Compassion Fatigue Solutions

A little update on what WHP has been up to in the last week:

Serious stuff:
-I have been making sugar cookies with kids and went to see the new disney movie Enchanted (actually a fun movie and excellent self care. Patrick Dempsey is a nice addition to the movie for us adults who enjoy his...acting)

Fun stuff:
-I had a very interesting and stimulating dinner conversation with Dr Pat Fisher who is a clinical psychologist and workplace wellness consultant based in NYC and Vancouver. Pat Fisher is the CEO of Fisher and Associates. Her company specialises in helping agencies address the health of their organization from a systemic approach. Over the past 10 years, she and her team have developed solid, empirically tested tools and a manualised approach to helping individuals, teams, managers and the organization as a whole face the challenges of CF, burnout and other major organizational transitions and stresses. I found her work to be of the highest quality and it has real depth and substance (unlike, to be honest, much of the workplace wellness material I have come across so far). This is material developed by helping professionals who are able to go deep and make a real impact. I look forward to future conversations with Pat.

-I have been making steady progress on the Compassion Fatigue Workbook, which is nearing completion. The most time consuming part is obtaining permissions to reprint certain testing scales and tools from publishers of other works. One such conversation has already been going on for one year. A typical email goes like this:

Publisher: "how many copies of this manual will you be printing on your first round?"
Me: I email an answer
two months pass....
Publisher: "will you be selling this on your website or in bookstores?"
Me: I email an answer (even though I told them all of this in the initial email)
two months pass...
Publisher: "do you prefer apple pie with ice cream or with cheese?"
two months pass...

So, at this rate, I may have to leave out a few tools or invent new ones myself!

I am also finishing a booklet on "how to run a workshop in your community" and the train the trainer manual. However, since the TtheT manual hinges on the WtheW workbook, I will focus on WtheW first and then complete the rest.

I hope you are well and taking some time to bake cookies with children or whatever is your equivalent self care activity (maybe buying cookies and eating them without a child in sight, that might also be very relaxing).

This week, I would like to offer you an article I recently wrote for my professional association's newsletter. It is currently being considered for publication.

Compassion fatigue (CF) is characterized by deep emotional and physical exhaustion and by a shift in a helping professional’s sense of hope and optimism about the future and the value of their work. It has been called “a disorder that affects those who do their work well” (Figley 1995) The level of CF a helper experiences can ebb and flow from one day to the next, and even very healthy helpers with optimal life/work balance can experience a higher than normal level of compassion fatigue when they are overloaded, are working with a lot of traumatic content, or find their case load suddenly heavy with clients who are all chronically in crisis.

The best strategy to mitigate the impact of Compassion Fatigue is to develop excellent self care strategies, as well as an early warning system that lets the helper know that they are moving into the caution zone of CF.

If would you like to assess your current level of Compassion Fatigue, visit Dr Beth Stamm’s website and take the compassion fatigue self-test: www.isu.edu/~bhstamm/tests.htm. This test not only looks at CF, it also assesses helpers’ level of compassion satisfaction which is “the pleasure you derive from being able to do your work well.” (Stamm, 1999)

For the past 7 years, I have been working as a compassion fatigue specialist, offering training and counseling to helpers through workshops and individual counseling work. Here are some of the top strategies that workshop participants have identified as being most protective:

1.Take Stock: Check-in with yourself on a regular basis. I have my clients draw a dinner plate on a piece of paper and list every demand/commitment/concern they currently carry with them inside the plate. Then, I ask them to identify the demands that may be changeable, even by one percent. Participants often comment that they rarely take the time to take stock, let alone try to identify areas where improvement is possible. This can become an important and useful tool in monitoring your level of work and home stress.

2. Find time for yourself every day: Whether it’s 5 minutes or one hour, time for yourself allows you to regroup and refuel. Aim to rebalance your workload if you can, by spreading out your most challenging clients, or having short breaks between sessions to take a walk, do some paperwork, talk with colleagues or visit a fun, non-work related website.

