Motivation and emotion/Book/2022/Compassion fatigue in mental health professionals

Overview
Compassion hurts. When you feel connected to everything, you also feel responsible for everything. You cannot turn away. Your destiny is bound to the destinies of others. You must either learn to carry the universe or be crushed by It.

The World Health Organisation (WHO) released a report in 2022 regarding national responses to mental health treatment globally. This report found that there are gaps in mental health services, there are several factors impacting people seeking treatment and the economic impacts of mental health were significant. The report found that further to this trained mental health professionals were scarce and there were national shortages of paid mental health workers including social workers, psychiatrists and counsellors (World Health Organisation, 2022). Given this shortage, it is important to focus attention on the recruitment and retention of mental health professionals.

This chapter focuses on compassion fatigue which may contribute to the impact of retention of mental health professionals as demonstrated by studies such as by Cao and Chen (2021) in their study of Chinese haemodialysis nurses. They found that compassion fatigue was the strongest predictor for nurse’s willingness to leave their employment.

Focus questions:


 * What is compassion fatigue?
 * What causes or predicts compassion fatigue in mental health professionals?
 * What are the impacts of compassion fatigue?
 * How can we prevent and treat compassion fatigue?

What is compassion fatigue?
As witnesses and healers, we cannot help taking on the emotional pain of those we are privileged to know and care for.

Compassion fatigue defined by the literature
The term compassion fatigue began appearing in literature in 1992 (Figley, 2002a) to describe nurses who were exhausted from managing emergency situations in hospitals. Figley (2002a) defines the term compassion fatigue as a ‘user-friendly’ alternative to ‘secondary traumatic stress disorder’ which seeks to label the impact of a person’s trauma on the emotional well-being of others, which typically occurs in professional or familial contexts. Compassion fatigue is often defined as an inability to cope with emotional distress as a result of helping others that are suffering (Gustafsson & Hemberg, 2022).

Related terms
Post-Traumatic Stress Disorder - Compassion fatigue is contrasted from post-traumatic stress disorder (PTSD) due to the ‘cause’ of the impact; PTSD is often the result of a direct individual experience according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013). It is likely that at a first thought most would not liken the experience of army veteran to the experience of a clinical psychologist, and nor should we. However, we will see later in this chapter that the impacts (symptoms) to individuals experiencing PTSD and compassion fatigue can be the same (Figley, 2022a; Pirelli, 2020).

Vicarious Trauma - Vicarious Trauma typically occurs in the context of repeatedly hearing of traumatic events occurring to another, such as a client (Pirelli, 2020). Vicarious trauma may cause changes to an individual’s ideology, cognitions and emotions (Hatcher & Noakes 2010). Vicarious trauma is similar to compassion fatigue in that it can be described as an emotional consequence of professionals being exposed to traumatised clients (Huggard et al., 2017) and can also present with similar symptoms to that of PTSD (Branson, 2019).

Burnout – Has been defined as a concept that impacts on work engagement from prolonged experience of stressful conditions (Hatcher & Noakes, 2010). Burnout is considered different to compassion fatigue in that it is attributed to workplace stress, for example meeting high job demands (Wynn, 2020), not exposure to another person’s distress (Figley, 2002a).

Branson (2019) notes there is a vulnerability in the validity in the literature regarding these interrelated terms exists in part due to using incorrect terminology, i.e.: using the term vicarious trauma when actually referring to secondary traumatic stress.

{Compassion fatigue and vicarious trauma are exactly the same. - True + False
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Mental health professionals
Beyond Blue (2022) defines a mental health professional as someone who is qualified in the treatment and management of mental health conditions. Whilst this list is not exhaustive this may include (Beyond Blue 2022):


 * General Practitioners
 * Psychologists
 * Psychiatrists
 * Mental Health Social Workers
 * Mental Health Occupational Therapists
 * Aboriginal and Torres Strait Islander Health Workers
 * Crisis Assessment or Acute Treatment Teams

Compassion in mental health professions
To understand compassion fatigue, it can be helpful to understand the definition of compassion. Compassion as defined by the Cambridge Dictionary (2022) is ‘a strong feeling of sympathy and sadness for the suffering or bad luck of others and a wish to help them’. Compassion is integrated into the daily work of a mental health professional (Joslin, 2021). The degree to which mental health professionals use compassion and empathy in their interactions with clients is seen to impact whether the client likes and trusts that professional (Figley 2002a; Figley 2022b). Client liking and trust are fundamental to building a therapeutic alliance (Figley 2002a; Figley 2022b). A strong therapeutic alliance has been thought to aid in the improvement of recovery outcomes in the treatment of issues including but not limited to: substance abuse disorders (Wiprovnick et al., 2015) psychosis (Browne et al., 2019) and depression (Cooper et al., 2015).

