Compassion Fatigue and Chronic Sorrow as Soul Injuries

All it takes is a beautiful fake smile 

to hide an injured soul;
they will never notice

how broken you really are.

Robin Williams

Hello, Everyone,

Lately I've been noticing that some of the people in the CF and CS workshops nod in immediate recognition when I describe full-blown compassion fatigue and chronic sorrow as soul injuries. They know, intuitively, that the suffering they experience is deeper and more pervasive than the emotional pain described and addressed in some self-care workshops. It is a relief for these folks to have someone acknowledge the severity of their pain. This acknowledgement is often a first step toward releasing shame and opening the pathway to healing.

Soul injuries are wounds of our souls or essence, the loss of our sense of inner goodness, beauty and vitality stemming from trauma, unattended loss, burnout and the guilt and shame of our own actions or omissions.

Soul injury symptoms are described by Opus Peace as the familiar signs of postraumatic stress plus a defense-penetrating breach in the integrity our deepest selves. They often include:

1.  A haunting sense of being defective or tainted,

2.  A sense of betrayal by one's self, others, an organization, religion or God/Higher Power, and/or

3.  A sense of emptiness arising from disconnection from the part of ourselves carrying the pain.

Some of us have carried these injuries from childhood and others have experienced them later in life or through longterm exposure to the trauma and suffering of those we serve.

While our souls or essence will never be killed by our work, we can become separated from our original strength, truth, wisdom and compassion. We separate ourselves from our souls each time we cover up, numb out or run away from our truth and that separation eventually generates it's own symptoms. On the other hand, when we own our truth (including its pain) in gentle respectful ways, our souls can expand to hold and heal our wounds.

The healing of a soul injury entails addressing soul issues. Not only must we grieve unattended losses and re-regulate traumatized nervous systems, we must also forgive and make a home for the parts of ourselves we have denied and split off due to guilt and shame.  Then, we need to develop and nurture a life of the spirit - deeply personal and meaningful beliefs, teachings, ceremonies and rituals that will provide a strong foundation for building resilience.

As Opus Peace says, we all need a class on:

...how to open our hearts to our losing and failing, paradoxically becoming whole in the process. Re-owning and then re-homing pieces of self (often hidden behind facades or exiled into unconsciousness)  can precipitate healing. Telling stories of our lostness (without the distorting illusion of how we wish our lives to be) is the first step toward freedom. Hearing other peoples stories en-courages us to liberate our own.

So as we become deeply honest with ourselves, at least one other person and Whom or Whatever Benevolence we believe in, trauma can be healed, losses grieved, guilt atoned, forgiveness accepted, shame dispelled and a future, strengthened and brightened by hope and small "s" spirituality, explored.



*** For those who've been asking, the next Caring On Empty Workshop for Helping Professionals will be held at The Granville Island Hotel on Monday May 7th from 9-4.  Brochures with registration forms are available at caregiverwellness@shaw.ca.   Please tell your friends and colleagues!



Photo from the Opus Peace website.

Compassion Fatigue Bibliography ...

Knowledge will bring you

the opportunity to make a difference.

Claire Fagin

Hi Everyone,

I have just been updating the bibliography for the Caring On Empty workshop in preparation for workshops in Calgary and Vancouver Island next month and I thought you might like to have a look at some of the additions. Here they are:


1.  Articles:

*  Anderson, L (2016) The impact of a knitting intervention on compassion fatigue in oncology nurses Clinical Journal of Oncology Nursing Feb 2016, Vol 20(1), 102-104

*  Claxton-Oldfield, S (2015) Hospice palliative care volunteers: Stressors, how they cope with them and implications for volunteer training/management  American Journal of Hospice and Palliative medicine Feb 10, 2015

*  Gilman, L et al (2015) Strategies to promote coping and resilience in oncology and palliative care nurses caring for adult patients with malignancy: A comprehensive systematic review JBI Database System Rev Implement Rep 2015 June 12;13(5):131-204

*  Labib, MYT (2015) Compassion Fatigue, the Wellness of Care Providers and the Quality of Patient Care BSc Honors Thesis Portland State University Paper 205

*  Jack, Kirsten (2017) The meaning of compassion fatigue to student nurses: An interpretive phenomenological study J of Compassionate Health Care (2017)4:2 doi 10.1186/s40639-017-0031-5

*  Miller, B and Sprang, G (2016) A components-based practice and supervision model for reducing compassion fatigue by affecting clinician experience Traumatology January 28, 2016  doi.org/10.1037/trm0000058

*  Thieleman, K and Cacciatore, J (2014) Witness to suffering: Mindfulness and compassion fatigue among traumatic bereavement volunteers and professionals  Social Work January 1, 2014

*  Zehr, KL (2015) The Effect of Education on Compassion Fatigue as Experienced by Staff Nurses Doctorate of Nursing Practice Thesis, Valparaiso University, Valparaiso, Indiana Evidence Based Practice Reports. Paper 65


2.  Books:

*  Levine, Peter (2015) Trauma and Memory: Brain & Body in a Search for the Living Past North Atlantic Books, Berkeley, CA

*  Richardson, Jan (2016) The Cure for Sorrow: A Book of Blessings for Times of Grief Wanton Gospeller Press, Orlando, Florida

*  Esfahani-Smith, Emily (2017) The Power of Meaning: Crafting a Life That Matters Viking Press

Enjoy!

Compassion Fatigue in Funeral Service Professionals...

Our hearts are too full of grief to care.

Rachel Remen, MD

Kitchen Table Wisdom

Hi Everyone!

Happy Autumn! It's a busy one already with two workshops completed before the end of September. I hadn't realized how little I knew about the lives of funeral service professionals (medical examiners, mortuary technicians, funeral directors, embalmers, advance planners, crematory operators, cemetery operators and others) until I facilitated two Caring On Empty workshops for the wonderful folk of the BC Funeral Association this month.

