Psychosocial aspects of stress management/compassion fatigue in

Outline: Psychosocial aspects of stress management/compassion fatigue
in the health care workplace. Elizabeth A. Pector, M.D.
Four-step model to manage stress
a. Claim it: all organisms have stress. Selye: stress response, stressors
b. Name it
i. ABC’s of personal needs
ii. TWERPS: Tasks-Time,Worries, Environment-Expectations-Events,
Roles-Responsibilities, People, Situations (the rest combined)
c. Reframe it (III.)
d. Tame it (IV.)
Specifics of Job Stress
a. Job stress model
b. Definitions & signs: Burnout and compassion fatigue
i. Burnout
1. Withdrawal, emotional exhaustion, low effectiveness
2. 6 elements: Overload, Lack of control, Little reward,
Unfairness, Value conflict, Lost sense of community
3. Gradual loss of idealism, energy, purpose
4. Related to unsupportive work environment
ii. Compassion fatigue= secondary traumatic stress, “cost of caring”
1. Exposure to client’s trauma, preoccupation with it
2. Less able to show empathy
3. Symptoms like post-traumatic stress disorder (see chart p. 2)
4. Gradual or rapid, depending on amount & type of trauma
5. Related to client’s traumatic experiences
c. General workplace and worker factors that contribute to job stress
d. Occupation-specific stressors in health care workplace & workers
Reframe it: Looking at stress in a new way
a. Worker factors that decrease risk
1. Hardiness: commitment, control, challenge
2. Coping styles & strategies: adaptive, maladaptive
b. Hardiness, attitude, adjusting expectations, humor
Tame it: Coping with stress
a. Prepare for the expected & the unexpected
b. Self-care:“Balance PIES”
i. Balance Work/Life
ii. Personal
iii. Intellectual
iv. Emotional
v. Spiritual
c. Dare to Dream, Decide & Act: stages of change.
d. Share burdens that are overwhelming
i. Cognitive behavioral therapy face-to-face
ii. E-therapy for anxiety & stress
iii. Face-to-face support groups in & outside work
iv. Online support groups: pros & cons
v. Compassion fatigue: trauma-focused CBT, relaxation, EMDR.
e. Be aware: Journaling, mindfulness, ongoing review of coping skills.
Alternative medicine strategies for self-care: evidence for effectiveness.
a. Includes: Music, yoga, Meditation/relaxation strategies, biofeedback.
Communication strategies: interpersonal and corporate
a. Characteristics of effective teams
b. Discussions after crisis; mutual respect and forgiveness.
Books, websites, and scholarly articles on stress & burnout:
1. Figley, Charles R, Ed. Compassion Fatigue: Coping with secondary traumatic stress
disorder in those who treat the traumatized. New York: Brunner/Mazel, 1995.
2. Figley, Charles R, Ed. Treating Compassion Fatigue. New York: Brunner/Mazel, 2002.
3. Kabat-Zinn, Jon. Wherever You Go There You Are: Mindfulness meditation in everyday
life. New York: Hyperion, 1994.
4. Leiter, Michael P. and Maslach, Christina. Banishing burnout: Six strategies for
improving your relationship with work. San Francisco, CA: Jossey-Bass, 2005.
5. Maddi, Salvatore R. and Deborah M. Kohshaba. Resilience at Work: How To Succeed
No Matter What Life Throws At You. New York: Amacom Books, 2005.
6. Maslach, Christina and Leiter, Michael P. How organizations cause personal stress and
what to do about it. San Francisco, CA: Jossey-Bass, 1997.
Alternative medicine: Mind-body practices
Compassion fatigue
Counseling, psychology (general)
Online counseling (an older view by an e-therapy client.), suggestions for clients re: therapy online.
Peer support (including online)
Relaxation exercises (free, choice of techniques, no music) From Beth Israel. Guided Imagery. Choose type
of imagery, male, female. (music, imagery, mind-body (progressive muscle)
relaxation, breathing) Free 15-min. guided imagery audio Healing Rhythms: biofeedback hardware & sensors, $299.00. Andrew Weil
Stress at work
Stress at Work. NIOSH Publ. 99-101.
Coping with disaster or traumatic event:
Stress in organizational settings.
NIOSH/Health care worker guidelines
NIOSH safety & health for health care workers:
JCAHO on workplace violence, recognizing & managing angry client
Journal articles:
Aasa U, Brulin C, Angquist KA, Barnekow-Bergkvist M. Work-related psychosocial factors, worry about work
conditions and health complaints among female and male ambulance personnel. Scand J Caring Sci. 2005
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3. Barak A, et al. A Comprehensive Review and a Meta-Analysis of the Effectiveness of Internet-Based
Psychotherapeutic Interventions. J Technol and Hum Serv, in press, 2007.