The development of compassion fatigue
A systematic review of 15 studies conducted by Singh and colleagues (2020) examined responses of 3356 participants from varying mental health professions. They reported that 19.8% of participants were experiencing some level of compassion fatigue. Both personal and workplace factors were identified as important contributors in developing compassion fatigue among mental health professionals (Singh et al., 2020).

Workplace and individual factors
Individual differences may predispose people or protect people from developing compassion fatigue. A study by Duarte, & Pinto-Gouveia (2016) looked at the impacts of empathy on compassion fatigue in two hundred and ninety-eight nurses and found that empathy could indeed be a risk factor for compassion fatigue. Udipi et al. (2008) surveyed 222 genetic counsellors and found that 7 intrapersonal and situational factors were associated with over 50% of the difference in compassion fatigue scores. Personal factors included having needs met through work, being self-critical and experiencing personal crises. They also found mental health professionals who are ‘burnt out’ have less ability to manage their stress and may result in an increased likelihood to develop compassion fatigue (Udipi et al., 2008).
 * Individual


 * Workplace

The context of the workplace can also be a risk factor for developing compassion fatigue. Research has demonstrated that may be a link with factors such as having a larger case load (Udipi et al., 2008), working with traumatised clients, working in inpatient care (Craig & Sprang, 2010), and a lack of support from supervisors (Bell et al., 2019). Another factor that has been linked to compassion fatigue is exposure to traumatic events. For example, Bell et al. (2019) conducted research with mental health nurses working in a large prison in London and found that 48% of nurses had been exposed to inmates engaging in self-harm or attempted suicide between one and ten times. These factors help us understand why compassion fatigue was described by Singh et al. (2020) as an ‘occupational health issue’ in his systematic review. .

Impacts on mental health professionals
Compassion fatigue can impact those experiencing it in a range of ways from the more immediate, such as difficulty sleeping, irritability and difficulty concentrating (Figley, 2002a). But may also contribute to the development of mental health conditions such as depression or anxiety (Cocker & Joss, 2016). Compassion fatigue may cause some mental health professionals to leave their profession altogether (Figley, 2002b). Todaro-Franceschi, (2019) identified the impacts for individuals under three categories: behavioural, emotional and physical, some examples can be seen in the table below.

Impacts to clients
Compassion fatigue in mental health professionals can also impact on those needing help. For example, it can impact working relationships, reduce productivity, and increase turnover (Showater, 2010). Compassion fatigue may also lead to mental health professionals to have a lack of understanding of client needs and cross boundaries (Figley, 2002a). Compassion fatigue may also impact the development of a therapeutic alliance (Figley, 2002a).

{What are signs someone may be experiencing compassion fatigue?. - Headaches. - Excessive substance use. - Difficulty sleeping. + All of the above.
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Workplace and individual measures

 * What can workplaces do?

Just because mental health professionals expect to experience traumatic events as a part of their work does not mean that they are not distressing, mental health professionals should be able to receive support before and after such events (Bell, 2019). A common support mechanism for mental health professionals is supervision, however, research indicates that the quantity of supervisions occurring is less important to mental health professionals than the quality (Sodeke-Gregson, 2013).

Compassion fatigue in the literature was also reduced where in which mental health professionals reported support from supervisors and co-workers, as well as adequate job resources (Singh et al., 2020). In addition to this, supervisors could be mindful of personal factors that may increase someone’s risk for compassion fatigue such as living alone (Bell, 2019). Providing mental health professionals with information about compassion fatigue so they can understand it, encouraging coworkers to talk to each other about compassion fatigue (Figley, 2002b), and providing Employee Assistance Programs (Todaro-Franceschi, 2019) may further help to reduce compassion fatigue.


 * What can mental health professionals do?

