I felt as if I needed to go talk to someone about my personal fears. We were able to talk about it openly, and the support of a good supervisor became my best protection.
The field of knowledge related to this subject is rapidly expanding, yet, unfortunately, it remains rare to see in-service trainings about compassion fatigue. In the past thirty years, research has provided us with information about risks, protective factors, and strategies for protecting and healing from personal distress related to exposure to traumatic material and challenging work environments. This knowledge is relevant and critical to our professional practice, not only for the protection of best practices for our clients, but also for the protection of professionals and trainees in the field. If every agency were to offer a training on this subject, it is entirely possible that the numbers of suffering social workers would decrease. According to the Code of Ethics, continuing education and good supervision are a part of ethically responsible practice.
Implications for the Profession
According to the Bureau of Labor Statistics, there were approximately 840,000 self-reported social workers in the United States as of the last national census (NASW, 2005). It is very unlikely that any substantial number have had exposure to training concerning compassion fatigue. Despite the fact that we know education helps, there is little (if any) training provided about these issues. The standard setting body for training programs in our country does not have requirements for exposure to this material, despite the growing body of evidence that there is a significant job hazard (CSWE, 2001).
Aside from the mandates contained in the Code of Ethics, there are other compelling reasons to guard against compassion fatigue. A healthier workforce will lead to better client outcomes and lower staff turnover. Additionally, personal distress is never completely contained to the work environment.
Social workers are individuals with personal histories and lives, and they are not immune to the effects of trauma and strain. Personal lives can be disrupted, leading to marital or intimacy problems, hypervigilance in the home, overprotectiveness or violence directed to partners or children, personal health issues related to stress, or other trauma-related symptoms. Entire families can become victims of the work-related strain experienced by one social worker!
Personal coping strategies, education, supervision, and support must be in place for every professional in the helping professions. Training about compassion fatigue needs to be introduced into the curricula of educational institutions and continuing education programs, and support/assistance programs need to be put in place by agencies providing direct care to clients. Such measures are already endorsed by research (Lyter & Selman, 2006; Pryce et al., 2007; Saakvitne & Pearlman, 1996). Self-care, a rich personal life, and support in our private and professional lives may be the greatest measures of protection from compassion fatigue that we can give to ourselves, and luckily these are not difficult to put in place.
Expert Charles Figley uses the example of the oxygen masks on airplanes to sum up this issue. If you have ever been on an airplane, you know that the flight attendants instruct you to put on your own mask first in an emergency, then help others. There is an important lesson in this simple instruction—we are no good to others if we are injured ourselves. The Code of Ethics exists to protect our clients, our practitioners, and the integrity of our profession. Clearly, compassion fatigue is an issue that has an effect on all three of those layers. Ignoring the issue leaves us injured. Only by learning to recognize and effectively protect and support each other can we truly say that we are keeping to our high ethical standards.
For More Information
Charles Figley’s publications:
http://mailer.fsu.edu/~cfigley/pubs.html
A source for lots of great articles:
http://home.earthlink.net/~hopefull/TC_compassion_fatigue.htm
References
CSWE. (2001). Educational policy and accreditation standards. Alexandria, VA.
Figley, C. R. (2002). Treating compassion fatigue. New York: Brunner-Routledge.
Lyter, S. C., & Selman, D. (2006). Woundedness in social workers: Views of experienced supervisors. Paper presented at the CSWE Annual Program Meeting, Chicago, IL.
McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor: Theory, therapy and transformation. New York: Brunner/Mazel.
Meyers, T. W., & Cornille, T. A. (2002). The trauma of working with traumatized children. In C. R. Figley (Ed.), Treating compassion fatigue. New York: Brunner-Routledge.
NASW. (2005). Assuring the sufficiency of a frontline workforce. Washington D.C.: NASW Center for Workforce Studies.
NASW. (2006). Code of ethics of the National Association of Social Workers. http://www.naswdc.org/pubs/code/code.asp.
Pryce, J., Shackleford, K., & Pryce, D. (2007). Secondary traumatic stress and the child welfare professional. Chicago: Lyceum Books.
Saakvitne, K. W., & Pearlman, L. A. (1996). Transforming the pain: A workbook on vicarious traumatization. New York: Norton & Co.
Stamm, B. H. (2002). Measuring compassion satisfaction as well as fatigue. In C. R. Figley (Ed.), Treating compassion fatigue. New York: Brunner-Routledge.
Valent, P. (2002). Diagnosis and treatment of helper stresses, traumas, and illnesses. In C. R. Figley (Ed.), Treating compassion fatigue. New York: Brunner-Routledge.
Tracy Wharton, M.Ed., MFT, is a doctoral student at the University of Alabama School of Social Work. She formerly worked as the Family Based Service Coordinator for the Cape and Islands Region of Massachusetts. She has worked with clients in Rhode Island and Massachusetts, and most recently has been working as a research associate at the Center for Mental Health and Aging in Tuscaloosa, Alabama. She is working on her Ph.D. in social work with an emphasis on intervention research.
CVD 