3. Have a transition from work to home: Aim to leave work behind and start fresh at home. This can mean changing out of your work clothes when you get home, walking twice around the block before walking into your house or some other mindful ritual that allows you to transition and leave the work-related worries and difficult stories back at work, where they belong.

4. Learn to say no (or yes) more often: Many helpers tell me that they realize they now say no to friends and family all the time as they feel too tired or depleted to give any more. Others say that they are caregivers in all aspects of their lives, and walk in the door from work only to get phone calls from family members in need, or a pager from work or from the numerous committees they are on. Explore ways to set better limits at work or with demanding family members or friends or, conversely, try to say “yes” to something each week that is time-limited. Learning to set limits is a key tool in optimal self care.

5. Assess your Trauma Inputs: Do you read about, see photos of, and are generally exposed to difficult stories and images at your work? Take a trauma input survey of a typical day in your life. Starting with the moment you get up in the morning, note how many traumatic images and stories you absorb through the media, newspaper and/or radio. Now look at your work. Not counting direct client work, how many difficult stories do you hear, whether it be in a case conference, around the water cooler, debriefing a colleague, or reading files? Now look at your return trip home. Do you listen to the news on the radio? Do you watch TV at night? What do you watch? If you have a spouse who is also in the helping field, do you talk shop and debrief each other? There is a lot of extra trauma input that we do not need to absorb or to hear about. We can create a “trauma filter” to protect ourselves from this extraneous material. This requires mindfulness and an awareness of what is coming at us.

And a few more strategies…

-Attend Workshops/Professional Training Regularly: Further professional development has been identified as one of the top protective factors against CF by researchers in the field. It makes sense: the more competent and confident we feel doing our work, the less stressful the work is, and the less depleted we become.

-Consider Joining a Supervision/Peer Support Group: This can be very informal and involve only two or three colleagues or friends. Debriefing and connecting with others is a significant way to protect ourselves from burnout and compassion fatigue.

-Consider working part time (at this type of job): It has been found that the optimal number of days of doing direct client work is three days per week. If you would like to investigate ways to make this financially possible, there are some excellent books on this topic, such as Your money or your life by Joe Dominguez and Marsha Sinetar’s Do what you love and the money will follow. You can also explore the possibility of job sharing direct client work and taking on other duties that feel complementary and interesting to you on the other two days.

-Learn more about Compassion Fatigue and Vicarious Trauma: Read books (see below), visit websites and attend educational sessions on CF and VT. Workshops can be validating experiences where you meet other helpers and learn new strategies.

-Start small: You may not notice it right away, but making one small change to your daily routine can have tremendous results in the long term. Imagine if you started walking up two flights a stairs per day instead of using the elevator, what might happen after three months?

Recommended books on Compassion Fatigue and Vicarious Trauma:

Figley, C.R. (Ed.). (1995) Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Saakvitne, K.W.; Pearlman, L. A., & the Staff of the Traumatic Stress Institute (1996): Transforming the pain: A workbook on vicarious traumatization. New York: W.W. Norton.

Stamm, B.H. (Ed.). (1999). Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators, 2nd Edition. Lutherville, MD: Sidran Press.

Self-Care books for Helpers:

Borysenko, J. (2003) Inner peace for busy people: 52 simple strategies for transforming your life.

Fanning, P. & Mitchener, H. (2001) The 50 best ways to simplify your life

O’Hanlon, B. (1999) Do one thing different: 10 simple ways to change your life.

Posen, D. (2003) Little book of stress relief.

Richardson, C. (1998) Take time for your life.

SARK, (2004) Making your creative dreams real: a plan for procrastinators, perfectionists, busy people, avoiders, and people who would rather sleep all day.

Weiss , L. (2004) Therapist’s Guide to Self-care.

Not as in art restoration, but as in refueling the self.

