For eight years, Dr. Beth Hudnall Stamm was a professional ski patrol member, performing rescues on steep terrain in remote areas around the country. During those years, she began to notice that different patrollers reacted differently when her team had to perform stressful rescues, especially when a death was involved.

"There were certain people who would get sick, and wouldn't come back to work for a few days," said Stamm. She began to think about how caretakers in general were affected by their encounters with trauma. Her curiosity led her back to school and into the field of research psychology. Now, assistant director of the Institute for Rural Health Studies at Idaho State University, Stamm until recently headed the Veterans Affairs National Center for Post Traumatic Stress Disorder Research in Vermont. For the past few years, she and colleagues, Edward M. Varra, MA, and Joseph M. Rudolph, MA, have been directing a wide-ranging research project into the effects of trauma.

"We asked 1,200 people to give us narratives on all their stress experiences," said Stamm. "We had everything from my dog died' to horrific tales of abuse."

As they listened over and over to the stories told by their research subjects they began to see that their world view was shifting.

One day, one of the researchers came running down the hall exclaiming exuberantly, "Oh, look! I've got a good one! A male rape victim."

"We began to think we have a problem here," says Stamm. "We were still all babes in the woods in understanding trauma and how it affected people."

Defining the problem
When you care about what you do, it's hard not to take your work home from the office.

You can't just shut it all off when the clock strikes 5.

The mathematician may go home with sums in his head. The musician may take a melody to bed. A secretary may be haunted by stacks of unprocessed paperwork

. But those who labor on the front lines of human experience may be haunted by something far more troubling: images and emotions that arise in the course of another day's work with victims of trauma and abuse.

Those secondhand experiences have the power to change the way we think about our world and the way we live in it.

Psychological toxic waste
"Mental health professionals en-counter the toxic waste of the world' on a daily basis," says Stamm.

Sitting in the comfort of a clinician's office seems safe enough Ñ but the calm surroundings belie the spectres that lurk there Ñ especially for those who bring the highest level of commitment to their work. Those who counsel the troubled, the depressed, the victims and survivors of the world, know all too well that life is not safe; that risk can't be entirely avoided no matter how many precautions we take.

Clients turn to mental health providers to tell the stories they can tell no one else; to share and hopefully to overcome, the psychic damage that has been done as a result of a trauma in their pasts.

The therapist hears not one story, but many stories. As human beings, they can't help but be affected by it all. There are stories they can't forget. At some point, they may "burn out" in a very particular way, exhibiting symptoms of what has come to be called "compassion fatigue" or "secondary victimization" or "secondary post-traumatic stress disorder."

Unlike the broader definition of "burn out," which can be caused by an accumulation of stresses in the workplace, or countertransference, which occurs when a client reminds a therapist of someone in his past, compassion fatigue directly results from a caregiver's interaction with abused or traumatized individuals.

Post-traumatic stress: the pre-curser to compassion fatigue
Since the Vietnam War, it has become commonly accepted that a traumatic experience can have long-lasting, sometimes permanent effects.

Post-traumatic Stress Disorder is a term that entered the common language in the post-Vietnam era to describe the plight of returning combat veterans who were exhibiting a variety of stress-related symptoms long after their return to "normal" life.

It was a syndrome of particular interest to psychologist Charles Figley, head of the Psychosocial Stress Research Program at Florida State University and a Vietnam Veteran himself.

After his return from the war, Figley became active in the anti-war movement. He founded a chapter of Vietnam Veterans of America and he went to Washington, D.C. with other veterans to throw his medals on the steps of the Capitol building to protest the war in Viet Nam.

While in Washington, the veterans camped out together, an experience that brought many of the veterans uncomfortable reminders of their time in Viet Nam.

Figley became aware early on that many veterans of Viet Nam weren't doing well in their post-war lives. Many had alcohol and drug problems. There were broken marriages and high levels of unemployment.

Seeking a more productive outlet for his own feelings of anger and betrayal, Figley decided to turn his attention to research in an effort to demonstrate that the traumas of war live on long after the conflict has ended.

After graduating from the University of Pennsylvania, he established the first consortium for veteran's studies at Purdue University.

Over the next few years, he interviewed more than 800 Viet Nam veterans. He was deeply affected by the stories he heard.

"It was really kind of noticing that we were helping people in harm's way, but that we were succumbing to the same disorder," said Figley, whose recently published book, Compassion Fatigue, provides an in-depth review of the problem.

While interviewing a man who had been a medical corpsman in Viet Nam, Figley began to realize that many of the veterans he interviewed were suffering not only from what they had directly experienced, but also from the harm they had seen inflicted upon others.

The corpsman described to Figley the emotional wounds he suffered as a medic in Viet Nam.

"He talks about the emotional pain not so much for fear of being killed but for fear of someone dying in his arms," said Figley.