Like many, I have to admit, I have occasionally endorsed stereotypes of money-hungry morticians out to bilk the public in their time of need and have participated in story-telling about crusty, unempathic,  funeral personnel.

Now, I must say, my eyes are opened. I've developed a deep respect for these professionals whose work involves constant exposure to loss, grief and trauma; who frequently work with insufficient resources; and who carry all the stresses of running either a 24/7 small family business or trying to provide empathic care within a large impersonal corporate structure focused on profit.

These death care professionals are rarely included in our lists of people at risk for compassion fatigue and yet their risk factors are many indeed. In a 2014 survey of 57 respondents from multiple countries done by author and blogger, Katie Hamilton, funeral directors identified the following emotional impacts of their work:

- Daily encounters with multiple traumatic images, smells and stories that are difficult to dispel.

- The stress of dealing with the emotionally-charged dynamics of devastated family members who may resent paying for funeral services or who cannot afford those services. 

- Coping with the physical impacts of sleep deprivation and undervalued self care.

- Exhaustion due to 24/7 availability to clients and families and the subsequent sacrifice of their own family life - and the tension between the two.

- Dealing with inherent family tensions while trying to run a family business.

- Working for a large firm whose values do not align with your own and the resulting lack of support.  

 - The stress of dealing with multiple external professionals - clergy, physicians, coroners, police. (This is an issue of time, administrative details, interpersonal stress, and having to repeat death details multiple times thus increasing trauma exposure.)

- The profound sadness of certain deaths - gruesome circumstances, infants, children, young people, suicides. And the expectation that "professionals" will not show their emotional responses.

- Being socially isolated from the general population by the nature of the vocation. 

Other stressors noted by those in the field include a lack of debriefing opportunities after a bad death, personally knowing those being tended or recognizing that they are friends of your spouse or child, gender bias within the profession (women are "too emotional" to hire or promote and are relegated to paperwork and tidying / "real men" don't show tender emotions), and having to keep clients' family secrets - such as the nature of a death - especially in a small community.

These risk factors can result in the familiar signs of compassion fatigue and accumulated grief - cynical sarcastic humour (as opposed to healthy black humour), irritability and impatience, chronic sadness, defensive cheerfulness and hyperactivity, chronic physical complaints, heavy drinking, loss of empathy and compassion, family breakdown and emotional disengagement from co-workers and the very people you're trying to help. Ultimately, many decide to leave their once-loved profession or go on to develop depression or, rarely, suicide.

Some resilience strategies  discussed in the workshops this month included:

- Creating an ongoing resilience plan and meeting regularly with a self-care buddy to review your progress and gain encouragement.

- Advocating for, and using, a good Employee Assistance Program, separate from the workplace, that recognizes the nature of your responsibilities. 

- Making use of new technologies to reduce your time at work and on call - pagers and smart phones, informative websites, a good answering service to screen calls, software programs for obituary placement and death certificate filing.

- Delegating responsibilities - eg hiring an appropriate removal company.

- Balancing your death focus with a life focus - gratitude journalling, outdoor activities, nourishing hobbies, regular downtime with your family and friends, vacation time where you're geographically away from your workplace.

- Focusing on the joy you can find in the work (Compassion Satisfaction)  

- Healthy eating and regular aerobic exercise. 

- Monitoring alcohol intake  - noticing when you're using alcohol and for what purpose. 

- Intentionally building and maintaining a nurturing spiritual life.

- Creating a professional support network of 4 or 5 people who will be consistently warm, accepting and supportive when called upon. 

- Avoiding re-traumatizing each other with competitive story-telling at conferences and other gatherings. (ie Leaving out the gory details!).

Serving and supporting others through their worst and most tragic days is a rewarding, but not necessarily an easy occupation. So, next time you see one of your neighbourhood death care professionals, why not take a moment to shelve any stereotypes and give them a smile and a greeting. I'm sure they'd appreciate the support.

   

Knitting Up a Wounded Heart ...

           Properly practiced, knitting soothes the 

            troubled spirit,

            and it doesn't hurt the untroubled

           spirit either!

         Elizabeth Zimmermann

Hi Everyone!

Knitting may seem a strange topic for this time of year but I'm planning to take yarn and needles to the cottage to teach a friend how to knit this summer so it's on my mind this week.

My Mom taught me to spool knit when I was six and and then to do "real knitting" when I was eight. Some fifty years later, my two younger sisters and I sat in a row in the hallway outside a busy intensive care unit knitting steadily as our Mom lay dying within. We hadn't consulted each other about bringing our knitting to our hallway vigil but, on reflection, there couldn't have been a better way of dealing with our stress or holding space for our mother's end-of-life.

As much by example as anything, Mom taught us to use knitting as a means of mending wounded hearts and as a stress reliever (- though she would never have used those actual words because  she belonged to a generation that didn't believe much in taking time to heal wounds or deal with stress. Life was hard and you just got on with it). If you had been mindful, though, you would have noticed that her knitting came out whenever things were tough at work, when she was worried about one of us kids, when financial resources were scarce or when my dad was having a mental health crisis or drinking too much. 

These days, we know that the knitting Mom used intuitively to deal with stress is showing up positively in the research literature. Knitting has a positive impact on health and wellness and may be part of the solution in reducing compassion fatigue. Studies suggest that knitting decreases stress, creates new neural pathways and can have an antidepressant effect. It can also help alleviate ruminating, delay memory loss and may help slow the onset of Alzheimer Disease. Learning to knit and seeing a finished product can build self esteem. And knitting also offers opportunities for creativity and calms and soothes through repetitive motion and the tactile softness and colour of the yarns.

