January 13, 2016 Articles

Compassion Fatigue: Caveat Caregiver?

By Jennifer Baum

Most of us are familiar with the stereotype of the burned out lawyer who drags herself to work in the morning, makes cynical comments throughout the day, no longer provides her best service to her clients, and goes home bored and uninspired. You may wonder why someone so uncaring ever became a child advocate in the first place, or how she lost her spark. And you know this could never happen to you. Right?

Wrong, according to a panel of experts convened by the ABA Section of Litigation's Children's Rights Litigation Committee in a teleconference examining the phenomenon recently termed "compassion fatigue." The teleconference, "Addressing Compassion Fatigue: An Ethical Mandate," was moderated by Trenny Stovall, Esq., director of the DeKalb County Child Advocacy Center in Decatur, Georgia, and featured:

• Alexandra Dolan, MSS, LSW, from the Support Center for Child Advocates in Philadelphia;
• Josh Spitalnick, PhD, ABPP, an adjunct assistant professor in psychiatry and behavioral sciences at Emory University in Atlanta;
• Françoise Mathieu, M.Ed., CCC., the coexecutive director of TEND in Ontario; and
• Danielle Lynch, Esq., the supervising attorney in the DeKalb County Child Advocacy Center in Decatur.

This article provides a brief overview of the teleconference as well as the materials.

What Is Compassion Fatigue?
The term "compassion fatigue" has been used since the 1990s to describe the negative effects experienced by caregivers, service providers, and other employees in certain high-stress fields resulting directly from repeated exposure to traumatized victims. Studies show that so-called helping professionals who work day in and day out with victims of serious trauma can, over time, show changes in their ability to demonstrate compassion and care, and these workers can themselves also suffer from symptoms of PTSD, such as nightmares and desensitization. For lawyers who embarked on a career in children's law specifically to work with at-risk youth every day, compassion fatigue threatens our effectiveness, our compliance with ethical and professional standards, our sense of career satisfaction, our personal relationships, and our health. And for the children whom we serve, the consequences are equally dire: their safety, their confidence in the legal system, and ultimately their access to effective legal representation are also compromised. Compassion fatigue has the potential to undo decades of dedicated work, creative energy, passion, and service. It is therefore critical to understand what it is, and how to address it.

Why Should We Care?
First, why should we care about compassion fatigue? Because compassion fatigue is real and dangerous. It harms our clients, ourselves, and our loved ones, but it is preventable. It is a naturally occurring coping mechanism arising from repeated exposure to victims of serious trauma, and it strikes widely across many fields, and to a broad spectrum of practitioners, including, of course, child welfare professionals. "As a coping mechanism, there is a desensitization that takes place just to be able to do the work," says Dolan. "Pretty much every family we are working with has experienced some kind of trauma that brought them into the system." And pretty much every type of practitioner can be affected: family court lawyers, judges, guardians ad litem, children's attorneys, social workers, paralegals, "many, many members of the legal profession are at risk," according to Mathieu.

Research has shown that compassion fatigue leads to an increase in direct negative impacts on clients, including legal errors, client profiling, general disorganization, and conflict and toxicity in the workplace ("horizontal violence"), which in turn leads to decreased job performance. For example, a very complex and high-stress work environment, such as where the child welfare system intersects with the legal system, correlates directly with increased conflict in the workplace. And "if we can't get along with each other, how on earth are we supposed to deliver ethical and good quality services to those who are the most vulnerable?" asked Mathieu. There is also in increase in sick leave and workplace grievances, which is expensive and leads to high turnover, also reducing job performance and productivity.

There is also the effect compassion fatigue has on the child welfare practitioners themselves. If you think the topic of compassion fatigue is too touchy-feely to deserve your full attention, think again. While compassion fatigue does impact self-esteem, relationships (personal and professional), attitude, personal health, and weight, it can also impact trial skills or a hard-earned reputation as a tough-as-nails litigator. Employees in fields experiencing high rates of compassion fatigue, such oncology, animal welfare, veterans' services, and child advocacy, can be exhausted and on edge. They can experience nightmares, depression, anxiety, and other debilitating side effects that directly impact work performance. These outcomes cost employees time and money in direct care or indirect effects associated with lowered functioning, and they translate directly into poorer client service as well.

