When Compassion Hurts: Burnout, Vicarious Trauma and Secondary Trauma in Prenatal and Early Childhood Service Providers
The Best Start Resource Centre in Toronto has produced an extensive, detailed manual on burnout, vicarious trauma and secondary trauma in prenatal and early childhood providers, researched and written by Greg Lubimov. The manual is available online for downloaded here. The manual is designed to address the fact that the nature of work with clients coping with distress and pain, and the close connection between service provider and client, means that “the question is not whether stress will appear as a result of this exposure, but to what extent (Wicks, 2006)”
While there is widespread agreement that impact exists, there has been considerable debate around terminology, including terms such as burnout, vicarious trauma, secondary trauma, secondary traumatic stress, and compassion fatigue, each with a range of descriptions. The manual uses the following terms and descriptions to describe the impact of stress on workers.
- Burnout:
- “Burnout is usually the result of prolonged stress or frustration, resulting in exhaustion of physical strength, emotional strength and/or motivation (Maslech, 2003). Burnout tends to be associated with the workplace, and is often a predictable outcome when the work environment demands a great deal from workers. One of the characteristics of burnout is that it occurs over a fairly long period of time and is cumulative. It does not afflict a person after one bad day.”
- Vicarious Trauma (Compassion Fatigue/Empathy Fatigue):
- “These terms have been used interchangeably to describe the impact of a specific type of experience and outcome. Vicarious trauma is a permanent change in the service provider resulting from empathetic engagement with a client’s/patient’s traumatic background (Pearlman & Saakvitne, 1995). Although there are some parallels to burnout, including symptoms such as exhaustion, [etc.], vicarious trauma is much more pervasive, impacting all facets of life, including the body, mind, character and belief systems. The relationship of the person suffering from vicarious trauma to the world around them becomes altered. Like burnout, vicarious traua typically develops over a period of time.”
- Secondary Trauma (Indirect Trauma/Secondary Traumatic Stress Disorder):
- “Secondary or indirect trauma occurs when a service provider relates to someone who has undergone a traumatic event or a series of traumatic events to the extent that they begin to experience similar symptoms of post-traumatic stress disorder that the trauma victim is experiencing (Baird & Kracen, 2006). In secondary trauma, the traumatizing event experienced by a client/patient becomes a traumatizing event for the service provider (Perry, Conroy & Ravitz, 1991). The difference between secondary trauma and vicarious trauma is that secondary trauma can happen suddenly, in one session, while vicarious trauma is a response to an accumulation of exposure to the pain of others (Figley, 1995)”
- Countertransference (Traumatic Countertransference):
- “Countertransference occurs when a service provider relates to the client/patient in a manner that replicates an existing relationship (often child-parent). …We are all subject to this phenomena, because it is usually at work at the unconscious level. If left unattended, it can be harmful to the helping relationship, since the helping relationship needs to be based upon the client/patient in the context of who they are and what they need.”
The manual offers examples of situations that illustrate each of the conditions, and a list of symptoms to compare burnout, vicarious trauma and secondary trauma, along with a set of Reflective Questions for self-study.
Biology of Stress and Trauma
In the second chapter, the manual looks at the biology of stress and trauma, and explores why, given the same situation, one person is traumatized but another is not. The author notes that, “threat perception and response occurs at the unconscious level and is not subject to a cognitive or rational process. Personality, emotional content, experiential background, beliefs and internal resources play a large role in determining the perception of threat or danger. This explains why two people in the same situation can have very different reactions.” He stresses that an understanding of the biology of stress is helpful in alleviating the sense of guilt and/or shame which can accompany stress and trauma. The chapter again ends with a story example and a set of Reflective Questions.
Signs and Symptoms
In this chapter, the manual outlines a range of physical signs of stress, along with common behaviours and emotions signaling stress. “A red flag for full blown vicarious or secondary trauma is the impact on the individual’s world view”, including:
- Feelings of being helpless, hopeless and/or powerless
- Feelings of lack of safety, trust
- Alienation from others
- Shattered assumptions about basic beliefs about life or people
- Loss of faith (anger with God)
The manual stresses, “one of the keys to diagnosis is that the symptoms are NOT consistent with the individual in terms of their personality, behaviour and characteristics. Their behaviour is viewed as abnormal by friends, family and colleagues. People who know the person often say, ‘That is not how they used to be.’” The chapter ends with a set of Reflective Questions and a note on what is called “The Silencing Response”, which refers to “the helper’s inability to attend to the stories/experiences of clients by redirecting to material that is less distressing or uncomfortable (Baranowsky, 2002)”, signs of which include:
- Changing the subject
- Providing pat answers
- Being angry or sarcastic with clients
- Using humour to change or minimize the subject
- Blaming clients for their experiences
- Faking listening
- Not being able to pay attention
- Being afraid of what is going to be said
- Suggesting the person just “get over it”.
Risk Factors
The manual points out that high levels of stress have become the accepted norm in many workplaces, and run the risk of being ignored, but that identifying physical stress triggers in the workplace is essential to building resilience.