A small February 2016 study of The Impact of a Knitting Intervention on Compassion Fatigue in Oncology Nurses in the Clinical Journal of Oncology Nursing noted that a knitting intervention, (learning to knit through the non-profit, Project Knitwell, and knitting squares with colleagues during break times), can provide the above positive effects as well as offering opportunities to debrief informally. Using the Pro-QOL before and after a knitting intervention showed a significantly positive change in burnout scores and trends toward significance with the secondary traumatic stress and compassion satisfaction scores. These improved scores applied particularly to younger nurses. It would be interesting to see the results with a larger cohort.

Project Knitwell has published a lovely little booklet called, The Comfort of Knitting: A How to Knit Guide for Caregivers and Families that shares research on knitting and health, teaches you knitting basics and offers 7 easy project patterns. They also offer a list of books on knitting and wellness including:

1.  Knit for Health and Wellness: How to Knit a Flexible Mind and More by Betsan Corkhill (Flatbear Publishing, 2014)

 2.  Love in Every Stitch: Stories of Knitting and Healing  by Lee Gant  (Viva Editions, 2015)

 3.  Knit Red: Stitching for Women's Heart Health by Laura Zander  (Sixth & Spring Books, 2012)

 4.  Knitting Yarns: Writers On Knitting  by Ann Hood  (Norton, 2014)

 5.  Knitting Heaven and Earth: Healing the Heart with Craft by Susan Gordon Lydon  (Potter Craft, 2008)

 6.  The Knitting Way: A Guide to Spiritual Self Discovery by Linda T Skolnik and Janice MacDaniels  (Skylight Paths, 2005)

7.  Mindful Knitting: Inviting Contemplative Practice to the Craft by Tara Jan Manning  (Tuttle, 2004)

 8.  Zen and the Art of Knitting: Exploring the Links Between, Knitting, Spirituality and Creativity by Bernadette Murphy  (Adams Media, 2002)

9.  Crochet Saved My Life: The Mental and Physical Health Benefits of Crochet by Kathryn Vercillo  (Self-published, 2012)

10. The Creativity Cure: How to Build Happiness with Your Own Two Hands by Carrie and Alton Barron   (Scribner, 2012)

Happy stitching, everyone!!

 

Beginning Again ...

In the middle of the journey of... life

I found myself astray in a dark wood

where the straight road had been lost sight of.

Dante Alighieri

The Divine Comedy

Hello, Everyone!

The experience of Compassion Fatigue (CF) is one that leads many of us to recognize that we have gone "astray in a dark wood where the straight road had been lost sight of".  It is an experience of lostness, anxiety, confusion and bewilderment. How did I get here? When did the caring person inside me begin to disappear? And, much more importantly, how do I find my way back to that caring self and begin again? 

Beginning again requires that we first take sufficient time to heal CF and then learn new and healthier ways of being and doing. Healing is different from curing. It is about gradually becoming more whole in ourselves rather than necessarily eliminating the signs of CF completely and forever. (Most helping professionals and family caregivers will ebb and flow through the early stages of CF as long as we continue working with people who are traumatized or suffering. The trick is building resilience before hand and then recognizing CF early in its progression so we can do something about it.) 

Beginning again is about re-membering our caring selves in a new way that promotes, not giving from the depths of our wells, but giving only from the overflow. It means transforming our accumulated primary and secondary traumatic stress and learning to reduce our trauma exposure. It means discovering our personal CF early warning signs so we can forestall further forays into "the dark wood". It means intentionally building skills and developing our physical, emotional, spiritual, social and professional lives so we have access to "something more" to ground and sustain us.

We need awareness, knowledge, courage and determination to make these kinds of life changes, one baby step at a time. I hope Celtic philosopher, John O'Donohue's, Blessing for A New Beginning, from To Bless the Space Between Us, will encourage you to take the first steps:

  

Blessing for a New Beginning

In out-of-the-way places of the heart,

Where your thoughts never think to wander,

This beginning has been quietly forming,

Waiting until you were ready to emerge.

For a long time it has watched your desire,

Feeling the emptiness grow inside you,

Noticing how you willed yourself on,

Still unable to leave what you had outgrown.

It watched you play with the seduction of safety

And the grey promises that sameness whispered,

Heard the waves of turmoil rise and relent,

Wondered would you always live like this.

Then the delight, when your courage kindled,

And out you stepped onto new ground,

Your eyes young again with energy and dream,

A path of plentitude opening before you.

Though your destination is not clear

You can trust the promise of this opening;

Unfurl yourself into the grace of beginning

That is one with your life's desire.

Awaken your spirit to adventure;

Hold nothing back, learn to find ease in risk;

Soon you will be home in a new rhythm,

For your soul senses the world that awaits you.

As I leave for a welcome long weekend visit to Vancouver Island, I wish each of you a very Happy Easter  (or whatever Spring observance you enjoy) and all the hopeful brightness of new beginnings!

And, if you are feeling ready to "begin again", do please join us for the Caring On Empty: Creative Tools for Compassion Fatigue Resilience for Helping Professionals workshop May 6th on Granville Island in Vancouver, BC.

Just email Jan at caregiverwellness@shaw.ca for a brochure. (And bring a colleague or friend!) The registration deadline is extended to April 22.

Spring 2016 Vancouver Compassion Fatigue Workshop ...

 The expectation that we can be immersed in suffering and loss daily and not be touched by it, is as unrealistic as being able to walk through water without getting wet.

 Dr Rachel Remen, MD

Hi Everyone!

 

The Caring On Empty: Creative Tools for Compassion Fatigue Resilience for Helping Professionals workshop will be held at the Granville Island Hotel on May 6th this year and we hope you can join us!