4. Beckering R, Brunner R. The lab shortage crisis: a practical approach. MLO-Med Lab Obs 2003 Jun;35(6):48-50.
5. Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of
Systematic Reviews 2005, issue 2.
6. Boscarino JA, Figley CR, Adams RE. Compassion fatigue following the September 11 terrorist attacks: a study of
secondary trauma among New York City social workers. Int J Emerg Ment Health. 2004 Spring;6(2):57-66.
7. Boudreaux E, Mandry C. The effects of stressors on emergency medical technicians (Part II): A critical review of
the literature, and a call for further research. Prehosp Disaster Med. 1996 Oct-Dec;11(4):302-7; discussion 307-8.
8. Boudreaux E, Mandy C. Sources of stress among emergency medical technicians (Part I): What does the research
say? Prehosp Disaster Med. 1996 Oct-Dec;11(4):296-301.
9. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA 2007 Oct 10;298(14):1685-7.
10. Demmer C. Burnout: the health care worker as survivor. AIDS Read 2004;14(10):522-537.
11. Desselle SP, Holmes ER. Structural model of certified pharmacy technicians' job satisfaction. J Am Pharm Assoc
2007 Jan-Feb;47(1):58-72.
12. Dowie R, Stoykova B, Desai M. Assessing the wellbeing of cytoscreeners: experience in two NHS cytology
laboratories. Cytopathology. 2006 Dec;17(6):366-73.
13. Eysenbach G, Powell J, Englesakis M, Rizo C, Stern A. Health related virtual communities and electronic support
groups: systematic review of the effects of online peer to peer interactions. BMJ 2004 May 15;328(7449):1166.
14. Felton JS. Burnout as a clinical entity: its importance in healthcare workers. Occup Med 1998;48(4):237-50.
(discusses different occupations within health care).
15. Gaither CA, Nadkarni A, Mott DA, Schommer JC, Doucette WR, Kreling DH, Pedersen CA. Should I stay or
should I go? The influence of individual and organizational factors on pharmacists' future work plans. J Am
Pharm Assoc (2003). 2007 Mar-Apr;47(2):165-73.
16. Heuer L, Bengiamin M, Downey VW, Imler NJ. Neonatal intensive care nurse stressors: an American study.
British J of Nursing, 1996;5(18):1126-1130.
17. Jonsson A, Segesten K, Mattsson B. Post-traumatic stress among Swedish ambulance personnel. Emerg Med J.
2003 Jan;20(1):79-84.
18. Judkins S, Furlow L. Creating a hardy work environment: can organizational policies help? Texas J of Rural
Health 2003;21(4):11-17.
19. Lafer, Gordon et al. Listening to Nurses: Dissatisfaction and Burnout on the Job. In : Solving the Nursing
Shortage, AFSCME. Accessed at:, 10/28/07.
20. Lahad M. Darkness Over the Abyss: Supervising crisis intervention teams following disaster. Traumatology 2000
21. Lapane KL, Hughes CM. Baseline Job Satisfaction And Stress Among Pharmacists And Pharmacy Technicians
Participating In The Fleetwood Phase III Study. Consultant Pharmacist 2004 Nov;19(11):1029-1037.
22. Maher L. Careers in the lab: an open door or a shut case? MLO- Med Lab Obs 1996 Apr;28(4):34-40.
23. Maher L. Is the door half open or half closed on the laboratory’s future—survey of laboratorians and pathologists
MLO- Med Lab Obs 1996 Jun;28(6):60-3.
24. Marine A, Ruotsalainen J, Serra C, Verbeek J. Preventing occupational stress in healthcare workers. Cochrane
Reviews, October 2006. Abstract accessed at:
25. Martin BG. Burnout in the lab: symptoms, stages, strategies. Medical Laboratory Observer, 1986.
26. Martin RA. Sense of humor and physical health: theoretical issues, recent findings, and future directions. Humor
27. McVicar A. Workplace stress in nursing: a literature review. J Adv Nurs. 2003 Dec;44(6):633-42. accessed at:
28. Mott DA, Doucette WR, Gaither CA, Pedersen CA, Schommer JC. Pharmacists' attitudes toward worklife: results
from a national survey of pharmacists. J Am Pharm Assoc (2003). 2004 May-Jun;44(3):326-36.