As Figley broadened his research into the phenomenon of post-traumatic stress, he became aware that this secondary suffering on the part of the corpsman was similar in nature to that experienced by a wide variety of people in the helping professions: emergency service workers, child protection workers, therapists, doctors, nurses, prosecutors, clergy and journalists who frequently have encounters with people in extrememly distressing circumstances.

Effects on the caregiver
Compassion fatigue may come on suddenly. A treatment professional who has an episode of trauma or abuse in his or her own background may be particularly at risk when a client relates a similar experience.

But compassion fatigue may also set in gradually, as the caregiver finds him or herself becoming increasingly affected by secondhand encounters with the human horrors of trauma and abuse.

The effects of this secondary victimization may turn up in the clinician's private life long before her professsional life is affected: the "go-home-and-kick-the- dog" syndrome.

There may be nightmares; tension; insomnia; a mental revisiting of the trauma the patient confided; a pervasive sense of insecurity; hypervigilance.

In the work environment, a therapist may find himself inappropriately joyful over the news that a client has cancelled a session.

When compassion fatigue sets in, many counselors and caregivers may begin to question their worth; to wonder if they are cut out for the job they're doing. And in a profession dedicated to assisting others in overcoming trauma, it can be difficult for caregivers to seek help for themselves.

How big is the problem?
"The incidence of compassion fatigue within the helping professions can't be overstated," Figley said.

n a study done in Georgia in the mid 1990s, Figley reports 38 percent of counselors were found to have active, secondary post-traumatic stress disorder. Many more of the study participants were found to have had symptoms of SPTSD and later recovered.

Those statistics are only the tip of the iceberg, Figley believes. Ironically, it is a syndrome associated with the most competent professionals.

"It's really weird, because we weren't expecting it," said Figley. "Those people who were most empathic were the ones who were most at risk. It is in some ways a conundrum. If you are not empathic and compassionate, you won't get compassion fatigue. But you won't get any clients coming back, either."

For the caring professional, the reality of the situation is not "if it's going to happen, but when," says Figley.

The incidence of compassion fatigue is on the rise in the healthcare professions these days as a result of managed care policies that have increased patient loads and negatively impacted the rewards a clinician experiencees from knowing that he or she has given good care.

Change can't occur soon enough for Dr. Jennifer Bolen, a psychiatrist in practice at Virginia Mason Medical Center in Seattle, Washington who frequently counsels fellow physicians at risk for burnout and compassion fatigue.

With the current healthcare system in a state of collapse, physicians are being asked to treat more and more patients in less and less time.

Patients admitted to hospitals these days are more acutely ill. Psychiatrists are seeing "the sickest of the sick." The incidence of assault on healthcare providers is skyrocketing. "All you have to do is be in the emergency room and you are going to have your life threatened more than once," Bolen says.

With sicker patients, increased patient loads and higher risk of lawsuits as a result of physician error and assaults as a result of patient violence, the burdens on treatment professionals struggling to render adequate care in an unsupportive environment are enormous.

In general, the current healthcare system doesn't encourage a sense of compassion satisfaction, and the consequences are devastating. "What we are seeing is a fairly high rate of people leaving the field," Bolen says.

In a community with a large multicultural, immigrant population, Dr. Bolen finds many patients come to her with major trauma in their histories. As treatment providers act to protect themselves, compassion fatigue sets in.

As Figley puts it, "You are losing your sensitivity and your humanity and your sixth sense in terms of what is going on. For instance, you might have CF if you check your voice mail and your client cancels and you start dancing."

One colleague of Bolen's, known as the staff "Teddy bear" because of his caring manner, was unsettled for days after a patient of his "got up and got in his face and accused him of being abusive to her," Bolen says.

The knowledge that such a thing could happen to one of the staff's most compassionate professionals contributed to a growing sense of unease for many of his colleagues. "It's hard to protect yourself from compassion fatigue," Bolen says.

"It's hard to protect yourself from being mugged, raped or assaulted. You can't, with entirety, go around and prevent bad things from happening."

During a seminar last fall on Patient Rage, Bolen related, a local attorney from the county stalking unit related the tale of a physician who was actively stalked for four years by an ex-patient.

Another physician who had been targeted by members of the anti-abortion movement, wore a bulletproof vest to work for five years before she ultimately decided to retire. "She retired earlier than she might have because of those experiences," Bolen said.

Those stories stay in the minds of those on the front lines of medical and psychological treatment, ultimately affecting the quality of care they are able to give.

Finding the cure
The good news about compassion fatigue is threefold: it's a disorder that affects those who do their jobs well; it is highly treatable; and most importantly, its negative impact is often tempered by a phenomenon that Stamm terms "compassion satisfaction."

With increasing focus on the problem of compassion fatigue, Stamm began to think about the rewards that walk hand in hand with the disadvantages of working with victims of trauma and abuse.

