Compassion Fatigue

"Compassion fatigue refers to a gradual decline in a provider's capacity for compassion, and is a relatively common phenomenon among those who work directly with surviving victims of disaster and trauma.  It encompasses a breaking down of our physical, psychological, and even spiritual resources.

Physically, those experiencing compassion fatigue often struggle with a chronic sense of exhaustion and fatigue, insomnia, headaches, stomach aches, and frequent bouts of sickness (e.g. colds, sore throats).

Psychologically, they may feel irritable or overwhelmed.  Their baseline capacities for empathy dissolve into numbness to others' pain, and they can become cynical regarding surviving victims' ability to change and/or even perceive them as being responsible for many of their problems.

Responders experiencing compassion fatigue often report a sense of feeling scattered and being unable to meet their professional (e.g. paperwork) and personal (e.g. calling home) obligations."

"Systems thinking requires that we, as providers, understand our role(s) with the patient and family systems with whom we work.  Our own personal health (psychological and physical) is as important to attend to as those we serve."

Mendenhall, T.J., & Berge, J.M. (2010).  Family therapists in trauma-response teams:  bringing systems thinking into interdisciplinary fieldwork.  Journal of Family Therapy, 32, 43-57. 

Despite being a common and universal phenomenon in the face of trauma work, professionals perceive stigma associated to compassion fatigue.  How many of us would raise our hands and say, "I am experiencing compassion fatigue" and then seek help and support?

When I read the reports of "feeling scattered" due to compassion fatigue, I can't help but be reminded of soul loss.  Many indigenous and shamanic cultures believe that traumatic events may result in soul loss - when parts of our soul check-out for self-protection. There is no need to continue to walk around with a maimed soul.  The soul parts can return home safely with proper intervention - you need only ask, believe and accept this healing.

For more information about soul retrieval and finding a shamanic practitioner, check out Sandra Ingerman's website.

Systems Thinking in Trauma Response

"Systems thinking brings an overt sensitivity to both intrapersonal and interpersonal family processes that are related to increased stress in the contexts of disaster and trauma, and this fosters and elicits positive individual, relational and family growth in both the acute and long-term phases of support.  It promotes an appreciation for respective family members' unique perceptions of meaning, and facilitates members' co-creation of new meanings in the evolution of healing and post-trauma growth.  It pushes us to consider our own role in the helping process and how the contribution of our training and background fits withing the larger efforts of our team's mission.  Finally, systems thinking commands attention to our own functioning, and highlights our obligation to self-care."

Mendenhall, T.J., & Berge, J.M. (2010).  Family therapists in trauma-response teams:  bringing systems thinking into interdisciplinary fieldwork.  Journal of Family Therapy, 32, 43-57. 

More Family Systems Theory

Sometimes you don't have time or interest in reading the whole article.  Fortunately, I do, so here are some excerpts I've pulled out just for you . . .

1.     "Family systems theory - or 'systems thinking' - represents a hallmark of family therapy and the many clinical approaches that it encompasses.  Key theoretical underpinnings including:

• attention to relational factors,
• interaction sequences,
• social and political contexts, and
• extra-therapeutic factors

guide everything we do."

2.     "Moving beyond primarily individual-oriented intervention strategies (and those focused on groups of individuals) in conventional approaches to psychological first aid and trauma responding, family therapy commands explicit attention to individual, relational and family systems as bounded sets of interrelated elements.  Family therapists bring an overt sensitivity to inter-member processes that are related to increased stress in the contexts of disaster (e.g. family conflict, over-functioning/under-functioning patterns) and trauma work, as well as opportunities to foster and push positive relational and family dynamics in both acute and long-term phases of support."

3.     "Family therapists...readily conceptualize 'systems' in accord with the biopsychosocial family systems model...to consider multiple and interconnected systems, including patients'. . .

• anatomical and physiological make-up (e.g. brain structure, somatic symptoms), 
• psychological functioning (e.g. PTSD, depression, anger, sense of hope and/or hopelessness),
• relational and family systems (e.g. attachment, communication, boundaries, cohesion, adaptability), 
• and larger social and ecosystemic structures (e.g. supportive peer and friendship networks, contemporary political milieux, neighbourhood wealth/poverty).

4.     "...we must honour the complexities of these multiple and interconnected systems, as they are all relevant and influence each other."

5.     "...integrating psychoanalytic ideas with systemic practices can contextualize individuals' respective functioning within families - and thereby synthesize competing perspectives in healing and growth..."

