Accelerated Recovery Program (ARP) For Compassion Fatigue
“The professional work centered on the relief of the emotional suffering of clients automatically includes absorbing information that is about suffering. Often it includes absorbing that suffering as well” (Figley, 1995, p. 2).
The only resource we had to help us cope with this emotional, physical and spiritual distress was ourselves” (Bloom, 1997, p.112) .
In Dr. Figley’s crucial book Compassion Fatigue, he came up with an issue that has bothered many clinicians, emergency response workers, and other care-givers who work with disturbed multitude of folks in caregiving industry. This work offered the language for the feelings of these challenged service providers. It then became exceptionally clear that the next step was providing ideas for addressing our own needs when we become victimized by our work.
Compassion fatigue (Figley, 1995) is the convergence primary traumatic stress, secondary traumatic stress (Stamm, 1995) and cumulative stress/burnout in the lives of supporting professionals and other care providers. When assisting others precipitates a bargain in our own well-being we are enduring Compassion fatigue.
The manifestations often mirror, to a lesser degree, those of our clients.
Vicarious traumatization (McCann & Pearlman, 1990) is an applicable term that also describes this tendency of the transmission of traumatic stress by observation and/or being a witness to the experiences of painful events.
Secondary traumatic stress happens when one is subjected to intense events directly experienced by another and is overpowered by this secondary exposure to trauma (Figley & Kleber, 1995).
More than a few theories have been offered but none have been able to effectively illustrate the system which accounts for the transmission of traumatic stress from one individual to another. Figley (1995) hypothesizes that the caregiver’s empathy level with the traumatized person has a vital role in this transmission.
Burnout, or cumulative stress, is the state of physical, emotional, and mental exhaustion caused by a depletion of ability to cope with one’s environment resultant from our responses to the on-going demand characteristics (stress) of our daily lives (Maslach, 1982).
High levels of cumulative stress in the lives of caregivers negatively affects their resiliency therefore making them more susceptible to compassion fatigue.
The Silencing Response (Baranowsky, 1997; Danielli, 1984) is an inability to attend to the stories/experiences of our clients and instead to redirect to material that is less distressing for the professional.
This occurs when client’ experiences/stories are overwhelming, beyond our scope of comprehension and desire to know, or simply spiraling past our sense of competency. The point at which we may notice our ability to listen becoming compromised is the point at which the Silencing Response has weakened our clinical efficacy.
Figley (1996) defines Compassion Fatigue as:
A state of tension and preoccupation with the individual or cumulative trauma of clients as manifested in one or more ways:
- re-experiencing the traumatic events,
- avoidance/numbing of reminders of the traumatic event,
- persistent arousal
- Combined with the added effects of cumulative stress (burnout) (p. 11).
Compassion Fatigue has many symptoms and often parallel to the symptoms of the traumatized clients with whom caregivers are working. While compassion fatigue has been most often written about in the rubric of psychotherapy as emotional contagion passed from client to clinician, there is growing evidence to support the trans-generational and societal transmission of this condition (Danieli, 1985; Baranowsky, 1997; Bloom, 1997).
Some of the symptoms of compassion fatigue include:
increased negative arousal,
intrusive thoughts/images of clients’ situations/traumas (or clinicians’ own historical traumas),
difficulty separating work life from personal life
lowered frustration tolerance/outbursts of anger or rage
dread of working with certain clients,
marked or increasing transference/countertransference issues with certain clients,
perceptive/assumptive world disturbances (i.e., seeing the world of terms of victims and perpetrators, decrease in subjective sense of safety)
increase in ineffective and/or self-destructive self-soothing behaviors
feelings of therapeutic impotence or de-skilled with certain clients,
diminished sense of purpose/enjoyment with career,
diminished ego-functioning (time, identity, volition)
decreased functioning in non-professional situations.
loss of hope
Any of these symptoms could be signaling the presence of Compassion Fatigue.
The eruption of violence, personal degradation, and physical/ psychological violations disrupt our notions of the sanctity of our assumptive world (Janoff-Bullman, 1992; Rando, 1996). Such traumas can result in symptoms of Posttraumatic Stress Disorder.
Posttraumatic stress effects individuals differently but is identified by three categories of symptoms: (1) intrusive thoughts, images and sensations; (2) avoidance of people, places, things and experiences which elicit memories of the traumatic experience, and (3) negative arousal in the forms hypervigiliance, sleep disturbances, irritability and anxiety.
These symptoms combine to form a state of physical, emotional, cognitive and spiritual volatility in traumatized individuals, families and groups (van der Kolk, 1996; Janet, 1889).
