Monthly Archives: November 2005

Extreme conditions test counselors

Michael Dubi, Jane Webber and J. Barry Mascari November 18, 2005

By the time Hurricane Katrina left the Gulf Coast region of Louisiana, Mississippi and Alabama on Aug. 30, it had become the most destructive and costly natural disaster in U.S. history. By Oct. 1, the official death toll stood at 1,242, and property damage was estimated to be in excess of $200 billion.

Homeland Security Secretary Michael Chertoff described Katrina as "probably the worst catastrophe or set of catastrophes" the United States has ever experienced. Hundreds of thousands of individuals fled the affected areas and relocated into neighboring states. Many had no personal belongings. Many were severely traumatized.

Counselors from all over the United States responded immediately to provide mental health and other services to persons affected by the hurricane. The American Red Cross and other groups deployed more than 1,200 licensed mental health workers to sites throughout the Gulf Coast.

According to Arnesa A. Howell, writing for the American Red Cross, mental health services have been provided to more than 340,000 people adversely affected by Katrina. This number continues to increase nearly two months later.

Disaster response conditions are challenging

Most disaster mental health volunteers worked long shifts every day for 14 to 21 days with little or no time off. Many other counselors added working with evacuees to their normal workloads. Counselors were asked to provide services to a seemingly endless stream of evacuees. Often the work conditions were challenging and primitive.

Sharon Cummings, a counselor from Memphis, has been working with evacuees from Hurricanes Katrina and Rita since the first week in September. She has provided counseling, case management and assessment services to almost 800 individuals and families, and this number continues to increase.

Cummings said this was a new experience for her and most of her colleagues. "We had never worked with so many people or been involved with such an overpowering natural disaster," she said. "Many of us were unprepared and became overwhelmed by the number of people who needed assistance. Some of the counselors left after the first few hours, and many others did not return after the first day." These occurrences were common throughout the Gulf Coast region, and there were multiple reports of counselors becoming overwhelmed by the magnitude of the events in which they were involved.

Charlie Gagnon, president of the American Association of State Counseling Boards and an employee for the state of Louisiana, described his experiences: "The difference between this and other hurricanes is that this is ‘the disaster that would never end.’ Katrina was devastating and many people were displaced, but many of them have nothing to return to."

He continued, "How do you replace a lifetime of memories and experiences? These people are literally starting all over again — with nothing! We are not putting lives ‘back together,’ we’re building new ones. Add another hurricane (Rita) and the disaster starts all over again. We simply add the new evacuees to the list of people needing help."

At times, the needs of the hurricane evacuees seemed overwhelming. Asked how he felt after working with so many people who are faced with the hard reality of starting over, Gagnon replied, "I need a vacation! Is this compassion fatigue?"

Compassion fatigue

For most counselors, empathy is an important element of the therapeutic relationship. Often, when the counselor works in emotionally charged situations over time, the empathy can become overtaxed and exhausted. This can happen even when the counselor attempts to maintain self-care and can lead to burnout, which, along with secondary traumatization, make up the components of compassion fatigue (CF).

According to the work of Beth Hudnall Stamm, burnout involves feelings of hopelessness as well as difficulties dealing with work, which can seriously impact a counselor’s job effectiveness. These negative feelings have a gradual onset and may be associated with a heavy workload or a nonsupportive work environment. Burnout may also involve feelings that your efforts make little difference.

CF or secondary trauma, which is related to vicarious trauma, concerns secondary exposure to the extremely stressful events experienced by counselors and other caregivers. CF’s symptoms are usually rapid in onset and most often associated with a particular event. The symptoms may include generally feeling afraid, having problems sleeping, experiencing flashbacks of the upsetting event and avoiding things that remind you of the event.

"CF will probably affect most caregivers at some point in their professional lives," said Eric Gentry, a developer of the Accelerated Recovery Program, which is designed to resolve the symptoms of CF. Gentry, who worked in Oklahoma City after the bombing, in New York City after the events of 9/11 and with Hurricane Katrina disaster workers, believes counselors working with disaster survivors are among those most susceptible to CF.

In many cases these counselors are also reluctant to reach out for the help they need for various reasons: They fear judgment, reprisal or ridicule by supervisors and peers; they fear self-exposure; they may have illusions of omnipotence; or they may have difficulty trusting other helping professionals.

The risk of burnout and vicarious trauma

Michael Barnes, a family therapist and trauma expert in Sarasota, Fla., stresses self-care with trauma workers. He believes that burnout and vicarious trauma go hand-in-hand, and that most counselors can handle the stress in normal situations. "But under extreme conditions counselors narrow their focus and lose sight of what is manageable for them," he warned. This can lead to CF in mental health workers.

The growing number of large-scale disasters, both natural and human-made, shatters our foundation of safety and security and increases our fear of potential future disasters. Passionately committed to alleviating human suffering, counselors risk vicariously (and quickly) experiencing the impact of Katrina and Rita, especially after a year in which we have witnessed a spate of hurricanes in Florida, the deadly Indian Ocean tsunami and, most recently, the earthquake in Pakistan. Suicide bombings and casualties in Iraq, plus terrorist threats and alerts at home, continue to erode our belief in a safe and good world.