6.     "...argues for integrating such approaches, highlighting how attention to family members' unique attachment histories influences the manners in which they experience trauma - thereby informing therapists' effective intervening and care."

7.     "Finally, systems thinking commands that we recognize and honour our own roles in the process of helping.  For example, attention to our personal emotional processes, self-care, and preventing burnout and compassion fatigue are not only important for our own and other team members' sake, but for the safety and well-being of the people and families we serve."

8.     "A 25-year-old woman who lost her colleague to suicide stated that she will tell her other colleagues daily what she appreciates about them so that they never feel unappreciated and lonely."

9.     "Regardless of what discipline ultimately brought us to it, providers of mental health entered this business to ease the suffering of those who are hurting, and to empower their growth and resolve in the face of hardship.  We can do this from a variety of professional platforms, in collaboration and synchrony with each other.

10.     "Common systems themes such as appropriate hierarchies (e.g. executive power), subsystems (e.g. parents, children/siblings), and interpersonal boundaries (e.g. as they relate to sexual behaviour or self-disclosure) are valuable concepts with which to inform teams' decision-making processes, overall structure and ongoing functioning.  In our own work, we have learned to address these challenges through straightforward and frank conversations with colleagues, supervisors and students - and maintain that these challenges call for consistent attention and diligence so that the safety of all team members is ensured and that ethical violations are not committed."

Mendenhall, T.J., & Berge, J.M. (2010).  Family therapists in trauma-response teams:  bringing systems thinking into interdisciplinary fieldwork.  Journal of Family Therapy, 32, 43-57. 

Practice, Policy & Research Triangle

Practice should influence research and policies:

• Practitioners and clients should give voice to their needs and strengths.  Researchers need to listen.  In this way, important research problems and questions are addressed.  That is, research is conducted that makes a difference in people's lives.  
• Practitioners and clients should also give voice to their needs and proposed solutions by participating in the political process - at the agency level, as well as local, state and federal levels. Policymakers need to listen.

Policy dictates or influences practice and research:

• Policies set the parameters, provide funding and regulations for how we conduct our direct practice work.
• Policies also dictate what type of research gets funded.

Research influences or should influence policies and practice:  

• Policies should be based on the best science available in addition to meeting the needs of constituents.
• Practice should also be based on the best science available as well as integrating practitioner experience/wisdom and community/client values.

It is high time that the severed parts work as a whole system.

More Notes from Mary McKay on Family Engagement in Children's Mental Health Treatment

I heard Mary McKay speak on Family Engagement strategies in Los Angeles again.  I told her I wasn't just a fan, I was a groupie.  I heard her speak about a year ago (see notes from that workshop on this blog).

After introducing myself and her offer to help me in the program any way she could (she is an LCSW and PhD too), I handed her my recently completed manuscript about a parenting intervention in schools for her review and feedback.  She is so gracious, warm, witty and wise - reminds me of Bonnie Hunt - love her.

Okay, this is the gist of what she said in her south side of Chicago accent ...

• In children's mental health treatment, 50% of parents never make it to their first appointment (according to national show/no show appointment rates).  

• 25% engage in children's mental health treatment (sadly, 75% do not).

• She interviewed parents to find out what we did well and what we needed to develop, in terms of children's mental health treatment. 

• Messages from therapists to parents:  
• "Life is complicated and there are no easy answers"
• "I don't have all the answers but I'd like to partner with you."

• It takes a lot of hard work to get good outcomes, in terms of family engagement and retention in treatment.  

Barriers/Obstacles to Engagement

• Concrete obstacles - schedule, transportation, language barriers, poverty.
• Perceptual barriers - parents own previous school experiences (in school based mental health services); ambivalence about treatment (are you going to be helpful or harmful?)

• It is good for families to come with a healthy mistrust and skepticism.  They are showing a pretty good sense - "I care about what happens to my family" and that is why they are hesitant about involving themselves in the mental health system.

• For mental health professionals concerned about our alliance with teens vs. parents:  Young people need their families and our task is to teach them how to mend those relationships.

• Parents may be fearful and discouraged and think, "You can't possibly be helpful."

• Parents are suspicious of mental health providers based on previous negative experiences with helpers when they have been called "bad parents."  Parents need to be understood, supported and not judged. 

• The variables found to be most significant when modeled (probably logistic regression) - stigma and fears of being blamed (perceptual barriers) - and not concrete barriers (transportation, child care, etc.)  Not all engagement barriers are created equal.

• Even poor people know how to run their lives (get to appointments that they deem important).  They will overcome concrete obstacles for what's important.  If their fears and concerns are not addressed, they will not use their limited resources to attend appointments.