The manual lists and outlines a number of individual risk factors, including:
- Personality and Coping Style
- Personal History
- Current Life Circumstance
- Social Supports
- Spiritual Connection and Resources
- Work Style
The author poses a number of questions to consider in regard to the person’s role at work and their work setting and exposure to trauma. “Perhaps the most important factor is the amount of traumatic content staff members are exposed to, as well as the proportion of challenging cases. The greater the exposure and concentration of challenging cases, the higher the risk for burnout, vicarious or secondary trauma.” The manual lists a number of work setting factors that can raise or lower risk. Factors identified that can lower risk and increase resilience include:
- Clear and consistent policies and procedures
- Fair and consistent application of rules for all employees
- Adequate resources to meet expectations
- Leadership is able to make quick decisions
- Leadership is able to and willing to take corrective action when errors are made by leadership
- Errors are seen as an opportunity to learn
- Recognition is given and employees feel valued
- Workers feel safe, or if conditions are unsafe steps will be taken
- Communication is open and issues are dealt with
- Issues are raised when they occur
- There are no surprises
- Environment conditions present (Safety/Belonging/Consistency and Predictability/Opportunity/Acceptance and Love/Hope) “When one or more of these conditions is absent or has been compromised, it will be more difficult for a person or group to reach their full potential. These conditions should be present throughout an organization including interactions with clients/patients.”
- Peer support is built into the organizational structure and accessible
- Reflective practice is standard practice for the organization
Community risk factors are also explored, including culture and community resources. The manual asks, “Are there community realities impacting the population as a whole? Do they put pressure on the community and on helping services? High poverty rates, working with a high need community, victims of a tornado or earthquake, and so forth, are examples of community stresses.” The chapter again ends with a group of Reflective Questions.
Protective Factors
The manual points out that, like risk factors, there are protective factors inherent in the person and in the organization. One key protective strategy identified is reflective practice, which the manual explores in detail in a separate chapter.
Individual Protective Factors include:
- Self-awareness
- Able to ask for help and/or get support
- Balance between home and work
- Personal strategies in place for self-care
- Open to learning and growing
- Optimistic
- Able to set boundaries at work and home
- Expression of feelings
- Compassion satisfaction
Organizational Protective Factors include:
- Positive relationships within agency
- Early identification of workers dealing with stress
- Resources available to staff
- Client centred practice
- Issues are dealt with constructively and effectively
- Communication is open and clear
- Opportunities for staff to learn and grow
The chapter ends with 6 self-study Reflective Questions.
Resilience and Self-care
Resilience is the ability to bounce back from major stresses in life. The manual stresses that there are two major areas that foster resilience in the workplace: one relates to what individuals are responsible for and the other is what leadership or agencies/organizations are responsible for.
Individual strategies include:
- Nutrition/balanced diet
- Exercise
- Rest
- Social connections outside of work
- Spiritual/faith life
- Personal goals
- Hobbies and interests
- Set limits/avoid taking work home
- Aromatherapy
- Massage
- Connecting with positive peers/friends
- Volunteer work that is totally different
- Use of reflective practice
- Having fun
- Time management skills
- Delegation
- Asking for help
- Ensuring there is fit between your beliefs and work values/beliefs
Agency/Managerial Strategies include:
- Policies that recognize, prevent and address vicarious trauma
- Positive support for staff
- Effective and regular supervision
- Professional development on vicarious trauma
- Limit setting for staff who are unable to do so for themselves
- Building in humour and fun
- Promoting diverse and balanced caseloads
- Using reflective practice
- Demonstrating appreciation for staff
- Providing access to staff for support/help
- Training managers in recognition of vicarious trauma and in response techniques
This chapter includes a graphic representation framework, a self-care assessment tool template, an example of the value of supportive workplace structures, and Reflective Questions for self study.
Reflective Practice
This chapter gives an in-depth exploration of the technique of Reflective Practice, “the process of stepping back from daily, intense hands-on work to examine, review and explore different ways of understanding the experiences we have had, in order to stimulate new solutions or new approaches”, a technique first formally introduced by Donald Schon in his book The Reflective Practitioner (1983).
Critical skills for reflective practice (Atkins and Murphy, 2004) include:
- Self-awareness: “Reflect on your thoughts, feelings and actions in relation to your work and consider how a situation has affected you.”
- Self-knowledge: “Recognize who you are and how you were shaped by your experiences.”
- Critical Analysis: “Consider a situation, identify existing knowledge, challenge assumptions and explore alternatives.”
- Synthesis: “Integrate new knowledge, problem solve and predict the likely consequences of actions.”
- Evaluation: “What have you learned about yourself through this process? Does this knowledge help you better understand your experience? Has this knowledge helped you explain or solve problems?
The chapter also explores Reflective Supervision, a model of supervisions that “promotes learning, growth, engagement, problem identification and resolution.” The National Resource Center for Family Centered Practice (2009) identifies a number of skills and barriers in utilizing reflective practice which are outlined in the chapter.
The chapter includes a number of questions for use in Reflection on Action (past), Reflection in Action (present) and Reflection for Action (future), along with Action Questions, Thoughts/Values/Beliefs Questions, and Feeling Questions.
The chapter also contains a Practice Case Scenario, and a series of Reflection Exercises with templates and practice examples.
The manual concludes with examples of actions that individuals or agencies have done to prevent and provide support for workers, along with a list of resources.
Appendix 1: Self-Assessment Tools
The appendix contains a number of self-assessment tools, including:
- ProQOL (Professional Quality of Life Scale)
- Stress Test
- Self-care Assessment Worksheet
- Mayo Clinic Stress Assessment: Rate Your Stress (with automatic scoring)
- “Care for the Caregiver” Presentation
- A link to the Headington video resources related to vicarious trauma and secondary trauma.