29. Murphy LR. Stress management in work settings: a critical review of the health effects. Am J Health Promot.
1996 Nov-Dec;11(2):112-35.
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approaches. Presented December 5, 2003 at MedNet 2003, Geneva, Switzerland.
31. Pector EA. How bereaved multiple-birth parents cope with hospitalization, homecoming, disposition for deceased,
and attachment to survivors. J Perinatol 2004;24(11):714-22.
32. Pector EA. Professional burnout: detection, prevention, and coping. The Clergy Journal 2005;81(9):19-20.
33. Pector EA. Views of bereaved multiple-birth parents on life support decisions, the dying process, and discussions
surrounding death. J Perinatol 2004;24(1):4-10.
34. Reddick, Catlin & Jellinek, Crisis within Crisis: Recommendations for Defining, Preventing, and Coping with
Stressors in the NICU, J. Clinical Ethics, Fall 2001; 12(3):254-65.
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37. Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder
(PTSD). Cochrane Reviews 2000, Issue 1.
38. Siebert DC. Personal and occupational factors in burnout among practicing social workers: implications for
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39. Smith, M. K. 'Bruce W. Tuckman - forming, storming, norming and performing in groups, the encyclopaedia of
informal education, 2005. Last updated: 10/23/07.
40. Spickard A, Gabbard G, Christensen JF. Mid-career burnout in generalist and specialist physicians: definitions,
risk factors and prevention. JAMA 2002;288(12):1447-50.
41. van der Klink JJ, Blonk RW, Schene AH, van Dijk FJ. The benefits of interventions for work-related stress. Am J
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42. van der Ploeg E, Kleber RJ. Acute and chronic job stressors among ambulance personnel: predictors of health
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Self-assessment tests: These are NOT meant for formal psychological or psychiatric
diagnosis. They may help you reflect on how you are currently dealing with work stress,
and may help you either alone or in consultation with a counselor or coach determine
how to better understand and cope with your stress. Dr.Pector.
1. Brief COPE
Reference: Carver, C. S. (1997). You want to measure coping but your protocol’s too
long: Consider the Brief COPE.International Journal of Behavioral Medicine, 4, 92100.
Downloaded & modified from:
These items deal with ways you've been coping with work stress in your life. There are
many ways to try to deal with problems. These items ask what you've been doing to cope
with work stress. Obviously, different people deal with things in different ways, but I'm
interested in how you've tried to deal with it. Each item says something about a
particular way of coping. I want to know to what extent you've been doing what the item
says. How much or how frequently. Don't answer on the basis of whether it seems to be
working or not—just whether or not you're doing it. Use these response choices. Try to
rate each item separately in your mind from the others. Make your answers as true FOR
YOU as you can.
1 = I haven't been doing this at all
2 = I've been doing this a little bit
3 = I've been doing this a medium amount
4 = I've been doing this a lot
1. I've been turning to work or other activities to take my mind off things.
2. I've been concentrating my efforts on doing something about the situation I'm in.
3. I've been saying to myself "this isn't real."
4. I've been using alcohol or other drugs to make myself feel better.
5. I've been getting emotional support from others.
6. I've been giving up trying to deal with it.
7. I've been taking action to try to make the situation better.
8. I've been refusing to believe that it has happened.
9. I've been saying things to let my unpleasant feelings escape.
10. I’ve been getting help and advice from other people.
11. I've been using alcohol or other drugs to help me get through it.
12. I've been trying to see it in a different light, to make it seem more positive.
13. I’ve been criticizing myself.
14. I've been trying to come up with a strategy about what to do.
15. I've been getting comfort and understanding from someone.
16. I've been giving up the attempt to cope.
17. I've been looking for something good in what is happening.
18. I've been making jokes about it.
19. I've been doing something to think about it less, such as going to movies,
watching TV, reading, daydreaming, sleeping, or shopping.