Persons who work closely with these groups and individuals are vulnerable to the contagion of this volatility. Some caregivers appear to be more resilient than others to the transmission of traumatic stress, however, any caregiver who continually works with traumatized individuals is at-risk for compassion fatigue.
Who is at-risk for Compassion Fatigue?
Compassion fatigue may occur in a wide range of persons involved in providing aid to others (Jay, 1995). We have found that it is most prevalent among professionals and personal family members, friends, and associates of trauma survivors (Baranowsky, Gentry & Dunning, 1997; Beaton & Murphy, 1995).
Psychologists, social workers, lawyers, disaster relief workers, nurses, psychiatrists, medical doctors, emergency service professionals, police, crisis phone-line attendants and shelter workers among others, are all susceptible to Compassion Fatigue.
When the therapist has encountered trauma through first-hand exposure this further heightens vulnerability to Compassion Fatigue (Baranowsky, Gentry & Dunning, 1997; Pearlman & McCann, 1995). Yet, in the emerging field of traumatology many of the therapists have such experience.
Just as it is not uncommon to find ex-substance abusers counseling those currently trying to break away from addictions, likewise, it is not uncommon to find those who are personally knowledgeable about trauma trying to aid others who have faced terrible events.
We urge these clinicians and caregivers to develop and maintain good self-care disciplines (see Pathways To Healing) and also complete a periodic self-assessment of compassion fatigue symptoms using the Compassion Fatigue Scale-Revised (1997, Figley, Baranowsky & Gentry).
The Good News : Compassion Fatigue treatment approach based on Figley’s work
The Green Cross Project, under the guidance of Charles Figley, Ph. D. , at Florida State University, has produced a short treatment (5 session) protocol for working people who are enduring the effects of Compassion Fatigue.
We believe from our initial trials with the Accelerated Recovery Program (ARP) that Compassion Fatigue is reactive to involvement and may even be the motivation that brings the improvement of clinical skills and personal life richness in the same way that a catastrophe may precipitate difference and growth in the lives of our clients.
Our perspective has been to improve, refine a program that would not only solve the problems of compassion fatigue for the care-giver but to favorably reinforce their future in their chosen role and improve their personal lives as well. Helping the care-giver to move toward turning into their ideal personal and professional selves so that they may live and work with ethics has always been our mission. We believe that our program supports caregivers toward this objective.
This system was engineered to support the professional to put into action strategies to regain functioning in their personal and professional lives that have been jeopardized due to Compassion Fatigue.
The Accelerated Recovery Program makes a determination to help clinicians and care-givers address and solve both the symptoms and the cause of compassion fatigue while, at once, helping them improve, refine a cutting-edge individual self-care style which boosts future resiliency to compassion fatigue.
Caregivers may learn a requirement to keep going with their work beyond the scope of the Accelerated Recovery Program, however, we have discovered that they will be much better fitted and geared up to deal with the difficult sequelae of primary and secondary traumatic stress soon after the finalization of this program.
The Road Back Home
We have used the metaphor of “The Road Back Home” to describe our program because Compassion Fatigue seems to rob the professional of their sense of well-being, comfort, purpose, identity and empowerment; all the qualities that one associates with being “at home”. The experiences of being “at home” in our bodies, our work, our thoughts and our spirit seem to diminish as the symptoms of Compassion Fatigue increase. The program we have created is designed with the hope of assisting helping professionals, to move rapidly toward comfort and empowerment in their professional and personal lives. Our program will challenge and assist the helping professional in finding their own personal “road back home”.
Cure helps the helping professional in starting a new relationship with the sense of hope and empowerment with which they joined their chosen field. With this is achieved, we motivating them to learn, appreciate and develop personal strategies for dealing with the difficult experiences which reduce hope and empowerment.
Secondly, the helping professional will be questioned to explore their “Silencing Response” both with their clients and themselves and to improve and refine techniques to navigate though this difficult crisis.
The Accelerated Recovery Program for Compassion Fatigue
The five-session treatment protocol is standardized and directed toward the completion of the following major objectives;
Identify, understand and develop hierarchy of the events, situations, people and internal experiences which trigger symptoms of compassion fatigue in their lives. This will include the creation and discussion of the Professional Life-Line in which the professional will explore the trajectory of their career assessing the experiences which have contributed to Compassion Fatigue.
Review present personal methodologies of addressing these difficulties and begin developing and maintenance of a self-care discipline in the following four areas:
a. Skills Acquisition
c. Connection with Others
d. Internal Conflicts
The Accelerated Recovery Program uses this self-help model which the caregiver develops throughout their enrollment in the program. This self-care plan is entitled Pathways To Healing and may be found in the attachments to this paper.
