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    Kathie 
    Erwin

    EdD, LMHC, NCC, NCGC

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  • Cultivating the Quality of Contentment, Part I

    As shall be demonstrated in this series, cultivating the quality of deep-seated contentment constitutes a key cornerstone in integrating a wellness mindset and lifestyle into recovery from alcoholism, drug addiction, and other addictive disorders. 

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  • National Perspective

    Over the past few years, the federal government has made a noticeable investment in fighting opioid abuse. Traditionally this subject was the purview of federal agencies such as the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA), or even the Veteran’s Administration (VA).

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Addiction Counselors in the Compassion Fatigue Cycle

Feature Articles

In Greek mythology, King Sisyphus was condemned to roll a huge boulder up a steep hill with only a moment of satisfaction before it rolled down the hill and he trudged back to repeat this endless cycle. Counselors who are committed to helping clients with addiction can understand Sisyphus’s struggle. As these counselors work diligently session after session to impart hope and come alongside clients in the early stages of counseling, there are moments of wonder in which the top of the hill seems achievable. With success in sight, the lure of the addiction becomes more powerful than the struggle and the “rock” rolls down the hill again. Dealing with this cycle of ups and downs in addiction treatment can take a toll on even experienced counselors. Some attempt to deny it, others mask the disappointments in harmful ways or assume a cloak of invincibility, but all are at risk for compassion fatigue. Borrowing phrases from Albert Camus’s essay The Myth of Sisyphus (1942), let’s explore the rocky road into and out of compassion fatigue.

 

Overcome by “Futile and Hopeless Labor”

 

Clients living with addiction may feel abandoned, alone, and discouraged as their addiction separates them from family and friends. The acceptance and compassion shown to them by addiction counselors is crucial for building therapeutic trust and a bridge to hope. However, as Dr. Charles Figley (1995) identified twenty years ago, the cost of sustained compassion and ongoing exposure to the client’s suffering can lead to secondary traumatization which later became known as “compassion fatigue,” a serious concern for counselors and other first responders. Yet there almost seems to be a conflict inherent in this condition since the nature of counseling is to actively listen to the details of suffering, trauma, fear, and despair. Some clients tell their stories in such vivid manner that counselors can feel captured by the descriptions and unable to shake the emotional impact. What escalates the stress to a higher level, according to Figley (2002a), is when it reaches “a state of tension and preoccupation with traumatized patients by reexperiencing the traumatic events, avoidance/numbing of reminders and persistent arousal associated with the patient” (p. 1435). 

 

Compassion fatigue is more than burnout, more than frustration with charting treatment notes, more than feeling underpaid and overworked, yet it can be complicated by some or all of these frustrations. “Burnout” is a catchphrase from the past millennium that persists as a sociological phenomenon which glorifies the multitasking, fast-paced existence. However, years earlier Pines and Maslach (1978) recognized how this overload can adversely impact counselors and social workers years before it became trendy. Figley’s (2002b) work in developing treatments further clarified the significant differences between burnout and compassion fatigue as an impact on mental health professionals who work with traumatized clients. Compassion fatigue is not confined to counselors who work on the front lines of a disaster or in other settings with traumatized clients. The nature of vicarious or secondary traumatization is not linked to a place, a situation or any direct proximity to the trauma incident. Thus it can catch counselors by surprise to be catapulted into an almost imperceptible moment of transference when clients’ traumatic experiences cross over into the psyche of counselors. That point of emotional contact can be difficult to identify, but the residual impact is noticeable first in small ways that gradually becomes overwhelming.

 

Keep in mind that some counselors choose to specialize in addiction counseling as a way to “pay it forward” for their own recovery experiences. However, listening to stories of traumatic incidents connected with addictive behaviors can trigger traumatic memories from their own addiction history. And thus the boulder that was secured at the top of the mountain begins to slowly and steadily roll downward . . . how far will it fall? How hard will it be to roll back the boulder while maintaining enough fortitude to help clients roll back their boulders? When does the struggle become too much?

 

Annie Fahy (2007) writes about compassion fatigue among substance abuse counselors with an insider’s perspective daring to say what others silently bemoan in her insightful article, “The Unbearable Fatigue of Compassion: Notes from a Substance Abuse Counselor who Dreams of Working at Starbucks.” Along with the difficulties of working in budget-strained treatment programs and with increasingly difficult clients, Fahy (2007) points to the unseen burden of counselors’ role confusion and mixed expectations to “straddle the high wire of therapeutic relationship, behavior monitor, and reporter to the judge” (p. 200). Fahy (2007) notes another less obvious issue exists because “most substance abuse workers believe that stabilization of substance abuse actually brings up more symptoms if the substance was used to numb PTSD symptoms. Abstinence may actually exacerbate symptoms and create another kind of coping crisis” (p. 201). Following the long tradition of developing autobiographies as part of the treatment, clients read and discuss these past incidents in individual and group counseling. Fahy (2007) suggests that this emphasis on “truth telling” has “a high potential to elicit trauma material” (p. 202). While the attention may be given to how this affects clients, less attention is paid to how repeated exposure to these detailed stories impact counselors.