20. I've been accepting the reality of the fact that it has happened.
21. I've been expressing my negative feelings.
22. I've been trying to find comfort in my religion or spiritual beliefs.
23. I’ve been trying to get advice or help from other people about what to do.
24. I've been learning to live with it.
25. I've been thinking hard about what steps to take.
26. I’ve been blaming myself for things that happened.
27. I've been praying or meditating.
28. I've been making fun of the situation.
Scales are computed as follows (with no reversals of coding):
Self-distraction, items 1 and 19
Active coping, items 2 and 7
Denial, items 3 and 8
Substance use, items 4 and 11
Use of emotional support, items 5 and 15
Use of instrumental support, items 10 and 23
Behavioral disengagement, items 6 and 16
Venting, items 9 and 21
Positive reframing, items 12 and 17
Planning, items 14 and 25
Humor, items 18 and 28
Acceptance, items 20 and 24
Religion, items 22 and 27
Self-blame, items 13 and 26
2. Burnout/Compassion fatigue
Copyright Information
© B. Hudnall Stamm, 1997-2005. Professional Quality of Life: Compassion Satisfaction
and Fatigue Subscales, R-IV (ProQOL). This test may be
freely copied as long as (a) author is credited, (b) no changes are made other than those
authorized below, and (c) it is not sold. You may substitute the appropriate target group
for [helper] if that is not the best term. For example, if you are working with teachers,
replace [helper] with teacher. Word changes may be made to any word in italicized
square brackets to make the measure read more smoothly for a particular target group.
Compassion Satisfaction and Fatigue Subscales—Revision IV
[Helping] people puts you in direct contact with their lives. As you probably have
experienced, your compassion for those you [help] has both positive and negative aspects.
We would like to ask you questions about your experiences, both positive and negative,
as a [helper]. Consider each of the following questions about you and your current
situation. Select the number that honestly reflects how frequently you experienced these
characteristics in the last 30 days.
0=Never 1=Rarely 2=A Few Times 3=Somewhat Often 4=Often 5=Very Often
I am happy.
I am preoccupied with more than one person I [help].
I get satisfaction from being able to [help] people.
I feel connected to others.
I jump or am startled by unexpected sounds.
I feel invigorated after working with those I [help].
I find it difficult to separate my personal life from my life as a [helper].
I am losing sleep over traumatic experiences of a person I [help].
I think that I might have been “infected” by the traumatic stress of those I
I feel trapped by my work as a [helper].
Because of my [helping], I have felt “on edge” about various things.
I like my work as a [helper].
I feel depressed as a result of my work as a [helper].
I feel as though I am experiencing the trauma of someone I have [helped].
I have beliefs that sustain me.
I am pleased with how I am able to keep up with [helping] techniques and
I am the person I always wanted to be.
My work makes me feel satisfied.
Because of my work as a [helper], I feel exhausted.
I have happy thoughts and feelings about those I [help] and how I could help
I feel overwhelmed by the amount of work or the size of my case[work]load
I have to deal with.
I believe I can make a difference through my work.
I avoid certain activities or situations because they remind me of frightening
experiences of the people I [help].
I am proud of what I can do to [help].
As a result of my [helping], I have intrusive, frightening thoughts.
I feel “bogged down” by the system.
I have thoughts that I am a “success” as a [helper].
I can't recall important parts of my work with trauma victims.
I am a very sensitive person.
I am happy that I chose to do this work.
This information is presented for educational purposes only. It is not a substitute for
informed medical advice or training. Do not use this information to diagnose or treat a
health problem without consulting a qualified health or mental health care provider. If
you have concerns, contact your health care provider, mental health professional, or your
community health center.
Self-scoring directions, if used as self-test
1. Be certain you respond to all items.
2. On some items the scores need to be reversed. Next to your response write the
reverse of that score (i.e. 0=0, 1=5, 2=4, 3=3). Reverse the scores on these 5 items:
1, 4, 15, 17 and 29. Please note that the value 0 is not reversed, as its value is
always null.
3. Mark the items for scoring:
a. Put an X by the 10 items that form the Compassion Satisfaction Scale: 3,
6, 12, 16, 18, 20, 22, 24, 27, 30.
b. Put a check by the 10 items on the Burnout Scale: 1, 4, 8, 10, 15, 17, 19,
21, 26, 29.
c. Circle the 10 items on the Trauma/Compassion Fatigue Scale: 2, 5, 7, 9,
11, 13, 14, 23, 25, 28.
4. Add the numbers you wrote next to the items for each set of items and compare
with the theoretical scores.
Rod Ogilvie LCPC, CRADC
Associates in Professional Counseling
708-448-0884 x8 - [email protected]
Self-worth / Self-awareness:
The value of a human life is not directly related to performance or the opinions of others. A
healthy self-worth creates more self-confidence and less insecurity and immaturity – but not
A healthy self-worth allows for more freedom for the individual, and is less impacted and driven
by fears (failure, rejection, blame, shame).