Compassion Fatigue, (the natural posttraumatic stress, "fatigued" compassion, diminished desire to be empathic and emotional disengagement from the very people we're trying to help), affects most helping professionals at various times in our careers. It develops as we hear and respond to more and more stories of others' trauma, loss and suffering.

Some warning signs that we may be at risk for developing Compassion Fatigue are the loss of our sense of humour, feed-back from our family and friends that we're not fun anymore, dreading going back to work no matter how much time we've had off, profound exhaustion, sleep difficulties, irritability, anger and cynicism, uncivil behaviour, anxiety, emotional numbness or over-reactivity, social isolation, self medicating, increased sick time and feelings of helplessness and hopelessness.   

This small (only 25 seats), discovery-based, multidisciplinary workshop will provide a safe and reflective space for:

*  Exploring the concept of Compassion Fatigue (CF) and how it differs from burnout,

*  Discovering your current CF risk and identifying personal early warning signs,

*  Assessing your current level of self care and learning to reduce trauma exposure,

*  Learning positive, practical strategies for reducing CF risk and building resilience and

*  Creating an ongoing personal resilience plan.

The workshop uses mini-lectures, film, self-reflection exercises and group interaction to help participants awaken to their current level of CF risk and create a personalized resilience plan. Others have loved the relaxed energy of this workshop and left asking for more!

So, if your work involves hearing stories of others' trauma and suffering - health care professionals and support staff, educators, therapists and counsellors, addiction workers, family court lawyers and judges, journalists, humanitarian workers, first responders, translators and interpreters, social service providers, clergy and pastoral care workers, and others -  this is the workshop for you. I hope to see you there! 

PLEASE NOTE:  The registration deadline is extended to April 22nd. 

You can email Jan at caregiverwellness@shaw.ca for a registration brochure.

Please share this information with colleagues and friends - Anti-Spam Legislation makes it more difficult to tell people about the workshop this year. Thank you!  Jan 

Softening A Hardened Heart ...

There is beauty to seeing stone 

turned to moist soil, broken open, receptive

to the seeds of love.

Omid Safi

Hi Everyone!

Last time, we spoke about how our hearts can become hardened through repeated exposure to our own and others' trauma. Today, I'd like to move on to how we can begin to soften our hearts, allowing us to receive more love, nurture and support.

We all have a wall around our hearts. According to Persian tradition, the heart is a walled garden, an inner garden protected by an outer wall. When we have experienced great pain, our own or others', that wall can become a hardened fortress, protecting us but also keeping out the very ones who could be a source of our healing and renewal.

Omid Safi, Director of the Islamic Studies Centre at Duke University, likens this hardened heart to dry land - hard, parched and cracked. To break it open, to till and water it so it is ready to receive a seed of love, (a kind glance, a touch, a word, a compassionate action), takes time, patience, effort and vulnerability.

As Professor Safi says:

The seed of love falls on the heart's soil. Is it a hardened earth, a rock-covered surface, one that will have the seed washed away with the first water? Or is it a soil that has been prepared, tilled, softened up, opened up again and again and again, ready to embrace the seed of love that would surely come?

When we suffer Compassion Fatigue, our hearts' soil hardens and we become less receptive to the seeds of love sown by our colleagues, family and friends. As we recognize and acknowledge that this is the case, we can consciously make an effort to till, water and soften that soil.

Three ways we can soften the soil of our hearts are to practice self compassion, learn heart-centered spiritual practices and consciously allow ourselves to open up and become more vulnerable in our daily relationships.

1.  Self-compassion researcher, Kristin Neff, describes self-compassion as, "acting the same way toward yourself when you are having a difficult time, fail, or notice something you don't like about yourself, as you would toward a friend." She says that instead of just ignoring your pain with a "stiff upper lip" mentality, you stop to tell yourself, "This is really difficult right now. How can I comfort and care for myself in this moment?" You can learn more about practicing self-compassion on her website. 

2.  Heart-centered spiritual practices can be found in most spiritual traditions. The point of these practices is not to resolve our emotions or to figure them out but to simply to allow them to have some space within us without pushing them away. Here is one (slightly abridged) practice written by Christine Valters Paintner, PhD, Benedictine Abbess of the virtual online monastery, Abbey of the Arts.  (It is a simple practice that should only take about 5 or 10 minutes to complete.)

1.  Begin by becoming aware of your body. Notice how your body is feeling simply by being present to sensations you are experiencing, welcoming in both the body's delight and discomfort. 

2.  Connect to your breath, deepening it gently. As you inhale, imagine Love breathing life into you. As you exhale, allow yourself to experience a moment of release and surrender into this time and place, becoming fully present. Take a couple of cycles of breath to simply notice this life-sustaining rhythm which continues moment by moment even when you are unaware of it.

 3.  In your imagination, gently allow your breath to carry your awareness from your head (which is your thinking, analyzing, judging center) down to your heart center (where you experience life from a place of greater integration, feeling, and intuition). Consider placing your hand on your heart to experience a physical connection with your heart center and draw your awareness to this place.

 4.  Breathe into your heart center and begin to notice what you are feeling right now in this moment without judging or trying to change it. Take a few moments to simply be present to whatever you are feeling and making some room within yourself to experience this without pushing it away (this alone can be revolutionary for many of us - to just allow ourselves to have the experience we are having without judgment.)

 5.  Call to mind the spark of Love which the ancient monks and mystics tell us dwells in your heart. Bring the compassion of Love to however you are feeling right now, not trying to change anything, but just gently holding yourself in this space.

 6.  As you experience yourself filling with compassion for your own experience, imagine breathing that compassion out into the world and connecting with other hearts beating across the world in a rhythm of love.

 7.  Gently allow your breath to bring your awareness back to the room and take a moment to name or write what you noticed in this experience.