I had a very busy October, and now I am chilling out a bit, taking some time to listen to music, run, think, and do some yoga (while of course still driving kids to soccer, hockey, doing laundry and cooking meals, I am, after all, still the mother of two active youths but I've decided to let myself off the hook in terms of nonessential chores. My messy basement can remain messy for another month (or year) non? Do I really need to start Christmas shopping? I went to bed at 9pm last night which to me is incredibly decadent and restorative. I really think that there are lots of ways to carve out some restoration time even if you are buried in family demands. You have to start small. As a workshop participant said a few weeks ago: "My goal is to drink an entire cup of coffee from start to finish without being interrupted by family demands!"

I have also decided to book a day off a week from my private practice to finish several writing projects related to Compassion Fatigue Solutions. I will post some more on this in the coming weeks.

Music to accompany restoration: anything by Ben Harper or Jack Johnson will do the job. Amos Lee has a beautiful touching song called "long line of pain" that brought tears to my eyes when I first heard it: "I come from a long line of pain, my family suffered greatly for my gain. (you can buy it from itunes for 99 cents). One would think this would not be a song that takes me away from thoughts related to CF, but for some reason I love the music in that song and his smoky, sultry voice.

Web: Visiting a non-work related site such as "A photo a day from Planet Earth" planetearthdailyphoto.blogspot.com

What do you do to refuel?

Widely published author and internationally respected researcher, Dr. Greenberg is one of the primary developers of emotion focused therapy (EFT) for individuals and couples. This workshop will teach clinicians practical and specific interventions to help clients resolve feelings of anger and hurt in their relationships with others.

Using a combination of lecture, videotape demonstration and focused Q&A periods, Dr Greenberg will present three major resolution processes with an emphasis on the importance of accessing and working through emotions related to the injury: Holding the other accountable, Letting Go, and Forgiving. Dr Greenberg will also explore the differences in the process of resolving injuries in individual and couples therapy.

Dr. Greenberg’s workshops are designed to provide participants with techniques they can readily integrate into their everyday practices. His workshops are highly praised and are renowned for their atmosphere of authenticity and warmth.

Topics covered will include: Steps of an empirically supported set of interventions for facilitating the process of resolution; The therapeutic tasks of exploring the impact of the injury; Processing the pain; Changing representations of self and other in adaptive ways; Accessing compassion and empathy for self and injurer.

About the Presenter:
Leslie Greenberg, Ph.D. is Professor of Psychology at York University in Toronto, Ontario. He is the Director of the York University Psychotherapy Research Clinic and is the developer of an Emotion-Focused approach to therapy (EFT). He was awarded the 2004 Distinguished Research Career award of the International Society of Psychotherapy Research.

He has authored all the major texts on emotion-focused approaches to treatment. These include Emotion in Psychotherapy (1986), Emotionally Focused Therapy for Couples (1988), Facilitating Emotional Change (1993). Working with Emotions in Psychotherapy (1997), Emotion-focused therapy: Coaching clients to work through emotions (2002), and most recently, Emotion-focused Therapy of Depression. He was recently funded by the Campaign for Forgiveness Research to study the process of forgiveness in couples and individuals.

Dr. Greenberg is a founding member of the Society of the Exploration of Psychotherapy Integration (SEPI) and a past President of the Society for Psychotherapy Research (SPR). He has been on the editorial board of many psychotherapy journals, including currently the Journal of Psychotherapy Integration, Journal of Constructivist Psychology, the Journal of Marital and Family Therapy.

Dr. Greenberg’s workshops are renowned for their atmosphere of authenticity and warmth. His workshops have brought him critical acclaim throughout Canada and the United States, and in the United Kingdom, France, Germany, Austria, Italy, Spain, Portugal, Finland, Norway, Sweden, Argentina, Brazil, Chile, South Africa and Australia.

Feedback from reviewers of Dr Greenberg’s publications:

“There is no doubt that Les Greenberg is both a pioneer and the field's premier investigator in the important work of applying the basic research on emotions to the process of psychotherapy. The focus on primary emotions and their change is what distinguishes this book. It is a fabulous compendium of strategies for working with emotions and draws from both behavioral and experiential therapies.”