• Unexpressed questions and concerns are significant barriers.  Yet, no family will say, "I won't come because I am afraid."  "Nice people" like mid-Westerners won't say, New Yorkers might say, "nice people" are strong-minded but nice.

• If you only problem solve around concrete barriers, then you won't increase appointment show rates.

• Some cultural values leave us less skilled/practiced at disagreeing with professionals due to respect for authority - but will go home and not do what they say.

• Don't leave engagement to chance.  If we don't do something differently, then more families will not become engaged.  If we employ empirically supported strategies for engagement, it is more likely that families will engage in treatment.  The hard work is in systematically doing something differently.

• Clinicians can address parental ambivalence about treatment by creating discrepancy and engaging in change talk.  

• How do you help people who do not see they have a problem?
• Psychoeducation - information about the disorder - depression, anxiety, etc.
• Child can tell his father about his experiences with anxiety and depression. 

Goals for Telephone Engagement (first call to families)

• Systematically incorporate engagement skills and tools; systematic attention to engagement
• Clarify the need for mental health care
• Increase caregiver investment and efficacy
• Encouraged disagreement about reason for referral to try to build alignment

• Working with adults:  Adult do not do things because they are told what to do, but because it's in their best interest.  

• Being judgmental is not good customer service.  If you're thinking, "duh," then I wonder how we might come off as judgmental in more nuanced ways, especially to families that may feel reticent or suspicious (or previously burned by mental health professionals).  Parents report, "I've gone to helpers and they haven't been helpful (judged me)."

• Clinician message: "I know you care about your child.  I care about your child too and I care about their success as a student."

Goals of 1st Interview

• Anxiety gets in the way of listening and learning and retaining information.  
• Achieving treatment goals requires intensive parent partnerships.
• "I can do nothing without 'we' " - "How are we going to work together?" - "What can we change?"
• If we see the child instead of the parent, then we can expect slow to non-existent change.  The research shows that seeing the parent is more effective.
• We can only go as fast as the family is able to go, although this may feel as slow as a snails pace.  Important to set a spirit of real collaboration.  Send the message, "I can't go it alone with just the kids," and mean it!  Partnership is necessary for treatment change and not just "nice."
• Parents wonder, "Can therapist offer me something that my sister or mother cannot?"
• If parents walk away without evidence that we can be helpful, they won't come back.
• Proven useful to show parents how to reduce stress, increase parenting skills, using tools created by and for parents.
• End interview with, "how was this for you? Are you interested in returning?"
• Big chunk don't come back because they don't want to - something went wrong in the first exchange.

How to make paperwork more engaging

• Review paperwork - what is most essential? Remove the rest.

• Talk to parents about approach to paperwork.  We come off as disempowered when talking about paperwork.  How can we come off as competent - show our self-efficacy?  Quit apologizing for paperwork because the research shows that this approach wasn't helpful.

• Parents described signing consent and wishing they hadn't after they left.

• Clinican message, "I don't want you to sign anything you don't feel good about.  I don't want you to walk out with any questions or concerns without an opportunity to discuss them."

• Parents want to feel respected and understand process.

• Frame sensitive assessment questions as opportunities to build trust.  Explain who will see the information and how it will be protected.  Families worry about access.

• Need rationale for developmental history questions (such as age of developmental milestones of walking and talking) - especially when working with 16 year old pregnant teen!  If parents don't understand why we are asking certain questions, then they think we are weird or wasting their time.

• Paperwork can be an opportunity to engage and allay fears.

• With systematic incorporation of these strategies, rates of return often double and triple.

• If setting for interviewing family is less than ideal, with regards to confidentiality, then encourage families to have the good sense to share only what is safe to do in such a vulnerable setting.

• Constantly seek feedback from family.

• If client can't articulate goals, then they aren't likely to get good outcomes.  Take out the service plan at every visit to track outcomes.

• If parents have had a "bad" experience, they are less likely to ask for help again.

• After one bad experience, parents are more likely to be suspicious at the next visit and likely to drop out.  Ask about and discuss past negative experiences.

• The most engaging characteristic is authenticity.

• Termination assessment:  "Is this a good time to end?  Has enough progress been made?"

• Clarify the reason for referral from the parents perspective.  Parents critique:  Clinicians miss the opportunity to ask about parents perspective on referral - "Do you agree with this referral?"

• What percentage do you think are excited about referral?  What percentage do you think are in agreement with the need for referral?  Parents usually blame the teacher (and every once in a while, the teacher is a problem).  