3.  Becoming more vulnerable to others, the third way we can soften the soil of our hearts, may seem like a risky weakness in our toughness-saturated workplaces. But, as shame and vulnerability researcher, Brene Brown, writes, "Vulnerability sounds like truth and feels like courage. Truth and courage aren't always comfortable, but they're never weakness."

It takes honesty and courage to open ourselves to speak from our tender places and to receive the healing love of others. While it is important to choose wisely those with whom you will be vulnerable, it is also important to have people in your life with whom you can really be yourself, "warts and all", knowing that you will be accepted and respected. To learn more about intentional  vulnerability, try listening to Brene's TED Talk on The Power of Vulnerability .

There are many more wonderful ways to soften the soil of our hearts but these three are a good start. Let me  leave you, once again, with the words of Omid Safi - There is beauty in stone being turned to moist soil, broken open, receptive to the seeds of love.

May this Valentine's Day bring each of you an opportunity to soften your heart and receive some much needed seeds of love.

  

The Hard Heart of Compassion Fatigue ...

We seem to value "strength". We want "hard" bodies, "strong" minds, "tough" wills, "hard-as-nails" determination,"rugged" personalities, "sturdy" character and so on. ...  But let us praise softness. ... Let us seek a heart that is not hard, but soft.

Omid Safi

Hi Everyone!

This is a story about hard and soft hearts written by life coach, Darren Poke, in 2011, in Melbourne, Australia. I'd like to share it with you today as we approach Valentine's Day:

There was a young man named Tom who lived in a small village.

He was an angry young man, overreacting to every offense and keeping others at a distance.

 In desperation, his parents asked Tom to go and see the eccentric old priest who lived in the village.

The priest was renowned for his unorthodox methods that somehow worked.

When Tom saw the priest, the older man told the youth to go away and come back with two lumps of clay.

He returned a few hours later and then was told to make a vase out of one of the lumps.

The young man thought that this must have been part of the therapy, so he threw himself into the task with enthusiasm, believing that the opportunity to create art would help him with his temper.

He made the vase, decorated it and put it in the kiln to harden.

Upon completion, Tom presented the beautiful vase to the priest. He was proud of his accomplishment and believed that he was now cured of his anger issues. 

The priest smiled approvingly and gave the young man a hammer.

"Now hit the vase with this hammer," the priest commanded.

"But it will break my beautiful creation!" Tom protested.

"Hit the vase with this hammer," the priest insisted.

"Don't you like it? Isn't it good enough for you?

"Hit the vase with this hammer," the priest continued.

Annoyed, the young man snatched the hammer from the priest and tapped the vase firmly.

The vase immediately smashed into pieces.

"Now look what you've done," Tom said angrily. "You've wasted all of my hard work."

The priest ignored the outburst and left the room for a moment.

He returned with the second lump of clay and placed it on the floor next to the young man.

"I suppose you want me to waste my time by making another vase? Well you can forget about it!" Tom said rudely.

 The priest looked at him with kindness and said,"Hit the clay with the hammer."

"With pleasure!" the young man responded.

He swung the hammer with all of his might and it hit the clay with a thud, leaving a large mark.

"Happy now? What was the point of that?"

The priest picked up the broken pieces of the vase and held them in his hands before the young man.

"See this vase? This is like your heart. You think that you need to be hard to cope with the inevitable disappointments that happen in life. You respond with anger, bitterness and violence, keeping people at a distance, but it doesn't work. Your hardness makes you more fragile. Adversity breaks your spirit too easily."

The priest then picked up the lump of clay, it had a mark where the hammer had hit it, but it was still in one piece.

"You need to soften your heart and be more like this clay. It is still impacted by what happens to it, but it can be restored more easily. A soft heart forgives, loves and uses soft words. It understands that pain and suffering is a part of life and instead of fiercely resisting, it absorbs the blow. It still feels the pain, but isn't broken by it."

The protective hardening of our hearts is a common way of dealing with over-exposure to others' trauma and suffering. Some people make a conscious decision to create a wall of coldness, withdrawal, anger or prickly behaviour, (I know someone who calls this her "force field"), in order to save themselves from further pain. Others don't even notice that their hearts are becoming stony. It happens so slowly and insidiously that they are shocked when others point out that they no longer seem to care.  However it occurs, this hardening eventually takes its toll and we pay the price in the irritability,  brittleness, reactivity, cynicism and emotional fragility that are hallmarks of Compassion Fatigue.

So, how is it with you right now? Is your heart so hard that, instead of feeling protected, you are shattered by any bad call, hard session or emotionally intense event? Are you wondering where the caring person inside you has gone? Are you wishing you could soften your heart and become the person you used to be? Are you afraid to try for fear of being shamed in a workplace culture that only seems to value strength and toughness?

In the next post we will look at some useful practices for beginning to soften our hearts ( - just in time for Valentines Day!).

 

Compassion Fatigue: Who's At Risk?...

A case manager is supposed to do just referrals and that's it, but many times ... you're the first one that they're telling ... everything to. ... You end up hearing everything as if you were their psychologist and (it is hard to know) how to deal with those emotions when sometimes we don't have training aside from whatever we review.

Case Manager, Los Angeles Children's Hospital

Hello, everyone,

It's the beginning of a new year, so I thought we could go back to the basics today and take a fresh look at who is at risk for Compassion Fatigue (CF).

The primary criterion for determining CF risk is exposure to the trauma stories of the people we serve.  (Other vulnerability and protective factors also come into play but this is the primary contributor.) The greater and more graphic the accumulated trauma exposure, the more likely we are to develop CF.

These days, we are quite used to thinking of moderate CF as a natural consequence of working as first responders (paramedics, physicians, nurse practitioners, fire and police professionals, and humanitarian and victim assistance volunteers) or other helping professionals like nurses, teachers, social workers, lawyers, prison workers, mental health professionals and clergy. On the other hand, there are helpers at risk of CF who don't come to mind so readily.

