Aspire MN

June 8, 2017 Duluth, MN

David X. Swenson PhD LP

Vicarious Trauma and

Resilience for Ourselves

and Our Staff

• Identify the sources and mechanisms

of vicarious stress/compassion fatigue

• Describe the impact of vicarious stress on our

work, relationships, and health

• Explore organizational, and personal methods for

promoting resiliency and stress management for

our staff and ourselves

A rose by another other name……

Secondary Trauma

…..Burnout

Historical Highlights of Post-Traumatic Stress

http://io9.com/5898560/from-irritable-heart-to-shellshock-how-post-traumatic-stress-became-a-disease

It’s not just war: Vicarious/Secondary

Trauma, “Compassion Fatigue”

Wanted: Superhero to work unending hours, under stressful conditions, etc…

• caring, dedicated, committed

• strong ideals, high expectations

• like variety & stimulation

• action-oriented

• take control, responsible

• must be knowledgeable, expert

• tolerate occasional helplessness

• make critical decisions

• very short time pressure

• exposure to pain, fear, grief

• continual flow of clients

• long periods of fatigue without relief

Rationale for Resiliency

• We work in a high risk, high stress profession

• We must take care of ourselves in order to

take care of our clients

• The effectiveness of our own stress management contributes to

our treatment climate and culture

• Our clients react to our reactions; they test us for security, care

and manipulation

• We role model to our staff how to deal with stress

• We do good work– we deserve good self care!

Friend or Foe: Effects of Adversarial

vs

Collaborative Investigations

• Sample: 125 child care agencies in 38 states

(residential, group home, treatment foster care,

day Treatment). All experienced at least one violation investigation

• Collaborative style: Courteous, trust, mutual goal of protecting

staff and clients, improvement in quality of care, learning from

mistakes, sharing information

• Adversarial style: No notice, “reading rights,” threats,

intimidation, predrawn conclusions, withholding information,

arrogance

Swenson, D. X., Wolleat, R., & Grace, D. (2003). Friend or foe: The effects of adversarial

versus collaborative styles of treatment violation investigation. Journal of Child and Youth

Care Work. 17, 204-217.

25% reported having negative

experiences with investigation

• 93% of staff had lower respect for the

investigative system

• 83% of staff morale deteriorated as a result

of investigation

• 80% discouraged staff commitment to the field

• 72% felt badly about themselves and the work they do

• 63% took a highly defensive position regarding investigation

• 43% showed self doubt and second guessing in subsequent

case decision making

• 37% became very cautious in sharing information with parents

• 13% reported that the quality of treatment had declined

The Point: Most investigations are collaborative and constructive; prepare

staff for the stress of investigation and those that are adversarial!

“Long ago and far away”:

Consequences of a client death

in a day treatment program

• A child died from respiratory arrest during a physical

hold while having an outburst of uncontrolled risky behavior

• The hold was applied per current training and certification; the facility

passed state review two months before

• Media, internet, and other local agencies perpetuated inaccuracies &

rumors, and socially alienated the staff

• One staff was convicted of negligent manslaughter & served 6 months in

jail, never to work in the human services field again

• 70% staff turnover related to the stress of investigation; some still report

symptoms of PSTD

• $100,000 fine for “negligence”; six years later, one law suit was still

pending

• On the bright side– it changed their culture and reduced holds by 80%

Prime factor: Exposure to the

pain & suffering of others

(child neglect & abuse, sexual

abuse, torture, intense grief,

graphic stories & documents,

suicide and homicide, drug

reactions, resistant clients and

families, etc.)