• Parent:  "If this encounter is lead by my need, then I will return.  Otherwise, I'm done."

• If parents bring up their concerns - talk about them.  If they don't bring them up, then ask and raise concerns proactively.  Explore by saying, "A lot of families have questions and concerns about...For example..."

• Parents wonder, "how is all this talking supposed to help?"

• Parents are as scared/nervous as we were (as clinicians) at our first intake.  Parents come in with their game face (cool and scary).  It's family's first time - they are worked up - it's our job to help them regulate and relax.  Don't get to the big Question too quickly - "How can I help you?" Talk for five minutes to allow families to take a breath and stop being nervous - so family can make an assessment of you as the clinician.  Parents only agenda at first meeting is to show up (against their good sense to stay away).  If we rush them, they'll leave out important details - "I don't know if I trust her yet.  I don't know if I'll tell her that yet."

Forgiveness Affirmation

A side effect of depression and anxiety is being too harsh - unforgiving - on ourselves and others.

The following Forgiveness Affirmation comes from Connie Domino, RN, MPH, from her book, The Law of Forgiveness.  After leading goal-setting workshops, she noticed some participants reached their goals faster than others.  She noted that a lot of it had to do with holding on to the weight of anger and bitterness - it can get in the way.  Release it and be free already.

Here is the Forgiveness Affirmation and instructions:

1. Make a list

It is helpful for some people to make a list of those they would like to forgive. It doesn’t matter if it takes you several days or weeks to work through your list. The important thing is you have begun the process. Make a list of everyone you can think of that you would like to forgive, from your present and your past. Also, make a list of people you have wronged, whose forgiveness you seek. Forgiveness works freely both ways.

2. Find a quiet space

First, set aside a quiet time when you are least likely to be interrupted. Turn off any disruptive electronic equipment. Make sure any people who live with you know not to interrupt and ensure your pets are settled. Sit or lie in a comfortable place and position.

3. Visualize the person in your mind’s eye

Bring the person you wish to forgive into your mind’s eye. As much as possible, see them happy and surrounded by healing light. Visualize their higher self, not their nasty, mean Earth self (their soul, not their personality). If you have a number of people to forgive, you may wish to complete this in several sessions.

4. State the forgiveness affirmation

Bring each person into your mind’s eye one at a time, and say the forgiveness affirmation to each of them. Next, visualize them smiling sincerely and accepting your forgiveness. When you say, “and all again is well between us,” this means “the energy is now released.” It doesn’t mean you’re now buddies. Next, see that person walking off a stage or out a door, and bring the next person into your mind’s eye. You can say the affirmation aloud or silently. If you are forgiving a group, organization or country, picture the group in your mind’s eye and state the forgiveness affirmation. You may even visualize the group members saying the affirmation to one another. To make forgiveness real, you must be sincere. It is recommended that you should state the affirmation as it is written, as it has proven so successful with numerous Law of Attraction and Law of Forgiveness students. Remember if you change the words around to continue to justify your anger such as, “I forgive you for not being the person I wanted you to be,” or something similar, this means you are not willing to entirely “release” and “let go.” Therefore, you will not receive the full benefits of complete forgiveness.

Affirmation to Forgive Others

I forgive you completely and freely, I release you and let you go. So far as I’m concerned, the incident that happened between us is finished forever. I wish the best for you. I wish for you your highest good. I hold you in the light. I am free and you are free, and all again is well between us. Peace be with you.

Affirmation for Others to Forgive You

[Name] forgives me completely and freely. He releases me and lets me go. So far as [name] is concerned the incident that happened between us is finished forever. [Name] wishes the best for me. [Name] wishes for me my highest good. [Name] holds me in the light. [Name] is free and I am free, and all again is well between us. Peace be with us.

Affirmation to Forgive Yourself

I forgive myself completely and freely. I release myself and I let me go. So far as I am concerned the incident that happened is finished forever. I wish the best for me. I wish for myself the highest good. I hold myself in the light. I am free and all again is well with me. Peace be with me.

Take a deep breath! You did it!

The 2 Sides of Fear

It may seem that fear has gotten a bad rap on this blog - overcome your fears, don't feed your fears and all that jazz.

Fear is a gift too (and the title of a book by Gavin de Becker).

When is our fear trying to send an important message for our safety, protection and well-being? And when is it getting in the way of what we really want to do?

All I can offer is that we listen to our inner voice, pay attention to our body clues and reflect - we are the experts of our own messages and we get to choose.