A healthy self-worth allows a person to accept their part in the overall team: knowing their limits,
protects against envy, ensuring healthy responsibility, and enhancing the overall health of the
Communication Skills:
Expressing your thoughts, desires, and/or feelings in a direct, respectful manner to
another person. Assertive communication takes into account: eye contact, body posture, gestures,
facial expression, voice, tone, inflection, volume, timing, and the content of the message.
Aggressive: An intense and anxiety provoking manner of communication – acceptable, but
should be utilized infrequently and with great caution.
Passive: A quiet or retreating response to communication – acceptable, but should be utilized
infrequently and with great caution.
Passive-Aggressive: A dishonest manner of communication, which is a communication
killer. Examples include: Procrastinating, leaving things undone, obstructing others, doing
things which were not requested, misplacing, “forgetting”, purposefully omitting things, being
late or slow, leaking information, withholding information, use of sarcasm.
Tips for increasing self awareness in communication:
Focus on what you really want
Focus Feedback on the behavior, not the person
Focus Feedback on observations rather than inferences
Focus Feedback on description rather than judgment
Focus Feedback on specific situations of the here and now
Focus Feedback on sharing of information, not necessarily giving advice
Focus Feedback on exploring alternatives instead of telling them the answer or what to
Focus Feedback on the value it has for the recipient, not the value it has in release
Focus Feedback on the amount a person can receive, not the amount you can put forth
Focus Feedback on what is said, not why you think it is said
Watch out for your “story”
 We add meaning
 We add motive
 We add judgement
 Victim Stories
 “It’s not my fault”
 Villain Stories
 “It’s all your fault”
 Helpless Stories
 “There’s nothing else I can do”
Utilize Active Listening Skills:
Encouraging – Can you tell me more?
Clarifying – When did this happen?
Summarizing – Let me see if I understand what you are saying…
Acknowledging – It sounds like you are …
Normalizing – Many people would feel the way that you do…
Empathizing – I can appreciate why you feel that way
Problem solving – What would you recommend?
Stress Management Skills:
Healthy stress management begins with an honest evaluation of oneself. It looks at how one
approaches situations, expectations and priorities, and acknowledges the differences in
personality as well. Some of the most effective stress management techniques include cognitive
restructuring tools, regular exercise, getting proper rest, having balance in one’s life, having
healthy friends and supports, and seeking professional assistance if needed.
Anger Management Skills:
Anger is a normal human emotion. It is a powerful and unsettling emotion, and therefore, much
caution must be used to manage it, so that it does not create regret. Anger is caused by our beliefs
and thoughts, not other people, events or things. Accepting this allows us to take full
responsibility for our angry responses.
Some Do’s and Do Not’s when addressing angry feelings:
Do speak up when an issue is important to you
Don’t strike when the iron is hot
Do take time out to think about the problem and clarify your position
Don’t use below the belt tactics
Do use “I” language
Don’t expect change to come from “hit and run” tactics
Do recognize that each person is responsible for his/her own behavior
Don’t speak through a third party
Do go through appropriate channels
Don’t become the third party in someone else’s triangle
Avoid secrets
Learn to apologize and forgive others
Healthy anger management includes: thinking; patience; finding a mutual purpose; assesses
timing, the situation and the others needs; affirms mutual respect; and listens to understand.
Tips for Managing the Angry/Entitled Client:
 First, Listen to understand.
– Listening and understanding does NOT equal agreement.
 Clarify and Confirm
– Mirroring, paraphrase, summary paraphrase
 Agree and/or Compare
– Agree only if you do. Compare focuses on the differences vs. “right/wrong”
 Identify a core Value of your work as it relates to the complaint.
 Delay when appropriate
– Can I ask you to write your complaints down on paper, so that I can relate your
concerns correctly?
– I can try and locate them for you, but you will need to give me a few minutes to
do so.
 Intervene when safety is breached.
– Speak clearly
– Emphasize the MAIN GOAL
– Seek assistance
– Follow protocol
 Take a Time Out (Mental)
– I do not need to prove myself in this situation.
– I am in control of myself.
– It is impossible to control other people and situations. The only thing I can
control is myself.
– I can survive criticism. I do not have to be perfect.
– If this person wants to go off, that’s their thing. I do not need to react to their
anger or feel threatened.
Recommended Reading:
Crucial Conversations: Tools for talking when stakes are high.
Kerry Patterson, Joseph Grenny, Ron McMillan, and Al Switzler
Copyright, 2002 – McGraw-Hill
How to Manage Anger: Gaining Control of Ourselves.
Anderson & Anderson, Anger Management –
George Anderson, LCSW, BCD