(Pines & Aronson, 1988)

Normal

Empathic

Response to

Victims &

Situations;

Rapid recovery;

work

satisfaction

Vicarious or

Secondary

Stress;

Compassion

Fatigue;

Prolonged

reactions to

work-related

indirect trauma

to others

Post-Traumatic

Stress Disorder;

Persistent and

severe

symptoms

“Burnout” or

Complex PTSD;

Pervasive

negative

attitude toward

self, work,

others, life &

inability to cope

with work

Increasing frequency, duration, intensity of stress

Increasing Levels of Interference & Impairment

The “Slippery Slope” of Burnout

https://openi.nlm.nih.gov/detailedresult.php?img=PMC2938301_ndt-6-517f1&req=4

Drivers Impact Consequences

• Personal

characteristics

• Job tasks

• Organizational

culture

• Crises

• Stress

• Compassion

Fatigue,

Secondary

Trauma,

Vicarious

Trauma

• Burnout

• Absenteeism, lost time,

replacement staff, added

workload

• Impact on other staff

• Impact on personal health &

relationships

• Interpersonal conflict &

grievance in the workplace

• High turnover, talent

replacement issues

• Poor productivity

• Physical injuries &

accidents

• Impact on resilience to

manage critical incident

stress

“Burnout”

• Emotional Exhaustion: depletion of

emotional energy and feeling emotional

resources are inadequate to continue

• Depersonalization: detached from clients,

responding in negative, callous, and

dehumanized ways

• Lack of Personal Accomplishment:

Staff feel incompetent in their work and

unable to reach work-related goals

Lakin, B. L. (2008). Predictors of burnout in children’s residential treatment

center staff. Residential Treatment for Children Youth, 25(3), 249-270.

Factors that affect

our vulnerability

• Time & error costs are greater with

more complex tasks

• Multitasking switching effectively reduced mental efficiency

equivalent to a loss of 10 IQ points or losing a night’s sleep

• During task switching you can lose up to 40% productivity & take

up to 50% longer

• MT produces physical stress resulting in release of stress

hormones & adrenaline

• Prolonged multitasking seems to interfere with learning to

concentrate on single intellectual tasks as well as attending and

recalling information

Rubenstein, J. S., Meyer, D. E., & Evans, J. E. (2001), Executive control of cognitive processes in

task switching. Journal of Human Experimental Psychology– Human Perception and Performance,

27(4), 763-797.

Multitasking

• Night shift staffing

• Double-shift

• Moon-lighting staff

• Overtime & Extended duty

• Emergencies & crises

• Poor sleep habits

• Vicarious intrusions in sleep

• Illness affecting sleep

Sleep & Fatigue

• Helps consolidate memory & learning related to new skill development

• Secures long term memory

• Sleep also promotes immune system & healing, improves muscle tone & complexion

• Produces brain proteins for neuron growth (“plasticity”)

• Enables disposal of brain waste products (may reduce Alzheimer risk)

• Napping prevents learning fatigue

What does sleep do anyway…

Repeated nights of sleep restricted to <8 hours time in bed (TIB) resulted in cumulative cognitive deficits equal to those found in 1-2 nights without any sleep

“Sleep debt” results from sleeping less than needed to be fully alert and at your best performance

Lap

ses

of

atte

nti

on

du

rin

g p

erf

orm

ance

(sl

ow

rea

ctio

n t

ime)

Zone of impaired performance

Repeated days of sleep restriction

(Dinges, 2002)

4h TIB

6h TIB Performance errors equal to being awake 40-64 hours

8h TIB

Performance errors equal to being awake 24-40 hours

Generally poor awareness of the adverse effects

<

Dawson, D., & Reid, K. (1997). Fatigue, alcohol, and performance impairment.

Nature, 388(6639), 235.

Scotney, R. (September, 2013). Compassion fatigue. Presented at Australian G2Z

Summit held in Gold Coast, Queensland.

STRESS

Threat Perception Coping Skills

Impaired Immune function

• Ulcer response

• Viral infections, bronchitis

• Increased absenteeism

Cortisol Response (Long term response)

Change Glucose Metabolism

• Insulin resistance,

• Pre-diabetes

• Diabetes & nerve damage

• Trunk obesity

• Fatigue

Neurochemistry changes

• Decreased serotonin: sleep,

mood, anxiety, depression

• Decreased dopamine:

pleasure, motivation,

concentration, addiction risk

Cardiovascular changes

• Increased blood pressure

• Increased arterial plaque

• Increased belly fat

• Heart attack & stroke

It’s all (or mostly all)

about Empathy

Our brains react as

if we are the athlete

Imitation &

“Mirror Neurons”

“I feel your pain”…literally!