Causes of Compassion Fatigue in Child Welfare Professionals
What causes compassion fatigue? There are several contributing factors. One can be safety concerns for the families we work with. Child welfare is a high-stakes field involving children and family safety and well-being, and representing a child in these cases is a very serious responsibility. Additionally, children who become known to us because of a preexisting unsafe condition often place themselves at additional risk during our representation, such as by running away or acting out physically or sexually. Sometimes safety concerns for a client cross over into our own lives, such as when there are fights in the courthouse waiting area, or when we need to conduct field visits in unfamiliar neighborhoods.

Another factor might be the Sisyphus effect: repeated experience with systemic homophobia, sexism, classism, racism (and other isms), and bureaucracy can lead to feelings despair and hopelessness in daily tasks. "Wading in those waters every day . . . can take its toll," according to Dolan.

Moreover, in addition to having a heightened stress level and highly charged emotional content in our daily tasks, Dolan adds that "we are all doing this . . . at a very fast pace, we're all working with and representing a lot of clients," with back to back meetings and hearings, "and that can be a difficult formula to be successful and healthy in."

How "Compassion Fatigue" Differs from Other High-Stress Workplace Conditions
According to Mathieu, there are four primary types of negative conditions that can result from high-stress workplaces, and they can co-occur to create an extremely unhealthy and negative experience for the employee and client alike. Mathieu differentiates them as follows:

Compassion fatigue is a "gradual erosion of the ability to tolerate difficult situations and other people's suffering." It is a form of desensitization, in which the painful stories of others may not feel real anymore, or they may seem boring.

Secondary trauma results from repeated exposure to traumatic stories, leading a professional to also become traumatized even though he or she was not present for the events being discussed.

Moral distress can occur when policies and laws conflict with what we think is right, i.e., clients who "age out" into homelessness.

Burnout occurs when working conditions do not adequately support workers: inadequate pay, lack of rewards and recognition, and insufficient training can all contribute to job dissatisfaction.

How Do You Identify Compassion Fatigue?
Lynch put it this way: "You start out saying, 'I love my job! I didn't even know this kind of job existed!' [But over time that changes into] starting to feel that dread . . . all of the work I am doing is for naught, it's not really making an impact, it seems like the bad outcomes are outweighing the good."

Spitalnick identifies some warning signs:

• Feeling despair;
• Not enjoying formerly pleasurable activities;
• Feeling stressed and anxious even after you leave your stressful environment;
• Having a pervasive negative attitude;
• Feeling overwhelmed;
• Inability to pay attention;
• Sleep disturbance;
• Questioning self-worth and professional identity; and
• Feeling guilty and unfulfilled.

If you find yourself recognizing these symptoms, you can ask yourself some questions to identify whether the culprit may be compassion fatigue:

• Where do your stressful stories go after work?
• Does the training you receive include support for self-care?
• Do you feel rewarded by your organization?
• How do you protect yourself?
• What are the biggest challenges you have in your current job, and do your supervisors know that these are challenges for you? Do your subordinates or peers know?

How to Treat or Combat Compassion Fatigue
All of the panelists agreed that doing unto others starts at home. Taking good care of and being kind to yourself (in small ways, if the large ones seem out of reach for now) is critical for combating daily feelings of futility and aggravation that can eat at self-esteem: have that cup of coffee, or a piece of cheesecake. Take a nap. Read for pleasure, not for causes of action. Get up and move around—go to the gym, take a walk, listen to music, take time for prayer—do things that move you physically and spiritually.