Identify resources (external and internal) available to the professional which can be utilized to develop and maintain resiliency to compassion fatigue.
Learn and master state-of-the-art negative arousal reduction techniques.
Learn and master state-of-the-art grounding and containment skills.
Contracting for self-care, boundary-setting and skills acquisition.
Explore, reframe and reprocess impediments to potency utilizing Eye Movement De-sensitization and Reprocessing (EMDR).
Learn and master video-dialogue, a technique for internal conflict resolution and self-supervision.
Development of self-administered after-care plan (Pathways to Healing).
Session One: Assessment/Evaluation
A thorough assessment and evaluation is be completed with each care-giver who enrolls in the accelerated recovery program. A full exploration of the symptoms that the professional is experiencing will be discussed along with the events of his/her professional and personal life which have contributed to these symptoms.
We recognize that discussion of these events will be difficult and, often times, intimidating for the professional. With this in mind we have placed the onus of responsibility for disclosure upon the professional and while we will offer the strictest confidentiality we respect any wishes that s/he has to not disclose any information.
The following assessment tolls will be utilized in the Accelerated Recovery Program:
Compassion Fatigue Scale-Revised (Figley 1995; Baranowsky & Gentry, 1997)
Silencing Response Scale (Baranowsky, 1997)
Solution-Focused Trauma Recovery Scale (TRS) (Gentry, 1997)
Between-session: Personal Mission Statement
Session Two: Personal & Professional Time-Line
Welcome and discussion of treatment goals/mission statement.
Categorizing these goals into the following three areas:
a. Skills Acquisition
c. Internal Conflicts
d. Connection with Others
Overview of program and informed consent
Progressive relaxation script (Gentry & Schmidt, 1996)
Safe-Place Visualization (Gentry & Schmidt, 1996)
Telling the story
Re-connection with hope and empowerment at beginning of career
a. Inventory of experiences which have combined to create Compassion Fatigue b. Review of past (week, month, year) to assess the specific situations which are triggers and catalysts of Compassion Fatigue.
Between-session Project: Professional Time-Line (graphic narrative)
Session Three: Re-framing & Reprocessing
Review of Session Two
Discussion of Time-Line:
a. Professional Goals
b. Personal Goals
c. Primary & Secondary Trauma
d. Silencing Response
e. Trajectory of Hope
Review of vicarious traumatic situations (triggers & catalysts)
Review of self-regulation strategies for managing these situations (i.e., Thought Field Therapy)
EMDR (Shapiro, 1996) with Target Experience/Memory which encapsulates most salient impediment.
Development/implementation of self-care/NAR plan
Letter from The Great Supervisor
c. The things the professional most needs/wants to hear from a supervisor.
Session Four: SUPERVISING THE SELF: Externalization
Review of previous sessions.
Identifying areas where professional needs skills acquisition and contracting to acquire these skills.
Identifying areas where professional needs to introduce, practice and master self-soothing/NAR/boundaries/self-care.
Video Dialogue (Holmes & Tinnin, 1995) with internal polarities/conflicts.
a. Read Great Supervisor Letter on videotape
b. Video-dialogue taking the negate stance
c. Continue dialogue towards negotiation
Between-session Project: Complete Pathways To Healing
Session Five: Closure and Aftercare
Review of program/goals
Inventory of incomplete goals
Addressing four Pathways to Recovery
a. Skills Acquisition
c. Connection with Others
d. Internal Conflict Resolution
Board of Directors (Baranowsky, 1997) guided imagery exercise
NOTE – It is highly possible that these techniques may exacerbate and/or expose a primary trauma in the history of the helping professional. We will be utilizing a specialized protocol of each brief procedure which, if primary traumatic stress becomes activated, will be designed to contain these experiences and sequelae while refocusing upon Compassion Fatigue Symptom Reduction. The helping professional who experiences the emergence of primary traumatic material will be offered confidential individual treatment for these symptoms if s/he chooses.