Marsha M. Linehan, PhD, University of Washington

"In a refreshing blend of clinical sensitivity and compelling research findings, the authors have done a masterful job of explaining why an emotion-focused intervention is central to therapeutic change, and describing how this may be implemented clinically. Their lucid, jargon-free exposition of conceptual and therapeutic issues proves an invaluable resource for practicing therapists of any orientation. This indeed is a landmark contribution to the field."

Marvin Goldfried, PhD, Professor of Psychology and Psychiatry, SUNY, Stony Brook

“... at the frontier of contemporary marital and family therapy”

Alan S. Gurman, Ph.D., Professor of Psychology, University of Wisconsin Medical School


Workshop Fees (lunch on your own):
$155 before December 1, 2007: $169 after December 1, 2007
Students: $120 if registered before December 1, 2007; $145 after December 1, 2007

To Register:
By phone: (613) 547-3247 (leave message for Françoise Mathieu)
By Fax: (613) 547-0655
By email: whp@cogeco.ca
By mail: 837 Princess St., Suite 300, Kingston, On., K7L 1G8
To Download registration form: www.compassionfatigue.ca

Method of payment - Please note: full registration fee is due prior to start of workshop.
Payment must be made by cheque only, payable to
Workshops for the Helping Professions.

**Cancellation Policy: An administrative fee of $30 will be charged for all cancellations 15 days or more prior to the workshop. After this cancellation deadline, no refunds will be available. If you cannot attend, you may send a substitute but must notify us ahead of time.

Workshop Outline:
Emotional injuries
• Emotion and self-organization
• Emotional change processes
Video Demonstrations
• Letting go & Forgiving
• Emotion-focused treatment of emotional injury
• Working with Injury as Unfinished business using empty chair dialogue
Resolving Emotional Injury
• Acknowledging the impact of the injury
• Working through painful emotions
• The emotional process
• Letting go of anger and hurt
• Accessing and restructuring emotional memories
Video Tape Demonstrations

Lunch: (on your own)

The Change process in working with injury in individuals
• Imagining the other
• Empathy
• The role of self-affirmation and self-forgiveness
• Change in view of the other
• Letting go and forgiveness
• Reconciliation
Video demonstration
The process of resolution of emotional injuries in couples
• Key steps
Video demonstrations
Comparing individual and couples work for resolving emotional injuries
• Common elements
• Differences
Discussion

This workshop is designed to help you:

1. Understand the phenomenon of emotional injury and forgiveness
2. Discriminate different emotions
3. Learn steps to promote forgiveness or letting go
4. Understand different emotional change processes

I just finished co-presenting a three day crisis intervention workshop (www.crisisinstitute.com) with my colleague Dr Mike Condra. This is a workshop we offer every October in Kingston and we meet dozens of crisis intervention workers from across the country who come to retool and hone their skills.

During this workshop, I am often asked questions related to working with clients who are chronically in crisis.

Most helpers say that they find clients in chronic crisis to be the most draining clients to work with: their seemingly endless demands, high needs, difficulty self-soothing and sometimes poor problem solving skills. The fact that we will work incredibly hard to set up a referral link for them and then the clients will sometimes sabotage the help they are being offered. The self-destructiveness, the splitting...

I have spent a lot of time pondering this challenge and seeking training on working with high need clients, and have the following suggestions for anyone wishing to continue helping such clients and retaining a respectful, helpful stance while not burning out.

1) Let's reframe success: I think that we need to re-evaluate what we consider to be progress or success in therapy with high needs clients. I call this "working with the toenail of the elephant". If, in the middle of a session, you find yourself feeling frustrated and stuck, re-assess your goals. Are you trying to fix the whole elephant at once? Clients in high emotional distress often see many issues as equally urgent and we can get swept away in the energy of this emotional disorganization. Focus the session on the smallest toe of the elephant and work from there.

2) Labeling - Rethinking the use of damaging diagnoses such as Borderline. Are we using the term borderline to refer to the high level of emotional disorganization a client is experiencing, or are we saying borderline to morse code "manipulative, frequent crisis, difficult, treatment resistant" to colleagues? What does it mean for a client to receive that diagnosis when they seek help in the future? Why are men almost never given the borderline diagnosis?