Another way to reconnect to yourself is to reconnect with others: hold off sending that text and pick up the phone or visit your friend or colleague instead. Take a mental health day. Engage in positive "selfish and selfless acts"—activities that make you feel good and don't hurt someone else: volunteer your time for an organization you admire.

And then, Spitalnick suggests, document your activities. Journaling and writing are mechanical ways to keep positive thoughts present. He suggests using specific prompts to combat the subconscious negative self-talk that can overwhelm the compassion-stressed: name three things that make you feel grateful. List three things about yourself that give you self-worth. List one way in which the world will be better off today with you in it. Reading these lists before going to bed or when you wake up fosters positive neurochemical responses. And this, in turn, forces out—even for a moment—more negative thoughts humming in the background, and over time retrains your brain to cast off the constant negativity and reembrace the sense of hope and promise that led you to this difficult work in the first place. And yes, there's an app for that! Spitalnick recommends Breathe2Relax, an app that helps you learn diaphragmatic breathing, which has been shown to reduce stress and anxiety. There are other stress-reduction apps as well.

Together, the panelists identified several other possibilities for reducing stress and compassion fatigue in the workplace: identifying two other people in your workplace who are not negative, and purposefully engaging conversations about moving the work forward, can promote positive problem solving.

Learning to say no is a critical skill. Lynch noted that "we are lawyers, so we are very Type A. We tend to go, go, go and don't stop." But we each need to learn how to say no, or not today. Say no to working over lunch, and take your lunch hour. Say no to bringing work home with you, and avoid scheduling your most problematic cases for Friday afternoons.

While you are in the office, celebrate the silly and the irrelevant: bring in birthday cakes. Have potlucks. One juvenile court has a "sunshine committee" that holds sports-themed parties to give everyone a mental health break. It will take the cynics and the most compassion-fatigued in the office more time to come around, but it is a step in the right direction.

Control your schedule any way you can. One study showed that when offered a choice between a raise or flextime, four out of five practitioners chose flextime, because controlling our schedules is so rewarding for us.

Starting self-care should be a priority, not a luxury, according to Spitalnick. Although as Dolan and Stovall point out, self-care has a stigma about it and "we aren't allowed to be in crisis," this must change.

Beyond Mindfulness: Systemic Change
It is true, however, that "all of the spinach and yoga in the world is not going to compensate for a broken system," as Mathieu eloquently put it. That is why organizations need to foster systemic change from within. Practitioners and organizations can ask themselves "what are the rewards of this work? How does it feel to succeed? Are the practitioners adequately trained? Is there both timely and good quality supervision?"

Simply reducing individual employees' exposure to trauma can also help. Fostering job sharing of two different types of jobs (wearing two different hats) is another way to "keep it fresh" and keep the overwhelming at bay: three days a week providing direct service, combined with two days a week doing community outreach, or training and education, might be one way to accomplish this (to avoid employees "swimming in the trauma soup every day"). It is generally recommended, for example, that Internet child pornography investigators rotate out of that job periodically. Stovall noted that paralegals in her office, whose job it was to read files about traumatized families all day long, were themselves traumatized, yet they never got the reward of holding a baby or reunifying a family. Including back-office staff in front-office work or giving them an emotionally rewarding break from constant exposure trauma and negativity could boost their morale.

"Feeling pain is important because it lets us know there's something there," according to Spitalnick. But it is up to each of us to treat our pain, and that treatment starts with taking care of ourselves. Once the oxygen mask is firmly placed on ourselves, we can continue the good and hard work of helping everyone else.

Keywords: litigation, children's rights, compassion fatigue, trauma, high-stress workplace, burnout

Copyright © 2018, American Bar Association. All rights reserved. This information or any portion thereof may not be copied or disseminated in any form or by any means or downloaded or stored in an electronic database or retrieval system without the express written consent of the American Bar Association. The views expressed in this article are those of the author(s) and do not necessarily reflect the positions or policies of the American Bar Association, the Section of Litigation, this committee, or the employer(s) of the author(s).

Jennifer Baum – January 13, 2016