Stamm began to develop a theory of "compassion satisfaction." As she puts it, "Why were so many people who worked around trauma doing well? Was it the sustaining positive resources? Slowly it became clear that to understand the negative costs of caring,' it was necessary to understand the payments' that come from caring."

While working as a consultant to the ZwaZulu-Natal Programme for Survivors of Violence in South Africa, Stamm observed that the program's founder, Craig Higson-Smith and his colleagues maintained a hopeful sensibility despite the fact that 20 to 100 people each month were dying as a result of low-level warfare in the area. "The people in this clinic continue to press on, often with joy. What I observed was not a negation of the struggle, but a celebration of hope. Were we asking only half the question?"

What Stamm discovered was that even though the South African rescue workers were experiencing high levels of compassion fatigue, they were also experiencing high levels of compassion satisfaction.

"...many of them like their work because they feel positive benefits from it," she wrote. "They believe what they are doing is helping their country, and in some ways, that it is even redemptive. Certainly, they believe that it is the right thing to do."

"Compassion satisfaction", Stamm proposes, "may be happiness with what a person can do to make the world in which he or she lives a reflection of what he or she thinks it should be."

While research into the area of compassion satisfaction is ongoing, Stamm is hopeful that identifying the components of compassion satisfaction may one day help to create policies and practices in the mental health field that will reduce the risk of burnout and compassion fatigue.

"In my heart of hearts, I dream that there is some kind of way we can understand the balance between satisfaction and the destructive aspects of trying to deal with this horror. My ultimate message is one of hope", said Stamm, who recently submitted a grant proposal for a statewide intervention program open to all healthcare providers.

A supportive work environment, close relationships with colleagues and a feeling that the work they do is making the world a better place are some of the positives that can balance the seesaw between compassion fatigue and compassion satisfaction, Stamm believes.

"Another potent antidote to the experience of secondary victimization is humor," Figley points out, relating a true story about two American soldiers who were captured by the Vietnamese, tied up on boards and left exposed to the burning sun in the heat of Viet Nam. "You look like hell," one told the other.

There are many experiences too devastating to be laughed about; but laughing when you can laugh is one way of releasing some of the stress that accompanies trauma.

Those who do suffer long-term may need the help of a caring professional to leave the past behind them and move on.

"Leaving the past behind doesn't mean that they forget what has happened," Figley stresses. In fact, they may remember more clearly, but the memory will no longer carry the same emotional weight that it did before.

"The hardiness of the human spirit helps most people come to terms with tragedy in their lives and move on", Figley agrees. In most cases, people eventually overcome the problems associated with the trauma and get better on their own.

But others may be kept prisoner by an experience that is locked inside them.
"On television shows," Stamm says, "a cop involved in a traumatic event is sent home for a few weeks. In real life, that way of dealing with the situation may just give the individual time to go home and ruminate.' A much better technique is to ensure that that person has support on a professional and also on a spiritual level, to get through the emotional crisis that is generated by compassion fatigue."

The 120 clinicians who are assisting with Stamm's trauma study and their supervisors make a practice of meeting at least once every other week as a preventive tactic in staving off compassion fatigue.

"We've had a few situations where, even as a supervisor, I have been so horrified by what I have heard," Stamm admits.

Stamm herself maintains a close relationship with colleagues across the nation via e-mail and teleconferencing. She doesn't hesitate to turn to them for help when she feels herself getting overwhelmed by the effects of secondary trauma.

"As a profession, we've made it difficult for people to ask for help," she says. "We define being wounded by your work as quote-unquote crazy.' If the institution thinks there is something wrong with you, there is no way you can admit it."

Efforts to intervene along the downhill slope that leads to compassion fatigue and burnout are growing. Crisis intervention programs for at-risk treatment professionals are taking place around the nation.

Treatment professionals are being guided in ways to "back off and set better boundaries" with patients.

t's important for those who deal daily with victims of trauma and abuse to remember to take good care of themselves. Stamm strongly advocates establishing close relationships with coworkers and colleagues who can monitor how you're doing and provide support when things begin to seem overwhelming.

"Basic self-care, such as getting enough sleep, taking two consecutive weeks of vacation and making time for hobbies and family life are also important," she says.

When you can't change the world, you can still achieve satisfaction in knowing that you can change a small part of the world, and that feeling can help to distance the caregiver from a close encounter with the horrors of the world.

Figley's program includes five or six different treatments for compassion fatigue, which include two days of desensitization training.

"Stress reduction mantras" such as "I'm only one person" and "This too shall pass" are tools a therapist can employ after dealing with a particularly stressful client.

All of us encounter the horrors of what we're working with," says Stamm. "Sometimes you just can't shake it. You need to step back for a while."

Eileen Moon is a freelance writer in Atlantic Highlands, N.J.

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