Setting Ethical Limits: For Caring and Competent Professionals ______________________________________
A counselor’s job is stressful for many reasons, including working in isolation; shouldering the burden of a client’s depression, anxiety, apathy, and suicidality; witnessing slow, gradual progress in the therapeutic process; and managing increasing administrative demands (e.g., insurance claims, documentation). These demands can often lead to increased stress and frustration for the counselor. Self-care includes stress management and vice versa. Self- care should be part of your preventative wellness routine, not instituted only when signs of illness or breakdown are already occurring. Activities that one recommends to clients to decrease their stress will also work for professionals. This includes healthy eating, time management, relaxation techniques, adequate sleep, and maintaining hobbies and outside interests. COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT When work-related stress is combined with a lack of self- care and support, more serious stress reactions can occur. Compassion fatigue can develop when a mental health professional cares too much or carries too much material [24]. Chronic day-to-day exposure to clients and their distress (e.g., sexual and physical abuse, military combat, community disaster) can be emotionally taxing for the helping professional and can result in compassion fatigue, vicarious trauma, or, ultimately, professional burnout [24; 25]. Vicarious trauma describes a profound shift in worldview that occurs in helping professionals when they work with clients who have experienced trauma; the professional’s fundamental beliefs about the world are altered by repeated exposure to traumatic material. Burnout describes the physical and emotional exhaustion that helping professionals can experience when they have low job satisfaction and feel powerless and overwhelmed at work. It is not the same as being depressed or overworked. It is a subtle process in which an individual is gradually caught in a state of mental fatigue and is completely drained of all energy. However, burnout does not necessarily indicate a change in worldview or a loss of the ability to feel compassion for others [26; 27; 28]. The chronic use of empathy combined with day-to-day bureaucratic hurdles (e.g., agency stress, billing difficulties, balancing clinical work with administrative work) can generate the experience of compassion fatigue [29; 30]. This type of listening and exposure can take its toll on mental health professionals, particularly when combined with the need to maintain strong limits and boundaries both inside and outside the office. Yet, no matter how well-defined the boundaries are, there will be times when the professional will be affected by listening to what the client has lived through in order to survive; it can be very difficult to hear. This is why peer supervision is necessary. The professional benefits from having a place to offload and receive support following an intense client session in order to mitigate the risk of negative consequences, such as post-traumatic stress disorder, which
can be an indirect response to clients’ suffering. Compassion fatigue can also cause professionals to lose touch with their own empathy. Strong emotions, as evoked by traumatic material, may strain the empathic ability of the therapist [31]. Symptoms of compassion fatigue result in a loss of interest toward holding empathic response to others due to feeling overwhelmed and burdened by the client’s trauma and illnesses. Caregivers with compassion fatigue may develop a preoccupation with re-experiencing clients’ trauma; they can develop signs of persistent arousal and anxiety as a result of this secondary trauma. Examples of this arousal can include difficulty falling or staying asleep, irritability or outbursts of anger, and/or exaggerated startle responses. Most importantly, these caregivers ultimately experience a reduced capacity for or interest in being empathic toward the suffering of others [32]. Overlap can occur between compassion fatigue, vicarious trauma, and burnout, with the mental health professional experiencing more than one emotional state. Some causes of burnout and compassion fatigue can result in part from the personality characteristics of the professional (e.g., perfectionism, overinvolvement with clients) [33]. Because burnout is largely identified in young, highly educated, ambitious professionals, many consider the conflict between an individual’s expectations and reality as one of the main characteristics of burnout [27]. Additionally, the professional’s attitudes, beliefs, and assumptions can have an impact on performance (e.g., “I must get all my clients better’’) and may lead to irritation, a sense of failure, or burnout. Some attitudinal issues are specific to particular client groups (e.g., people who get hostile or perpetrators of sexual assault) or to particular elements of the therapy process (e.g., “I must be available for all of my clients all the time’’) [34]. In order to prevent or decrease cases of burnout, compassion fatigue, and vicarious traumatization among professionals, it is important that they receive education on the signs and symptoms of each and that they have access to an open and supportive environment in which to discuss them.
MITIGATING THE COSTS OF CARING Disengage
As noted, counselors are at increased risk for compassion fatigue, burnout, and/or vicarious trauma when the majority of their caseload involves trauma cases; when there is a lack of balance between work, rest, and play; and when there is a lack of attention to spiritual needs. To reduce their risk, counselors should learn to let go and leave work at work—they should learn to disengage. Disengagement can lower or prevent compassion stress by allowing counselors to distance themselves from the ongoing misery of clients between sessions. The ability to disengage demands a conscious, rational effort to recognize that one must “let go” of the thoughts, feelings, and sensations associated with client sessions in order to live one’s own life. Disengagement is the recognition of the importance of self-care and of the need to carry out a deliberate program of self-care [30]. When counselors employ self-care, they model for their
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