In one of the best written articles on CF I've read in a while, Sophie de Figueiredo and her colleagues at Children's Hospital, Los Angeles and USC describe the cross-diciplinary experience of CF among service providers for highly traumatized children and adolescents, focusing much of their attention on case managers. 

We rarely think of medical receptionists, medical office assistants or case managers as being at risk and yet, of course, they are. Not only are they often the first to hear peoples' trauma stories and crises, they can be obliged to write or re-tell these stories again and again as they communicate information to other helpers, thus increasing their exposure exponentially. Hear some of the case manager risk factors de Figueiredo reports in her 2014 article in Traumatology:

Descriptive findings provide evidence to suggest that case managers may be more susceptible to CF than other providers. Their caseloads were significantly larger than those of other provider groups. They were less likely to report having access to reflective and individualized supervision and reported higher dissatisfaction with the amount of supervision they received. Generally, they were younger and reported fewer years of education. Case managers were also less likely to receive trauma-specific training in traumatic stress or on the effects on providers of working with traumatized populations... Unfortunately, these providers received the least amount of support to address and combat the development of (CF and burnout).   (p 293)

Also at risk are middle managers and administrators who may hear the most difficult of the trauma stories and situations, ones that can't be dealt with lower in the hierarchy, and yet have no primary "hands-on" contact with the trauma survivors and thus are left holding painful stories without an outlet of direct action to alleviate suffering (the survivors' or their own).

This fall, I've also been surprised to speak with a number of 5th Step volunteers in 12 Step Programs who have developed CF over years of hearing others' 5th Step stories. (The 5th Step = "We admitted to God, ourselves and to another human being the exact nature of our wrongs.") Hearing "the exact nature" of others' behaviours while in the throes of addictive behaviour can be more than a little traumatizing, though I have to admit I hadn't thought to include these folk within the fold of CF risk.

Others who might be at risk but not necessarily cross our minds as needing education and support are the translators/interpreters and community volunteers who are making significant time, energy and emotional commitments to the Syrian refugees coming to Canada over the next few months. These helpers may have little or no understanding of the potential impact of refugees' trauma stories on their lives. It will be crucial to provide these caring folk with CF information before they become overwhelmed by trauma stories of the people they seek to help.

Not-for-profit workers in food banks, meal programs, community outreach programs and disease-specific support organizations may also be at risk and unprepared.

Even librarians can suffer CF in some circumstances. Librarians and library techs in home library programs form strong, long-lasting bonds with homebound patrons who can experience the abuses and/or traumas and losses of chronic ill health and disability. During harsh weather and harsher economic times, the homeless and displaced may also seek shelter in community libraries and spend time sharing their stories with kind but untrained and unprepared helpers.

These are just a few of the under acknowledged at-risk populations that come to mind this morning. I'd be interested to hear of any others you believe to be poorly recognized.

It's a Matter of Choice: Considering Physician-Assisted Death ...

Ultimately, in our view, when beneficial medical options for cure and for palliative care diminish, the patient, after being properly informed, increasingly becomes the final arbiter in accepting or rejecting these options.

Gerrit Kimsma, MD and Evert van Leeuwen, PhD (2004)

Hello, Everyone,

I'm late with this post after waiting for and then pondering how to respond to the Supreme Court's decision to allow physician-assisted death in Canada. In the end, I think all I can do is to tell my husband's story and to highlight a few important concerns.

On September 30, 2004, my husband of almost twenty years died three weeks after stopping all treatment but palliative care so that his viral cardiomyopathy could run its course. It had been 7 years since his diagnosis and he'd spent the last 3 years confined to bed. He was not clinically depressed and, despite a considerable amount of grief, had been a wonderful role model for how to live life fully and well with ever diminishing energy and abilities. He taught us how to live well and, when the time came, how to die well.

When he told me of his decision to stop treatment, he put it this way. "I feel like a weary traveller on a railway platform waiting for the train. The only thing that makes me sad is knowing that you won't be coming with me." He was exhausted, suffering and ready to die. Any exertion, even listening to music with a quick tempo, caused him chest pain;  every few days he was subjected to the uncontrollable and excruciating pain of catheter changes with a hypersensitive bladder; and the loss of control, pain medication and diminishing oxygen to his brain triggered frequent posttraumatic stress flashbacks to his childhood in wartime England. He had had enough and, although I didn't ever want to lose him, I supported his choice so his suffering could end.

Would he have chosen a physician-assisted death if it had been available at the time? I honestly don't know. But, aware of his lifelong desire to have and carefully consider options in any situation, I think he would have wanted to consider the possibility. (And I'm quite sure that I will want to consider the possibility for myself when the time comes.)

Several things concern me as we wade into the early days of implementing this decision. Three of the most important follow. The first is that we need to see physician-assisted death as part of the continuum of care rather than as a separate choice over and against disability-support and palliative care. Such dualistic thinking will only cause more grief and suffering to patients and families. It is not a matter of either-or but of both-and. Yes, we must improve the quality of and access to sufficient and wide-ranging disability, palliative and hospice care but that doesn't mean that we cannot also provide assisted-death to the few whose suffering cannot be eased and who request that final option. As Dutch physician, Kimsma and medical ethicist, van Leeuen, put it in Physician-Assisted Dying: The Case for Palliative Care and Patient Choice:

(Placing euthanasia in opposition) to palliative care in the way critics have suggested fundamentally disregards the wishes of the patient in the face of death.

Surely that is not our purpose in providing end-of-life care?