We are hardwired for

empathy

Laughing baby ripping paper https://www.youtube.com/watch?v=RP4abiHdQpc

Emotional

Enmeshment

& Contagion

Compassion,

Supportive

empathy:

“I Care”

Psychopathic

callousness:

“It’s all about

me”

The Empathic Continuum

Emotional Empathy Cognitive Perspective Taking

David X. swenson PhD LP 2016 32

Professional

distancing:

“Hard

Decisions”

• About a third of new therapists report

previous trauma (Pope & Feldman-Summers,

1992).

• Lack of trauma training and practicing self-care methods increase risk

• New therapists may be more vulnerable to vicarious trauma (Adams

& Riggs, 2008)

• Low starting wages & benefits, lack of respect, and unmet

expectations in relation to their role and duties

• An exaggerated sense of idealism may turn to frustration and

disappointment with the realistic challenges of work.

• Unsupportive or unavailable supervisors, poor coping skills, and

challenging clients

• Many child and youth care workers only last 2-5 years in the field

before turnover or changing professions (Savicki, 1993, 2002)

What we know about new

child and youth care therapists

Hiring for Resilience

Interview

• This can be stressful work– what are some of the challenges

you expect to encounter?

• Self awareness: How do you know when you are under stress?

• What are things you do to take care of yourself and manage

stress? How often do you practice these?

• Have you experienced critical incidents or crises before? How

did they affect you and how did you manage the stress of

them?

• How do you use supervision when you are stressed?

• Imagine that you are beginning to have intrusive and

preoccupying thoughts about client adverse experiences.

Think through out loud what this might mean and what you

will do.

“Like watching a slow-motion accident”–

Dealing with helplessness as a therapist

How to know when you’re

in over your head—

• You are working harder than the child– more

responsibility for thinking about it, working on it,

and acting to change it

• Feel fearful, anxious, apprehensive about being with the child or what the child

might do

• You show signs of stress or burnout: sleep problems, appetite change, apathy,

resent child, avoid child, dark humor, etc

• You feel strong disgust, revulsion, or distaste for the child regarding their

behavior

• You feel confused, frustrated, ambivalent, or conflicted about the problem or

child

• The child’s problem elicits emotions/concerns from your own past experiences

• You worry about the child intruding into your family, or jeopardizing family

safety

• You spend a lot of time thinking or worrying about the child after work

Over your head

Common staff reactions to working with JSOs

Common staff reactions

• boundary violations (84%), sexualized by clients (42% female, 16% male)

• feel angry (84%)

• fear for safety or retribution by clients (79% female, 63% male)

• disillusioned & depressed (79%),

• change views of criminal justice system (77%)

• doubt competence (74%) & feel inadequate (58%)

• discomfort telling others they are sex offender therapists (68%)

• questioning past sexual behavior (68% males, 53% females)

• intrusive imagery of client offenses (67%)

• fear for safety of children or grandchildren (59%)

• feel “unclean” after a session (58%)

• more cautious behavior around children (57%)

• decrease in current sexual interest/behavior (48%)

• entered therapy for themselves since working with JSOs (43%)

• feelings of sexual arousal (42% male, 16% female)

• feel guilty (42%)

• sexual fantasies about clients (41%)

“So– what’s

a body to

do?”

Directions:

1. Place kit on FIRM surface

2. Follow directions in circle of kit

3. Repeat Step 2 as necessary, or until unconscious

4. If unconscious, cease stress reduction activity

Lawson, G. (2007). Counselor

wellness & impairment. Journal

of Humanistic Counseling,

Education, and Development,

46(1), 20-34.