I recall when I was studying at Columbia University my instructor, Dr Farber, told us that borderline personality disorder (bpd) should really be renamed ptsd as the stats on the number of clients with bpd who have experienced childhood abuse and neglect was in the 90%. If this is true, and bpd clients are nearly all trauma survivors, doesn't it then make sense that they use poor self-soothing techniques at times?

3) Do some reading/attend workshops. There are some good books on this topic, as well as some excellent workshops working with clients in chronic crisis.

John Briere, trauma expert and gifted researcher and presenter offers a deconstruction and reconceptualisation of the concept of BPD. He will be presenting in Toronto in November (see sidebar for information) and I highly recommend attending his training for tools and new ideas on this topic and on trauma therapy in general.

Any presentation by the school of Narrative Therapy (Michael White and others) offers a truly refreshing look at "treatment resistance".

If you have other suggestions, feel free to post a comment at the end of this blog entry.

Books:
James Masterson has written a very powerful book called "THE SEARCH FOR THE REAL SELF: Unmasking the Personality Disorders of our Age" (1988). Interestingly, in a personal communication with John Briere, where I asked him how he felt about Masterson's book, he replied that he felt Masterson wasn't compassionate enough towards clients with personality disorders and he found him too labelling. I have to agree with Briere, but Masterson still provides a very helpful angle that focuses on empathy and compassion and uses attachment theory to better understand why some clients are so emotionally disorganised. So, caveats aside, the Search for the Real Self still remains #1 on my book shelf.

Here is a description of the book, excerpted from Masterson's own website:

"Some are outwardly charming, confident, and apparently successful; others are obviously struggling with feelings of inadequacy; while still others lead lonely, isolated lives. All of these individuals suffer from today's characteristic personality disorders - borderline, narcissistic, or schizoid - caught in a knot of self-destructive behavior that eventually sabotages their lives.
Many compensate for their inability to know themselves or establish meaningful relationships with others by forming superficial friendships and pursuing empty life-styles focused on competition for status rather than personal satisfaction, or resorting to alcohol, drugs, and impersonal sexual encounters. Their inner torment has long confounded themselves as well as their colleagues, family, lovers, friends, and even the professionals to whom they turn for help.

Now, in this long-awaited book, renowned psychotherapist James F. Masterson provides the keys to understanding these previously untreatable disorders which have become the classic psychological disturbances of our age, afflicting thousands of modern Americans.

The volume begins by explaining how the healthy real self develops and how it functions to enable the individual to adapt successfully to life's challenges and opportunities, express deepest needs and desires, and find true fulfillment in love and work.

Masterson then describes how the impairment of the real self early in life leads to a personality disorder: when the child's self-expression is not adequately supported, he or she may experience powerful feelings of rejection and fear of the "abandonment depression," precipitating the creation of a protective yet ultimately harmful "false self" whose function is to suppress these painful feelings at the expense of true self-fulfillment, intimacy, or even a clear perception of reality.

Drawing on vivid case histories from his practice, the author examines how this false self behaves at work and in relationships. The narcissist is often intensely competitive and domineering, demanding constant adulation from others to support his inflated false self. The borderline can be clinging and manipulative and frequently pursues an unfulfilling "instant intimacy" with a distant or unavailable partner. The schizoid remains cold and aloof, often immersing himself in work or in a wholly imaginative alternative world rather than engaging in any relationship which would threaten to engulf his fragile sense of himself.

Offering practical guidance and real hope for therapeutic success, Masterson delineates the most effective treatment approaches to help borderline, narcissistic, or schizoid personalities overcome their trauma, reconstruct their psyches, and rejoin the mainstream of life. He exposes the common pitfalls and explains how to develop the necessary and appropriate therapeutic alliance to treat each personality disorder.