Options for Further Work:
All helping professional will be offered the option of continuing individual treatment. This treatment could include:
a. Primary traumatic event/traumatic stress
b. Secondary traumatic stress
c. Grief work
d. Problematic clients/therapeutic impasse
e. Personal blockages/inhibitions
g. Stress reduction/management
All individual treatment will attempt to employ brief treatment protocols (where applicable) such as EMDR (Shapiro, 1995), TFT (Callaghan, 1994), TIR (Gerbode, 1989), TLTT(Tinnin, 1989, 1994), V/KD (Bandler & Grinder, 1979)
Groups may be offered
Training/consultation in treating traumatic stress may be offered
Assistance in establishing study groups/peer supervision
Opportunity for membership in Green Cross Project
Membership in Traumatic Stress E-Mail Forum
Apply for Registered Traumatologist for assistance in disaster relief and other emergencies Discussion
The Accelerated recovery Program was developed at Florida State University’s Psychosocial Stress Laboratory. It was initially developed as a three (3) session model and sessions One and Five were added as the authors practiced the protocol with each other rotating as client, practitioner and observer. Session One was added when the authors discovered that primary traumatic stress was becoming and important and potentially confounding factor in the treatment protocol. Unresolved primary traumatic stress in the life of the clinician, we soon discovered, significantly negatively impacted the clinician’s resiliency to compassion fatigue. The most difficult challenge that the authors faced in the development of this protocol was to: (a) develop a program which assisted the impaired clinician to address and resolve his/her symptoms of compassion fatigue, while, at once, (b) respectfully addressing and challenging the clinician to resolve any primary traumatic experiences which may be contributing to the symptoms identified in the assessment process.
We resolved this dilemma by offering a program which addresses and assists with the resolution of the etiology of compassion fatigue in the professional life of the clinician: primary traumatic stress, secondary traumatic stress and cumulative stress. However, if the care-giver identifies primary traumatic experiences in his/her developmental trajectory and/or adult life, then we offer and urge this care-giver to continue treatment with the ARP therapist following their completion of the Accelerated Recovery Program to resolve their traumata. The fifth session was added to reinforce this position as well as offering a comprehensive closure and debriefing protocol. The fifth session also serves as a transition from clinician-assisted recovery to self-managed recovery and self-care via The Pathways To Healing.
The Accelerated Recovery Program for Compassion Fatigue was alpha tested (4/97 – 10/97) with ten (10) caregivers who were Marriage & Family doctoral students, nurses, MSW students, trauma therapists (South Africa & Bosnia) and a death-penalty mitigation specialist. All ten (10) caregivers reported improvement in functioning and a lessening of compassion fatigue symptoms. One caregiver experienced an acute and marked decrease in functioning as a primary traumatic event for which she had been previously amnestic became figural in her treatment, however, she was able to regain functioning and reported that the ARP was helpful in her healing process.
Keep Balance in Your Life
- Practice excellent self-care
- Nurture yourself by putting activities in your schedule that are sources of pleasure, joy and diversion
- Allow yourself to take mini-escapes- these relieve the intensity of your work
- Transform the negative impact of your work (find meaning, challenge negativity, find gratitude)
- Get medical treatment if needed to relieve symptoms that interfere with daily functioning- don’t use alcohol or drugs to self-medicate
- Get professional help when needed to get back on track- we all need coaches and consultants at times
- List one mini-escape or diversion that worked well to restore and renew you
- List one thing that brings you joy
- Name 3 things you feel grateful for today
- Think of something that has brought you a sense of joy (Make your top ten list)
- Who do you love that you can reach out to today? (Call them!)
- What made you laugh today? (Share it!)
Find Your Passion
- We all have hidden sources of energy and healing power.
- When you identify the things that fuel you, the things that you have true passion for, your fatigue will disappear.
- Balancing your life involves putting the things that we value and have passion for in our schedule.
Balance For Your Soul
- Have quiet alone time in a calm, beautiful place- a safe retreat where you feel renewed
- Have an awareness of what restores and replenishes you.
- Find ways to acknowledge loss and grief
- Stay clear with commitment to career goals or your personal mission
- Know how to focus on what you can control
- Look at situations as entertaining challenges and opportunities, not problems or stresses
The Accelerated Recovery Program for Compassion Fatigue combines several trauma brief treatment protocols (Time-Limited Trauma Therapy, Thought Field Therapy, Eye-Movement Desensitization, Video-Dialogue, Visual/Kinesthetic Dissociation, Hypnotherapy) with a comprehensive assessment (Compassion Fatigue Self Test – Revised, Solution-Focused Trauma Recovery Scale, The Silencing Response Scale, Structured Clinical Interview) and self-administered self-care plan (Pathways To Healing). This constellation of treatment/training strategies, distilled into five (5) sessions, seems to have combined to provide an effective means for caregivers who suffer with compassion fatigue to address and resolve many of their symptoms. While there is yet no empirical data on the efficacy, utility and/or safety of this approach, many of the protocols from which the program borrows have shown promise in each of these areas. Therefore, the authors of this program offer this protocol to clinicians who work with caregivers who suffer from compassion fatigue as the first comprehensive treatment program of its kind. We hope that clinicians will join us in beginning to utilize this protocol in treating impaired professionals and assist us in continuing to develop and refine its utility.
In the coming year, we plan to begin systematic outcome research on the efficacy and utility of the Accelerated Recovery Program for Compassion Fatigue.
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