Before mental health professionals can act on compassion fatigue, they must first understand it (Figley, 2002b) and have self-awareness of it within themselves (Todaro-Franceschi, 2019). This awareness allows mental health professionals to act such as accessing counselling, requesting debriefing, or scheduling time off, taking action is a protective factor in itself (Todaro-Franceschi, 2019).

Having social support is a protective factor for a few reasons; at work, peer support can act to break the silence regarding compassion fatigue which Figley (2002b) compared to the silence of other critical issues such as family violence and racism. In addition to this mental health professionals seem to really embrace their professional identity and conceptualise that they are there but to serve others, this can reduce the likelihood they will seek help for themselves (Figley, 2002b). Increasing personal social connections outside of professional connections is said to increase the mental health professionals’ feelings of humanity and increase the likelihood of them accessing support (Figley, 2002b).

In addition to having others to support us, we need to look after ourselves. The term self-care summarises the actions that we take to look after our health according to the world health organisation. Self-care includes looking after our physical health and taking care of our bodies such as by eating well and limiting substance misuse (Todaro-Franceschi, 2019). However, self-care may also include making time for things you enjoy, staying connected to people who matter, and being aware of things that make you smile (Todaro-Franceschi, 2019) i.e.: observing a pretty flower.

Why do mental health professionals do this work?

 * Let's talk about compassion satisfaction

Compassion satisfaction is a term used to describe the joy a mental health professional experiences from feeling they are doing a good job (Bhutani et al., 2012). The degree to which people experience compassion satisfaction can be heavily impacted by contexts occurring in the workplace. Compassion satisfaction could be seen in some research to be increased when there was perceived support from supervisors (Sodeke-Gregson, 2013). In addition to this Sodeke-Gregson (2013) found that increased time engaging in research and development opportunities increased compassion satisfaction. Increases in age, as well as increased time spent in employment in the field, were related to increased compassion satisfaction, it was theorised that older and/or more experienced mental health professionals may have developed ways to cope (Sodeke-Gregson, 2013).

Poor working conditions and under-resourcing can decrease compassion satisfaction (Bhutani et al., 2012). Bhutani et al. (2012) discussed in their medical exploratory study that they had found that clinicians in government jobs experienced significantly less compassion satisfaction as compared to their privately employed peers. It was suggested that private workplaces had better work equipment, trained staff and good working conditions that promote compassion satisfaction

Conclusion
There is a world-wide shortage of mental health professionals (WHO, 2022) and compassion fatigue is a phenomenon contributing to professionals leaving their employment (Figley, 2002a; Showater, 2010; Cao & Chen, 2021). Compassion fatigue is seen in the literature accompanied by terms such as burnout, post-traumatic stress disorder (PTSD) (Figley, 2002a) and vicarious trauma, but is distinct from these (Branson, 2019).

Some mental health professionals are more at risk than others due to individual factors such as being self-critical or having a personal crisis, or workplace factors such as high workloads (Udipi et al., 2008), or a lack of support from supervisors (Bell et al., 2019).

Compassion fatigue impacts mental health professionals physically, behaviourally and emotionally (Todaro-Franceschi, 2019) and can also contribute to the development of mental health conditions (Cocker & Joss, 2016). Compassion fatigue also has an impact on people seeking mental health support as their needs may not be correctly understood (Showater, 2010) or they may have difficulty developing a therapeutic alliance (Figley, 2002a).

As the development of compassion fatigue occurs within the context of the individual and the context of the workplace it can be managed both in these contexts. Workplaces can support mental health professionals to be less at risk of compassion fatigue by providing support before and after traumatic events (Bell et al., 2019), resource professionals adequately to do their jobs (Sing et al., 2020), and by providing employees with information regarding compassion fatigue (Figley, 2002b). Mental health professionals can reduce the risk for themselves by talking about compassion fatigue with others, expanding their social circles and looking after their mental and physical health (self-care).

Compassion satisfaction refers to a concept regarding feeling enjoyment from being compassionate at work and feeling you’re doing a good job (Bhutani et al., 2012). Compassion satisfaction increases were notable when people had good working conditions (Bhutani et al., 2012).

To support the retention of mental health professionals globally it would seem that whilst an individual can take steps to manage compassion fatigue. Working conditions and experiencing burnout are strongly related to compassion fatigue (Udipi et al., 2008), if the issues cannot be addressed on an individual level, and workplaces don’t support staff effectively, mental health professionals could develop working groups to improve working conditions and also to raise awareness within their respective workplaces.