A second concern is that we should make our choices regarding the implementation of this decision based on research and compassion rather than on our fears. For example, we know that despite some fears that people will be "put to death" in terrible circumstances, in-depth interviews with patients and families in other jurisdictions point to assisted-death as a moving and positive experience with less traumatic grief experienced after the death than that found in counterparts whose loved ones had died a "natural death". Other studies tell us that physicians can have a very difficult time, emotionally and in relationship with their families, in the days before and after assisting with a death, calling into question the fear that they will become inured to the experience and begin to make such decisions too easily. There are many cases in which our fears regarding physician-assisted death can be allayed by the facts. So, let us be sure to examine the evidence before allowing fear to determine our actions.

My third concern is based on the physician studies noted above. If we are to begin offering patients physician-assisted deaths, it is vital that we first have conversations about what comprises adequate support for the health-care professionals involved. It will be important to put our knowledge of compassion fatigue and burnout to use in creating the best possible support for these caring people.

I believe that if we are open-minded, reflective, compassionate and wise, physician-assisted death can become another important tool for providing comprehensive and compassionate end-of-life care.

Summer Harvest: Or What I (Re)Learned On Summer Vacation ...

Hello, everyone!

I'm back from an unexpectedly busy summer and enjoying the quickening of heart and mind that always seems to accompany this time of year. As the days of summer shorten and I gear up for fall workshops, I find myself reflecting upon the things I've learned (or re-learned) this summer -  the fruits of my summer harvest.

1.  Remember to rest: 

This year's vacation began with two wonderful weeks at Kahshe Lake in northern Ontario. There, my body relaxed and I was reminded, once again, of the importance of rest and respite. Sitting on the deck, doing nothing, wrapped in the piney fragrance of sun-warmed trees is one of the most restorative things I can imagine and yet I can lose track of my need for this deep rest once I move into the busyness of the teaching season.

This year, I've decided to build rest days into the calendar in advance. On these days, I will stay at home by the fire, be silent, avoid screen and phone time, eat pre-prepared meals, perhaps read bits of poetry or fiction, and mostly, just rest. (I did learn this lesson more than ten years ago when my husband was ill but it seems that it takes intentionality and commitment to remember to use it during my busiest times.)

Perhaps you'd like to join me in honouring our universal need for rest and re-creation this fall? If your life won't accommodate a full rest day, perhaps a half day, or a couple of hours, or 30 minutes every morning or a 10 minute power nap in the afternoon would be a place to start ...? The important thing is to choose what works for you and then protect the time to do it.


2. Recommit to a spiritual practice:

As I've said elsewhere, most people believe that we have a spiritual life to tend as well as physical and psychological ones. After a very full late summer with considerable family caregiving and much writing, I found that I had lost the rhythm of two of my much-needed spiritual practices. I was falling asleep during (or sleeping right through) my early morning meditation/prayer time and I was skipping my treasured walks at the lake. (Not a good sign when fall's busyness hadn't yet begun!) Fortunately, I was able to get some rest, and with rest came the desire to refocus on this vital piece of self-care.

Research tells us that developing and maintaining a regular spiritual practice is important for our wellbeing if we want to work with people who are traumatized. Spiritual practice creates space - space for healing and transformation and space for building resilience. Whether you meditate, practice centering prayer, commune with nature, write a gratitude journal, read inspirational writings, dance or sing, or practice a nightly examen, consciously attending to your spiritual life can go a long way toward mitigating compassion fatigue.

If you have had a regular spiritual practice in the past but have let it slip away, why not consider beginning again this fall? First, take some time to consider why you are not practicing now. Has your life changed? Did you become bored with the practice? Was it not a good fit in the first instance?  Once you know why you stopped, begin again or do some exploring to discover new possibilities. Be sure to choose a practice congruent with both your personality and your current life circumstances.

As I re-learned when I returned to my regular practices last week, taking the time to deepen your spiritual life positively affects every other aspect of your being.


3.  Make heart connections with supportive people:

Isolation is both a source and consequence of compassion fatigue. When we hide painful emotional responses to our work, either in the name of strength and stoicism or because there's no energy left to connect with our support systems, we increase the likelihood of being traumatized. And when we become traumatized, we are likely to isolate and hide our trauma for all the same reasons. Isolation becomes entwined in the experience of compassion fatigue and healing involves connecting or reconnecting with loving, responsive supporters.

I felt a measure of this isolation recently, first as I supported an elderly friend for five weeks following emergency surgery and then, as I companioned extended family following a loved one's life-threatening post-transplant lung infection. In the days before I knew about compassion fatigue, I might have spiralled into a state of exhaustion and depletion. Fortunately, these days I can recognize when my early warning signs are saying, "Enough!"  One of those early warning signs is realizing that I haven't had contact with anyone on my KIT (Keeping In Touch) List.

My husband introduced me to the idea of keeping a KIT list. He kept a list of 6 or 8 good friends front-and-centre on his desk and committed to contacting each one at least once a month so that his important relationships could be regularly nourished. Sometimes, he wrote them "proper letters" with envelopes and stamps; sometimes they had coffee or lunch; sometimes they went for walks, hikes or a bike rides; and sometimes they just enjoyed short or protracted phone conversations. The point was that he was intentional about having regular heart-to-heart connection with people who mattered to him. It is this kind of connection that reduces stress and protects both our physical and emotional health. If the idea appeals to you, why not give it a try?


So, these are a few of the summer's lessons for me. What about you? What has been your summer harvest?

The ABCD's of Compassion Fatigue ...

Hi everyone!

Despite having spent a number of years teaching compassion fatigue workshops, I'm always surprised to discover how many people believe that compassion fatigue is "a form of burnout" to be "cured" with relaxing bubble baths and hikes in the woods. So, in today's post, I'd like to spend a little time going back to the ABCD's, the basics of compassion fatigue:

A definition:  

Compassion fatigue is exactly what the words say it is:  fatigued compassion. It is the symptoms of posttraumatic stress, diminishing empathy and emotional disengagement that arise from helpers' exposure to others' suffering and trauma.