Career-

Sustaining

Behaviors of

Counselors

You have strong reasons not to change, but

consider the trade-offs in immediate demands vs.

long term consequences

“What fits your busy schedule better, exercising

one hour a day or being dead 24 hours a day?”

Yerkes-Dodson Law: Too Much/Little = Stress

Incremental Buildup of Stress

Gradual

accumulation of

minor stresses

throughout the

day/week

Low stress

level

Noticeable

stress

reaction

Moderating Stress Buildup

Stress

reduction

activities

Personal Stress

Management

• Adequate sleep (8 hours)

• Regular, frequent exercise

• Balanced nutrition

• Muscle & alertness relaxation

• Hobbies, recreation removed

from the treatment world

• Diverse socializing friendships

• Mindfulness/meditation

• Sense of humor

• Social support, caring

relationships

• Values, faith, philosophy

• Focus on positives (even when

small)

• Vicarious resiliency

Personal Stress

Management

Constant cues

for tensing

Spot-checking

Nature Walk:

Real or Virtual

https://www.youtube.com/watch?v=gU_ABFUAVAs

• Nature break, real, video or

imagines, can held reduce

stress

• Large collection of images,

video, and music online via

Google keyword search

• Videos from 5 minutes to 8

hours for relaxation,

meditation, and sleep

• Can be viewed on

computers & other mobile

devices

Mindfulness

“Sometimes I

sits and I thinks,

and sometimes I

just sits.”

Impact of mindfulness

on Therapists

• Promotion of empathy & perspective

taking

• Enhanced compassion for self and

client, nonjudging & nonreacting

• More attentive to therapy process, comfortable with silence

• Decreased stress, anxiety, depression, emotional fatigue

• Perceived better quality of life

• Improved self-efficacy, self-awareness, body-awareness

• Increased patience, intentionality, gratitude

• Clients of mindful therapists showed greater reduction of

overall symptoms, faster rates of change, higher ratings of

well-being, & perceived Tx as more effective

http://www.apa.org/monitor/2012/07-08/ce-corner.aspx

Laughter is good medicine!

Improved O2 level Relaxes muscles

Improves alertness,

concentration & memory

Stimulates

immune

system

Increases

blood flow

Relieves pain

Releases

endorphins

Improves mood

Reduces stress

hormones

http://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-relief/art-20044456

Kindness Reflection: Unusual Animal Friends

Exercise & Activity

• Decrease tension & promote

relaxation

• Release endorphins (feel good,

reduce pain)

• Lowers blood pressure & cholesterol

• Reduces level of stress hormones

adrenaline & cortisol

• Controls appetite & weight

• Enhances immune response

• Improve sleep

• Increase alertness, attention, concentration

• Improves mood; reduce depression & anxiety

Staff from Elevate

Treatment Center stay fit

Staff at WNY Child

Development Center Kids and staff reduce

stress together with yoga

Yoga & T’ai Chi

T’ai chi is moving

mindfulness

meditation that also

has low impact

exercise and

relaxation benefits

“Reframing” our Thinking:

Vicarious Resiliency

• Originally developed by psychotherapists who

worked with political survivors of trauma/torture

• Ability to see positives in an adverse situation; to benefit by

learning and become stronger for it

• The “wounded healer”– turning trauma into service to others

• Appreciating how a crisis can become a pivotal point for

change

• Noticing how trauma survivors demonstrate the vitality of the

human spirit

• Witnessing the coping and mastery of others in crisis; what

helped them survive

• Advocating for and assisting others with stress

Positive Outcomes of

Crises

Individual Outcomes

• Motivation to change

• Enhanced creativity, coping & esteem

• Higher personal integration

• Expanded and tested support system

• Outreaching skill building

• Second chance resolution

• Catalytic effect on family/social/work system

• Survivor advocate Organizational Outcomes

• Creates natural turning point for organization

• Increases interpersonal cohesion

• Identify and protect organizational vulnerabilities

• Better prepare for future crises

• Linkage with community resources

• Improve organizational culture

• Demonstrate competency & values to stakeholders

• Improves organizational image and reputation

• Increase organizational commitment

• Assessment of leadership potential “under fire”

• Opportunities for new initiatives

Roundtable Discussion

• Stimulated by “Schwartz Rounds” on

sharing the stress of being a physician

• One hour meeting, with discussion of

questions or themes (e.g., futility, un-

expected progress, whe things go wrong, etc.)