While therapy offers hope of overcoming the impairment of the real self, it is not the only area in which the real self can emerge. Individual creativity also offers a valuable avenue for self-expression. In analyzing the behavior of artists with personality disorders, Masterson offers surprising insight into the lives and works of Jean-Paul Sartre, Edvard Munch, and Thomas Wolfe, whom the author respectively refers to as the philosopher, painter, and novelist of the abandonment depression. However, it is not only the creativity of artistic genius that expresses the real self. Masterson argues that the real self is reflected in everyday innovation and creative problem solving which enable us to experiment in work and in love, to find and achieve the sense of a personal meaning essential for a fulfilling life."
(From www.mastersoninstitute.org)

Another excellent resource is Scott Miller. Miller is a clinical psychologist, workshop presenter extraordinaire, co-director of the Institute for Therapeutic Change (www.talkingcure.com) and co-author of "The Heroic Client" a book that looks at empirically valid therapeutic approaches and "what works" in therapy. If you have a few minutes to spare, go visit his website and see for yourself.

I would also suggest reading or re-reading Judith Herman's pioneering book: Trauma and Recovery and Pearlman and Saakvitne's hefty tome Trauma and the Therapist: Countertransference and Vicarious trauma in psychotherapy with incest survivors.

If you live near Ottawa and are ever looking for a great locale for a meeting or retreat, I would highly recommend Strathmere (www.strathmere.com). Strathmere is a country retreat, with barns that were converted into beautiful meeting rooms and it has excellent food and outstanding service. I have been looking for the ideal setting for our CF retreats and I think this is it. The also offer overnight accommodation which would make the possibility of an overnight retreat very appealing. Something to think about down the road.

This week was the Fall offering of WHP's Walking the Walk workshop, and I had the pleasure of meeting a highly varied group of helpers. For those of you who participated in this workshop, I have enclosed below the self care strategies that you produced during the "bowl game." My only regret is not taking a photo of peewee the pumpkin, but she's standing guard at Strathmere, full of the rewards of the work that we gave her during our circle.

The best part of these workshops is the privilege of having a group of helpers spend a day together, sharing common experiences and offering validation and support to one another. We spend so much time working in isolation during our day to day work. In fact, in their ARP training program for compassion fatigue therapy, Baranowsky and Gentry list the following key elements as being key to keeping compassion fatigue at bay:

1) Resiliency Skills: “rebounding from life and work difficulties” - “strengthening areas of our lives to cushion the fall when the going gets rough”

2) Skills acquisition: "What symptoms are being caused by areas of work where I do not have adequate training?"

3) Self Care: “What symptoms are caused by the professional overextending themselves in their work or personal lives?” Strategies involve developing or improving soothing skills, boundaries.

4) Internal Conflicts: Unresolved personal issues, knowing what we need to do yet being unable to do it (eg physical exercise, proper eating etc)

5) Connection with others: “Developing a personal “therapeutic community” is mandatory in preventing CF." (Excerpted from Baranowsky and Gentry, ARP training manual (1999))

Here they are, in no particular order. Can you pick three you can commit to in the next month?

-Pedicure
-Walk in nature
-Play hooky for a day
-"Chill out dude!"
-Time with kids/pets
-Cooking/baking
-Short road trips
-Soak in bathtub with candle light
-Connecting with friends (call them, go to movies)
-Play dress-up with child
-Try something new (new place, new food...)
-Book a massage
-Gardening
-Listen to music/dance
-Play a musical instrument
-Enjoy loud music to unwind without worrying about others
-Share food with friends/co-workers
-Laugh/have fun
-Lighten up/get silly
-Take a nap
-Have a cup of tea
-Creative endeavour: knitting, painting
-Dancing (ballroom, belly)
-Take flying lessons (or not!)
-Learn something new (hobby)
-Connect with friends over lunch
-Take time off
-Exercise, try a new sport
-Enjoy a glass of wine
-Reflexology/pedicure
-Go to the beach
-Have a party
-Read a fun book
-Start recreational swimming at the Y
-Humour in the workplace
-Develop your spirituality
-Walk/cardio
-Nature-related activities
-Take birthday off
-Go to a spa
-Book a weekend getaway
-Get your hair done
-Spend time with nature
-Photograph new things
-Go to movies, museums, art gallery
-Try something new