CF occurs when primary traumatic stress (the trauma we experience directly in our own lives) converges with secondary traumatic stress (the trauma we experience indirectly through knowing about trauma and suffering in others' lives) in the presence of burnout (the chronic stress of perceived workplace demands exceeding perceived resources).

Compassion fatigue is essentially a trauma issue, a normal and expectable response to caring for others in pain. It is a condition of people who care deeply about the suffering of others and who work hard to alleviate it. (You don't find compassion fatigue in people who don't care.)

Compassion fatigue lies at the far end of the stress continuum. If left unattended, can lead to physical and mental illnesses including clinical depression.

 Beware of these warning signs:

The warning signs of compassion fatigue include, but are not limited to:

• loss of sense of humour 
• emotional numbness
• incivility / emotional reactivity (compulsive or impulsive reactions to perceived threats) 
• difficulty relaxing 
• difficulty separating work from personal life
• lowered frustration tolerance / increased outbursts of anger or rage
• dread of working with certain individuals
• negative changes in worldview - tendency to see the world as an unsafe place and others as "victims" or "predators"
• ineffective or self-destructive self-soothing behaviours (eg overuse of alcohol or other drugs, compulsive spending/exercising/eating etc)
• hypervigilance (constantly scanning the environment, looking for danger to self or others)
• decreased feelings of work competence
• diminished sense of purpose/enjoyment in career
• diminished functioning in nonprofessional areas of life (eg marriage, parenting etc)
• silencing response (consciously or unconsciously preventing others from sharing painful information with you because you just can't bear to hear it anymore)
• feeling depressed
• loss of hope 

  Any one of these warning signs could indicate the presence of compassion fatigue.

Create coping skills:

Because compassion fatigue is a trauma issue, healing and resilience-building must focus on helping us cope with the intersection of primary traumatic stress, secondary traumatic stress and burnout, at home (family caregivers) and in our workplaces (helping professionals and volunteers). Empowering compassion fatigue resiliency skills can be developed in each of the following areas:

• Self-regulation:  learning to intentionally control the activity and intensity of our fight/flight/freeze response while engaged in daily living.
• Intentionality:  learning to respond intentionally (vs reacting compulsively or impulsively), in keeping with our personal values and beliefs, in response to perceived threats.
• Maturing perceptions:  learning to shift the degree of perceived threat we see in the working environment.
• Connection and support:  developing an environment or network where we feel supported, heard and cared about by colleagues.
• Self-care and revitalization: becoming stronger and more mature so we are not diminished by witnessing and absorbing the pain of those for whom we care.

 Do something about CF resilience:

If you recognize yourself in these descriptions of compassion fatigue, NOW might be the time to do something about it. Why not JOIN US for the following workshop in Vancouver, BC to discover more and to build your own resilience plan:

• Caring On Empty: Creative Tools for CF Resilience (For helping professionals and volunteers):  June 16th and Nov 8th, 2014 

 You can email me for a brochure and registration form at caregiverwellness@shaw.ca  

          

Healing Compassion Fatigue...

Every year, I drive across Vancouver on the first Saturday morning in December to attend the Open House at the Vine & Fig Tree, a small bookshop owned by my friend, Elaine Perry. As I drive, I happily anticipate the twinkling fairy lights, the spicy aroma of mulled cider, the home baking donated by grateful customers, Elaine's welcoming hug and, of course, her eclectic mix of books, (eastern and western spirituality, current fine fiction and poetry, children's books), and gifts, ( Advent calendars, fair trade African bracelets, beeswax candles, Buddhist singing bowls, journals, and Chor Leone and Electra CD's , among others). The air hums with holiday greetings and wide ranging conversations and there's a sense of happy "community" throughout the shop.

This year, I was fortunate to meet a lovely woman, a fellow adult educator, while pausing between purchases to sip a cup of cider. She is involved in teaching instructors to be better educators and she generously shared her philosophy of teacher development with me - in a nutshell, that learning the theory and technique of teaching is much less important than our individual development as human beings. That it is our healing and wholeness, our individual growth and development, that make us into good and credible educators. I was very grateful for this conversation, and for a similar one (by email) with CF Specialist, Eric Gentry, PhD, for I believe that both have a light to shine on the paths of those of us seeking to build compassion fatigue resiliency.

As with the process of creating better educators, the process of building CF resilience must, to my mind, focus first on the individual health and wholeness of the helper. There is no question that systemic issues and toxicity in the workplace must be addressed wherever found, but, ultimately, it is our individual wellness, our capacity to regulate our traumatic stress, that determines our CF resilience.

CF is, primarily, an individual trauma issue. We are secondarily traumatized in our work because our personal trauma and loss history has taught us to perceive personal threat where none exists. ie Due our previous personal trauma, our autonomic nervous systems mistakenly activate upon hearing stories of threat to others and we become symptomatic.

So, if trauma is the core problem in compassion fatigue, the solutions must center around the healing of that trauma. If we work successfully on our individual trauma recovery, we will ultimately make better systemic decisions and our workplaces will improve.

Some will object to this viewpoint, believing that in stating it, I am "blaming the victim". I do not believe this to be so. As Eric Gentry says, "People in recovery have resolved this paradox better than anyone: Addicts are not responsible for having the disease of addiction but are responsible for their recovery from it." In the same sense, we who experience CF are not responsible for developing CF, but we are responsible for our own recovery.

So, what am I saying here? Just that if we are to solve a problem, we must be able to state that problem clearly. Once we've done that, we have the resources of the universe at our disposal for our healing, growth and development. The grace that is recovery is available to each of us if we can find the courage to seek it out. There is a light in the darkness beckoning each of us to a place of greater wholeness and wellness this holiday season.