Healing for the healer. Burnout, compassion fatigue and self care.

Giving care to others can be stressful, professional caregivers have to strike the balance between good self care and professional care giving to others. Helping professionals need to ensure that they are robust and emotionally well in order to be able to care for others.

This can be challenging in the workplace, they may have demanding case loads, little time to reflect on practise and difficulties with managing a good life/work balance.

This makes helping professionals at risk of both burnout out and compassion fatigue.

Understanding burnout and compassion fatigue

Experiencing high levels of stress as is often the case in the helping profession, puts the individual at risk of burnout.

Burnout is caused by stressors which are external, it is not caused by internal factors and is usually shorter term than for example an episode of depression.

Burnout can often be attributed to high demands within the workplace, low levels of control and little recognition for the work you are doing.

Symptoms of burnout can vary from person to person. In interview for this article one health care professional who had experienced burnout wrote:

"I have suffered burn out when working in addictions. I addressed this by changing jobs. I knew when I was becoming detached from the work when I started becoming inefficient with my time keeping and not being concerned about cancelling appointments."

Another professional discussed how burnout left them feeling:

"I have experienced care give burnout, it left me feeling empty and unaccomplished. "

The experiences described are typical of the symptoms of burnout which include:

Physical signs:
excessive fatigue and feeling drained
changes in appetite
changes in sleeping pattern
lowered immunity
headaches
muscular aches

Behavioural signs:
isolation
withdrawal
anger and frustration
procrastination
increased use of alcohol, food or drugs
absence from work

Emotional signs:
lack of motivation
negative outlook
self doubt
feeling a failure
detachment
loss of purpose and meaning

Burnout in the care giving profession is closely related to compassion fatigue.

This is sometimes known as secondary stress syndrome, whereby the caregiver becomes traumatised vicariously when assisting the client with their problems and may over identify with the client.

This can also manifest when working with very rageful clients and in effect 'taking in' their hostility towards the practitioner.

Symptoms may include:

increased startle response
increased anxiety
increased perception of threat
sleep problems
changes in appetite
difficulties concentrating
self medicating – alcohol / drugs/food
fatigue
feelings of hopelessness and helplessness
Isolation
thoughts of dread of working with certain clients
loss of enjoyment in life
reduced self caring behaviours
inability to 'let go' of work
doubts of ability as a caregiver
intrusive thoughts and images prompted by clients trauma
compulsive helping of certain clients

How do employers support care workers in preventing burnout and compassion fatigue?

'High touch' professions such as care workers, nurses and therapists should be working under agency supervision.

However this often will be line management supervision which may take the form of 1:1 or group supervision.

The British Association for Counselling and Psychotherapy recommends therapists receive a minimum of 1.5 hours of supervision per month.

In my experience as a therapist supervision differs within each agency but usually internal supervision has been given by a line manager.

This presents it's own difficulties as the relationship with your boss, holds the dynamic of this. It is very different from seeing an external clinical supervisor for 1:1.

In my opinion this is essential in caring for yourself whilst in a caring profession, although this may be expensive typically £50-60 per session.

Similarly group supervision with peers can bring it's own challenges and I have sometimes found it difficult to be heard in this type of supervision arrangement.

It is becoming rarer for agencies within these times of austerity and government cuts to pay for external supervisors to come in to work 1:1 with therapists.

The functions of supervision are very important when considering how this space can prevent burnout and compassion fatigue.

This model developed by Proctor (1988) is frequently used in supervision within the care field. This names the functions of supervision as:

Normative: a place for the worker to reflect on their practise and examine their work

Formative: learning from the supervisor and developing the workers skills

Restorative: supporting the worker and allowing them to talk about the impact of their case load

Within good supervision there can be containment of the worker's feelings and a space to debrief.

One therapist I spoke to discussed the benefits of good quality, clinical supervision:

"I find that supervision would be better taken fortnightly however there are financial constraints preventing this.
I find supervision to be vital for my well being and for my client work.

I take my difficult cases to supervision and also use the sessions to talk about my own feelings around the work. I find my supervisor has been able to provide an atmosphere where I can be completely honest. She is also challenging which I find very helpful in my work."

This contrasted sharply with another interviewees, experience of line management supervision:

"I do not find 1 – 1 sessions helpful, in fact they not only keep me away from work but also produce more work for me."

Therefore we can argue the importance of senior managers in care agencies auditing the quality of supervision notes and providing adequate supervision training to line managers if they are supervising workers.

Agency culture and burnout

From the interviews I conducted the workload of staff was an important factor in burnout prevention.