 

The Conscious Hero’s Awareness

 

At some point, Sisyphus had to realize that the stone was not going to stay on the mountain. Yet he went back to the valley, fully conscious of what would happen again and again. With the same persistence, addiction counselors shake off yesterday’s frustrations and client disappointments to press ahead for the next day. Those who are able to continue in this field and maintain their emotional well-being must become “conscious heroes.” Compassion fatigue does not have to sideline capable counselors or cause them to leave the field where their expertise is desperately needed. The real heroes are those who admit their limitations and seek support for emotional overload. 

 

At what point does the burden of counseling become compassion fatigue? The symptoms of this secondary traumatization are similar to those seen in clients. To place these in a context of the counseling relationship, these are symptoms of concern that are early warning signs of compassion fatigue:

 

  • Persistent intrusion of client stories and emotions into one’s thought processes and feelings
  • Client stories have become triggers for one’s past trauma memories
  • Unexplained emotional changed such as low frustration tolerance, sarcasm, anger or rage
  • Attempts to avoid certain clients without explaining the reason to supervisors 
  • Hyperarousal, even when situations do not warrant vigilance
  • Taking out work frustrations on partner, children, family or friends
  • Inability to emotionally leave work at the office
  • Casting blame on self or others in a depreciating manner
  • Increasing of self-medication, whether with substances, exercise, food, smoking, prescription drugs or other external sources
  • Isolating with solitary hours of television or Internet gaming 
  • Negative attitude toward potential efficacy of counseling and/or one’s ability to effectively counsel
  • No longer able to distinguish transference and countertransference with clients
  • Unwillingness to discuss these concerns with a supervisor or seek outside supervision/counseling

 

The presence of any of these compassion fatigue symptoms is cause for concern. When counselors fail to recognize the symptoms leading to compassion fatigue, colleagues or supervisors must confront these counselors in a proactive manner. Evaluating the impact of compassion fatigue also involves breaking through the denial. Often the first response is to deny, minimize, and become angry at being confronted with these symptoms. In some work situations, such as a hospital or treatment program, admitting to the symptoms may mean being relieved of counseling duties for a time. That can leave a financial impact as well as concern about professional reputation. It can feel that these counselors are being singled out as ineffective. Just as Hippocrates cautioned a physician to “heal thyself,” that can be a difficult message to hear. The conscious heroes are the counselors who can take in that message and recognize that it is a blessing, not a curse, for helpers to receive help.

 

So in which work settings are addiction counselors most likely to fall victim to compassion fatigue? There is no single place where this can happen. Lent and Schwartz (2012) suggest that counselors working in community mental health are substantially more at risk than counselors working in private practice or within an inpatient treatment program. A look at several other studies seem to suggest that the workplace is not in and of itself a breeding ground for compassion fatigue. However, receiving emotional support and social connectedness from counselors and supervisors in the workplace was an important factor in sustaining counselor well-being (Ducharme, Knudsen, & Roman, 2008). Because it is so important to have coworkers who can see and are willing to compassionately confront their fellow counselors who are in a slippery slide into compassion fatigue, such a collaborative environment can become a protective factor for everyone. 

 

There is no shame in acknowledging the need for support. Addiction counselors who have worked many years in the field and insist that there has been no emotional toll, physical stress or sleepless nights are most likely not acknowledging the reality of human limitations in this complex work. How many times have we heard about the “wounded healer”? To shrug that off as “someone else, not me” is to remain wounded and a less capable healer. The conscious heroes have taken a share of wounds, stepped away to heal, and come back stronger. If that were not the case, how could Sisyphus have the strength to roll the rock back up the hill again?  

 

The Absurd Hero’s Passion 

 

Sisyphus made his share of mistakes, yet he was passionate about life. Addiction counselors have their own stories about the ups and downs of life, yet they remain passionately committed to helping their clients. Even in the face of relapses and therapeutic dropouts, addiction counselors have to cling to the belief that each client has the potential to move past the immediate obstacles and reconnect with the true self. 

 

For families trapped in the addictive cycle, the optimism of counselors surely seems absurd. For counselors in other psychotherapeutic specialties where success stories occur more frequently, addiction counseling seems absurd. Looking at the counseling process from a lens of burnout, addiction counselors have to decide whether there is enough inner strength and courage to fulfill the role of absurd heroes.