Witnessing the devastation, injury and death caused by natural disasters also threatens the spiritual foundation of responders. In the midst of horrible tragedy, both survivors and responders may experience an existential crisis. Their view of the world as good is threatened, and they may ask, "Where is God?" Natural disasters are often more difficult to understand than terrorist attacks since, for some people, there may be no one but God to blame. Personal and communal activities — journaling, meditation, organized prayer, rituals, musical chants, Tai Chi, drawing and moments of silence — can serve a restorative function to spiritual strength.

Counselor self-care

On-site leaders must be aware of CF risks and provide structure. Counselors should be required to exercise self-care, such as taking regular breaks despite their workload. "The frustrating part," Gagnon observed, "was looking at these folks who are directly involved with rescue and recovery and are definitely affected. There appears to be a lack of understanding that responders are affected by their work and may need some intervention." During TOPOFF-3, a recent Homeland Security terrorism response exercise (which the American Counseling Association participated in), healthy food was available all day, and those in charge encouraged rotational breaks for staff.

Awareness of the potential effects of disaster response work and the symptoms of secondary or vicarious traumatization are essential components of professional development long before the possibility arises of volunteering for deployment. Deployment can come about as quickly as 48-72 hours after a disaster. At that point there is no time to develop needed habits of self-care such as regular exercise, support networks, healthy nutrition, proper sleep habits and time for family, friends and self.

Multiple deployments and disaster responses can deplete  your reservoir of resources — coping strategies, emotional and physical energy, and support systems at home and at work. Taking time, no matter how brief, for meals, breaks, walks, supervision and after-hours discussions with fellow workers will provide a respite and refill your reservoir of resources.

Defusing and debriefing are essential before counselors return home, where the transition back to family routine may be very stressful. New friendships were made at the disaster site and life-altering experiences were shared only with other disaster workers. A desire to return to the intensity of being deployed may also preoccupy disaster volunteers, increasing the potential for clinical mistakes on the job.

Problems with intimacy or relationships with family members and co-workers may threaten the support system needed for validation and recovery. When symptoms appear, counselors need therapeutic opportunities to tell their stories and transform the experience. On the other hand, some counselors returning from a disaster site may surprise relatives and co-workers with a positive benefit of deployment — increased positive feelings and the ability to let go of the small stuff and deal with what’s really important.

Common symptoms of compassion fatigue

CF, as a construct, is relatively recent, although it has likely been around for as long as humans have cared for one another. Many CF symptoms seem to parallel the symptoms of post-traumatic stress disorder. These symptoms include:

  • Increased negative arousal
  • Intrusive thoughts and/or images of situations/trauma
  • Difficulty separating work from personal life
  • Lowered frustration tolerance
  • Increased outbursts of anger or rage
  • Dread of working with certain clients
  • Increased transference/countertransference in work
  • Depression
  • Ineffective and/or self-destructive behaviors
  • Hypervigilance
  • Decreased feelings or work competence
  • Diminished sense of purpose/enjoyment with career
  • Reduced ego-functioning (time, identity, volition)
  • Lowered functioning in nonprofessional situations
  • Loss of hope

As Gentry noted, "The good news is that these symptoms are very responsive to treatment, and there are various interventions counselors can implement to protect against compassion fatigue." He listed five personal interventions counselors can use to help protect themselves against the symptoms of compassion fatigue.

1. Learn and practice the skills necessary for self-regulation. Pay attention to your arousal level and try to minimize it with relaxation, meditation, music and exercise. Self-regulation is essential for the counselor’s effectiveness and well-being.

2. Remain within yourself as a counselor. Do not be concerned with results and specific outcomes. You don’t need people to express gratefulness for your work. This is referred to as self-validated caregiving.

3. Try to maintain as healthy a lifestyle as possible, especially when experiencing extreme conditions. Eat well (avoid the doughnuts and sugary foods that are sometimes staples at disaster sites), rest whenever possible and recenter yourself. Exercise if you have the chance. This is probably similar to what you would recommend for your clients.

4. Share your experiences. It is helpful to offload your traumatic images and talk about your experiences. This can help to remove "psychic plaque." Again, this is something that counselors would encourage their clients to do.

5. Appreciate the experience you are engaged in and pace yourself. Try to remember that you are in a marathon and not a sprint. Also remember that what you are engaged in is a humbling experience.

Barnes added to the list by encouraging counselors to spend as much time as possible with family and friends during times of extreme stress. This will help counselors to maintain a therapeutic balance in their lives. Accessing social support networks has proved to be the most effective way of coping with the stress of disasters.

CF treatment

Counselors with CF are responsive to appropriate treatment, and tested and effective protocols are available to caregivers. Certified compassion fatigue specialists throughout the country are trained in the evidence-based, five-session Accelerated Recovery Program. This method has a proven history in treating CF and reducing symptoms. To locate a certified compassion fatigue specialist or to obtain information, contact Gentry at www.compassion unlimited.com.

The compassion satisfaction and fatigue test can assist you in estimating your status and gauging your risk level for burnout and CF.

Team leaders and supervisors should understand the signs and symptoms of vicarious trauma, secondary trauma, burnout and CF in order to help workers. The American Red Cross recognizes these problems in its disaster mental health training course, which is required for deployment of licensed mental health counselors.

The new International Association of Trauma Counseling advocates training in these areas in graduate counselor programs and professional development conferences. For more information on IARC membership or training, contact Mike Dubi at mdubi@argosy.edu or Jane Webber at jwebber@monmouth.edu.