All of the interviewees I spoke with discussed working to the demands of high targets, unrealistic numbers of clients which heightens the risk factors for compassion fatigue and burnout and leads to a lower quality of service.

One interviewee discussed how they are able to manage their case load in a more productive way:

"I am able to decide my own work load but there is a minimum amount of clients I must see each year. My manager who is not a therapist does not have any issues with how I arrange my work."

Another discussed ways that employers can improve their care for staff:

"Employers need to have a much more compassionate and holistic approach to staff who do suffer sometimes from secondary trauma.

Proper breaks, a comfortable and pleasant working environment and being properly remunerated for the work would be a step forward. "

In my experience I found that more compassionate services tend to have healthier staff with less staff turnover.

Services which adopted a less understanding, confrontational approach I often found to retain staff less and maintained a culture of unhappiness and difficulties with honest communication.

Sadly this type of un-healthy working culture can contribute to staff burning out, as an interviewee discussed:

I have experienced excessive worry or distress about my case load and received little support.

Another therapist spoke of how they:

"find generally it's the working environment and other colleagues that cause the most stress!"

Most care organisations have an employee assistance programme; this gives staff a chance to talk confidentially about what is troubling them.

Most employee assistance programmes also offer a limited amount of face to face counselling sessions to staff which are free of charge.

Another important factor for employers to consider in caring for their staff is to provide training opportunities. This can assist staff in developing competency in areas they may not be familiar with and add to confidence and competency.

It is also important that agency manager assess prospective referrals in terms of suitability for the service and for the individual worker, this is to prevent workers attempting to support clients whose needs cannot be met by the service.

It is vital that workers who feel unable to work with certain issues are able to voice their concerns and be supported within the team.

Self care for preventing burnout and compassion fatigue

When caring for others it is very important to make the space for self care. Self nurturing is vital to keep healthy and avoid burn out.

One way of doing is is making time for hobbies, relaxation and exercise. This also includes as Skovhold and Trotter-Mathison discuss in their book 'The Resilient Practitioner' making room for activities and thoughts which foster self compassion.

Mindfulness mediation and relaxation techniques could be of support as one therapist I interviewed described her weekly mindfulness group was part of her self care.

Social support outside of work is vital for self care, spending time with friends, family and pets can help to switch off from the clinical role.

As can taking time for holidays and for some practitioners time away from the caring field or finding a role with part time hours or a different specialism.

Many of the practitioners I interviewed felt that on-going personal therapy whist working in a caring role was a vital space for self care and replenishment.

Finding outlets to express your and work with emotions are vital, these might be journalling, painting, cooking or hitting the gym.

As are taking care of yourself by eating well, practising good sleep hygiene and rewarding yourself with treats such as a massage, cinema or whatever makes you feel cared nurtured.

I balance my counselling work with my hobby of sewing and find that this helps me switch off from work and takes my attention elsewhere, it has been invaluable to me in terms of self care.

Having good boundaries is also a vital part of self care, this means working in a boundaries way with clients to ensure that you do not over identify and take on their issues.

Do you give certain clients extra time in sessions? Do you keep 10-15 minutes between clients to prepare yourself and have some breathing space?

Assessing your boundaries is very important, for example are you taking work home with you? Do you check your emails when out of work? Do you worry about your work when you are at home?

These are all examples of fuzzy boundaries and lack of self care. Similarly within the agency you work for do you ask for help or tell your superiors when you are taking on too much?

Does your line manger contact you about work related matters in your free time? Are you ok with them doing this?

After experiencing burnout or compassion fatigue

Many caring professionals experience burnout and compassion fatigue. It is very important to remember that you are not alone and take good care of yourself if this has happened.

Learning from the experience of compassion fatigue or burn out is vital as is gently building resilience to help you re-build. One way of doing this is setting new goals for yourself, and assessing what needs to change for you.

It is very important after a burnout to nurture yourself and see yourself from a positive viewpoint, this will help you in maintaining an optimistic outlook which is key in re-building a sense of well being.

As with preventing burnout, after a burnout practising self nurturing behaviours and thinking is important.

Listening to your needs is key here, allow yourself the time to replenish and learn skills for self care. Make sure you ask for and accept help.

Do not remain in an isolated space but seek out the compassion and support of others. Allow yourself to express how you feel and use the experience to grow and develop yourself.

Care giving professionals do invaluable work, they are not always appreciated but I can almost guarantee that you have made a positive difference in someone's life.

Now is the time to give yourself that standard of care, you deserve to feel good about yourself, you are worth it!