 

Part of accepting the absurdity of the counselor’s role is to lay down the mantle of invincibility. Knowing theories and techniques is like possessing a collection of brushes and paints. Unless these tools are in the hands of an artist, no amount of rote actions will produce a masterpiece. The same is true with models, diagrams, and multistep approaches to counseling. These are useful tools, but only in the hands of passionate, creative, and sensitive counselors. One aspect of compassion fatigue can occur when counselors are constrained by a treatment plan or agency policy that works in a one-size-fits-all approach that removes their ability to respond to the unique needs of each client. Removing that sense of the artistry of counseling can make this deeply personal process become stagnant and repetitious.  

 

Fahy (2007) advocates the renewed view of substance abuse treatment models both for the benefit of clients as well as preventing burnout and reducing conditions for compassion fatigue among addiction counselors. Among the treatment options that Fahy (2007) supports for addiction counseling are the trauma recovery and empowerment model (TREM), motivational interviewing (MI), and narrative therapy (NT). The TREM model uses group therapy based on psychoeducation and personal skill development with emphasis on finding alternative, healthy way to cope with stress and triggers. MI and NT are client-focused, individualized approaches that take the power from total control of addiction counselors and continually bolsters clients’ ability to take back personal power in constructive ways. Fahy (2007) suggests that these “may have benefit to counselors dealing with trauma and the complexities of active substance use” (p. 203).  As more client-centered approaches become popular, there is a shift of power from prior models of therapeutic relationships between addiction counselors and clients.

 

Perhaps Fahy is one of the absurd heroes who is willing to set out in new directions that may be a better fit for the upcoming generation of substance abuse clients and counselors.

 

Becoming Stronger than the Rock

 

Camus reflects on Sisyphus’s seemingly endless toil: “At each of those moments when he leaves the heights and gradually sinks toward the lairs of the gods, he is superior to his fate. He is stronger than his rock” (1942). To overcome compassion fatigue is indeed to be “stronger than the rock” that seeks to weigh down, discourage, and distance addiction counselors from the calling to counsel. Let us take up the challenge to help counseling students and fledgling addiction counselors to recognize and seek support for compassion fatigue. Think back to your early career experience working with substance abuse. The anxiety, feelings of inadequacy, frustration with difficult clients, shock at hearing some of clients’ traumatic experiences, and stress of an internship and studying are fertile grounds for compassion fatigue. Yet what intern or new counselor wants to admit to these symptoms for fear of losing the position? And how many supervisors show an open-door attitude toward hearing this? It is easier to say “next” and bring in the next newbie than to take time to invest in that intern. The unspoken message is this: never admit weakness or need in order to keep a position in this field. 

 

Newbie or veteran, we all face the rock. Or as the infamous line from Pogo cartoon of yesteryear announced: “We have met the enemy and he is us.” Failure to acknowledge compassion fatigue is the rock over which most counselors in addiction and trauma will stumble at some point in the work. We also need to point out the dangers of the rock to others at risk such as physicians, nurses, police, firefighters, emergency medical technicians, domestic violence shelter workers, attorneys, crisis shelter workers, and crisis hotline workers. How many people from these walks of life have come through addiction programs? How many are exposed to vicarious or secondary trauma as well as on-scene trauma situations? Can you see the connection? 

 

Becoming stronger than the rock is the triumphant side of compassion fatigue. Addiction counselors who have become stronger did so by first acknowledging and dealing with weakness. Maintaining positive self-care is key to sustaining emotional well-being. Taking time off for relaxation and having fun with family and friends is as powerful an inoculation against compassion fatigue as any medical inoculation is to fight disease. Self-care is not just for clients; it is equally important to sustain addiction counselors. The ability to help clients starts with hope, and counselors must have hope to give hope. Hope is stronger than the rock.

 

 

 

References  

 

Camus, A. (1942). The myth of Sisyphus. Retrieved from http://dbanach.com/sisyphus.htm
Ducharme, L. J., Knudsen, H. K., & Roman, P. M. (2008). Emotional exhaustion and turnover intention in human service occupations: The protective role of coworker support. Sociological Spectrum, 28(1), 81–104.
Fahy, A. (2007). The unbearable fatigue of compassion: Notes from a substance abuse counselor who dreams of working at Starbucks. Clinical Social Work Journal, 35(3), 199–205.
Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C. R. Figley, (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 1–20). New York, NY: Routledge.
Figley, C. R. (2002a). Compassion fatigue: Psychotherapists’ chronic lack of self-care. Journal of Clinical Psychology, 58(11), 1433–41.
Figley, C. R. (Ed.). (2002b). Treating compassion fatigue. New York, NY: Routledge.
Lent, J., & Schwartz, R. (2012). The impact of work setting, demographic characteristics, and personality factors related to burnout among professional counselors. Journal of Mental Health Counseling, 34(4), 355–72.
Pines, A., & Maslach, C. (1978). Characteristics of staff burnout in mental health settings. Hospital and Community Psychiatry, 29(4), 233–7.