• 3-4 staff share their experiences (15”) emphasizing emotional

impact, followed by other sharing thoughts and reflections

• Ground rules: Confidentiality, voluntary, personal rather than

clinical reflection, expression rather than problem solving,

interdisciplinary attendance

• Intent is to reduce isolation, share experiences, normalize

stress, maintain compassionate care, build community &

supportive culture

• “Increased insight into the social and emotional

aspects of client care; increased feelings of

compassion toward clients; and increased

readiness to respond to clients’ and families’ needs.

• Improved teamwork, interdisciplinary

communication, and appreciation for the roles and

contributions of colleagues from different

disciplines.

• Decreased feelings of stress and isolation, and

more openness to giving and receiving support.”

https://www.theschwartzcenter.org/supporting-caregivers/schwartz-center-rounds/

Benefits of Rounds

• How does vicarious trauma affect your

organizational culture & staff?

• What do you do that promotes a culture of

resiliency? What else could you do?

• What do you do for yourself for stress

management and resiliency? What else would

you be interested in trying?

• Of the ideas discussed, what practices for your

organization and self will you take back?

Discussion Questions

Professional

Codes of

Conduct–

Career

Requirements &

Constraints

Performance

Impact • Insensitivity

• Indifference

• Impatience

• Indecisive

• Irritability

• Intimidation

• Stereotyping

• Low confidence

• Inattention

• Poor memory

• Cynicism

• Demoralization

Interpersonal &

Family Impact • Absence

• Irritability

• Family conflict

• Inappropriate

joking &

comments

• Social isolation

• Low discretionary

time

Health Impact • Substance &

med abuse

• Diabetes

• Headaches

• Eating

disorders

• Hypertension

• Heart

disease

• Insomnia

• Depression

• Anxiety

• Seizures

• Stroke

• Etc…

Stress Reaction • Sleep disturbance

• Inattention

• Fatigue

• Sadness

• Anxiety

• Headaches

• Etc…

Culture/Working conditions:

• Long hours

• Heavy case loads & behind

• Traumatic cases

• Confidentiality & isolation

• Staffing cuts & turnover

• Lack of control over outcomes

• Court cases

• Conflicts with colleagues

• Public ignorance of issues

• Public image & scrutiny

• Uncooperative professionals

• Violence & safety concerns

The Vicarious

Trauma

Process &

Intervention

Personal Factors • Empathy/identification

• Personality, temperament, style

(e.g., introversion extraversion)

• Personal history

• Resiliency

Professional Ethics &

Codes of Conduct–

Career Requirements &

Constraints

Culture/Working conditions:

• Long hours

• Heavy case loads & behind

• Traumatic cases

• Confidentiality & isolation

• Staffing cuts & turnover

• Lack of control over outcomes

• Court cases

• Conflicts with colleagues

• Public ignorance of issues

• Public image & scrutiny

• Uncooperative professionals

• Violence & safety concerns

Personal Factors • Empathy/identification

• Personality, temperament, style (e.g.,

introversion extraversion

• Personal history

• Resiliency

• Good work-life balance

• Supportive friendships

• Feeling of control

• Alertness & energy

• Constructive pastimes

• Renewed commitment to career

• Long, active & satisfying career

Stress Management • Clear boundaries

• Physical fitness

• Relaxation

• Recreation, hobbies

• Community involvement

• Writing & teaching

• Mentoring

• Friendships outside of field

• Honest dialog, etc…

…and how it can be