The High Cost of Caring – Coping With Workplace Stress
Dr. Barbara L. Anschuetz
It is a well documented fact that we live and work in a high-stress society. A recent study sponsored by the Homewood Health Centre suggests that 25% of white-collar workers and 40% of blue-collar workers in Canada have had a stress-related absence in the past year. Statistics Canada calculates the annual cost of work time lost to stress as CDN$12 billion1. American statistics show that 75-90% of visits to primary care physicians are for stress-related problems. The U.S. National Safety Council estimates that 1 million employees are absent on an average workday because of stress-related problems and that 40% of worker turnover is due to job stress. A recent phenomenon that has been studied in workplace stress has been the increase in workplace violence due to stress. Homicides accounted for almost 20% of the more than 6,000 workplace deaths in the U.S.A. and it was the leading cause of death for working women. Toronto Police Service records show that there were 82 reports of supervisors or employers accused of workplace assault in 1997 and 88 reports in 1996. Two models for the conflict-producing workplace that have been developed are the high-demand / low-control workplace and the high effort / low reward workplace. In either case a burdensome workload combined with a sense of powerlessness or injustice produces a worker at the limits of his ability to cope1.
In addition to the more well-known physiological responses to stresses as researched by Selye (1974) which he defined as the "sum of all non-specific changes caused by function or damage", current studies have documented other areas of work-related stress, that of burnout, critical incident stress, cumulative stress, compassion fatigue, and vicarious traumatization. More recently, it has become obvious in the area of research on stress that the psychological impact of different types of stresses, particularly traumatic stresses, can have a profound effect on a worker's ability to perform effectively.
Critical Incident Stress
One of these areas of stress is that of Critical Incident Stress. A critical incident is the body's normal response to an abnormal event. It occurs as the result of a traumatic event, an event outside the range of usual human experience and an event that causes unusually strong emotional reactions. Categories of traumatic events include natural and technological disasters, man-made disasters including deliberate disasters (such as hostage-taking, bank robberies, murder and personal violence) and accidental disasters (industrial accidents, air crashes). Physical, cognitive, behavioural and emotional responses to a critical incident usually subside within a few weeks. If not, symptoms can develop into Acute Stress Disorder or Post-Traumatic Stress Disorder (PTSD). Short term and non-deliberate critical incidents have a greater prognosis for early recovery. Those events which are long-term and anticipated, such as child abuse and domestic violence are more likely to take longer for recovery and more likely to lead to symptoms of PTSD. While dealing with the traumatic impact of a critical incident it is not unexpected for the worker's job performance to decline while s/he tries to find a place to fit the trauma into his or her world view.
As has been documented with emergency services personnel, those who work with critical incidents on a day-to-day basis become vulnerable to the effect of cumulative stress as a form of burnout. Other health care workers, particularly those working with clients involved in traumatic events, such as child protection workers, are also highly vulnerable to the effects of critical incident stress.
Cumulative Stress
Another debilitating form of stress, cumulative stress, is usually caused by a combination of a wide range of work and non-work stresses2. There are 4 distinct phases to cumulative stress: warning phase, mild symptom phase, entrenched phase and severe/debilitating phase.
Phase 1 – Warning
Warning signs of an impending cumulative stress reaction are predominantly emotional. They may take a year or more to grow to any noticeable degree. The earliest signs are feelings of vague anxiety, depression, boredom, apathy and emotional fatigue. Early action can produce early recovery. Talking about feelings, taking a vacation, a change of activity and taking time for oneself are positive steps to combat early the warning signs of Phase 1 of cumulative stress.
Phase 2 – Mild Symptoms
If neglected or ignored, the warning signals of cumulative stress become fixed and intensify. Over a period of 6-18 months, physical signs add to the emotional signs. The more common symptoms include sleep disturbances, more frequent headaches and colds, muscle aches, intensified physical and emotional fatigue, withdrawal from contact with others, irritability and intensified depression. An aggressive lifestyle change at this stage is imperative. Short-term counselling to create a balance in work and home life can help with mild symptoms.
Phase 3 – Entrenched Cumulative Stress
The entrenched phase occurs when people have ignored the previous two phases. Entrenched changes are difficult: careers, family life and personal happiness are on the line. Numerous symptoms can occur including increased use of alcohol, smoking, non-prescription drugs, depression, physical and emotional fatigue, loss of sex drive, ulcers, marital discord, crying spells, intense anxiety, rigid thinking, withdrawal, restlessness, sleeplessness, etc. Medical and psychological intervention is usually necessary.
Phase 4 – Severe/Debilitating Cumulative Stress Reaction
This phase is self-destructive and usually occurs after 5-10 years of ignoring symptoms of growing stress problems. Careers end prematurely and victims almost always need significant intervention from professionals. The following severe symptoms are common: asthma, coronary heart disease, heart attacks, diabetes, cancer, severe depression, lowered self-esteem and self-confidence, inability to perform one's job and manage one's personal life, withdrawal, uncontrolled anger, grief and rage, suicidal or homicidal thinking, muscle tremors, extreme chronic fatigue, over-reaction to minor events, agitation, frequent accidents, carelessness, forgetfulness, paranoia, moderate to severe thought disorders and other physical and emotional symptoms11.
Burnout
Another type of work-related stress – burnout – is the body's response to constant and chronic sources of emotional and interpersonal stress. Burnout can also develop from exposure to people in emotional pain and from the strain of having to continually convey empathy to others9. When occupational caregivers who are involved in abuse work and systems of support and law enforcement fail to protect or serve the client appropriately, the human services worker can also experience distress and frustration leading to burnout4. Components of burnout include physical, emotional and physic exhaustion. The exhaustion is due to excessive demands on energy, time, strength and personal resources in the work setting6. Depersonalization and reduced personal accomplishments characterize this phenomenon which can occur among individuals who work with people in some capacity.
"The burnout syndrome is a particular problem for caregivers since their focus is on people-oriented responsibilities at various levels. For the professional, there can be emotional costs when attempting to achieve that goal of helping others."7
Burnout can be broken into two categories: rapid or gradual onset.
- A professional who experiences rapid onset burnout is one most likely exposed to a tremendous amount of stress in a short time period. Those workers in the disaster trauma emergency services work are more prone to rapid onset.
- Gradual onset burnout occurs as a result of being exposed to stress for extended periods of time, as in the case of the social worker or child protection worker. Gradual onset burnout can have more serious and permanent effects than rapid onset3.
Those workers most vulnerable to burnout are those who are dynamic leaders, idealists, perfectionists, committed and overextended, unable to confide in others, who present an ironclad will and a tendency to externalize blame for work problems. These characteristics are also synonymous with those who enter the human services field, whether in the role of therapist, emergency services personnel, social worker, child protection worker, etc.
Comments made to me over the past year from human services workers in the area of child protection aptly describe the symptoms and effects of burnout:
- "This job is like managing a neurosis: the job should be doable and it's not."
- "I am no longer treading water; I feel I am drowning."
- "I feel I am burning and nobody is there to put out the fire."
- "I work like a machine; I act like a robot."
In this society, we expect that those who deal with tragedy on a day-to-day basis will eventually become immune to the impact of it. However, our knowledge of the effects of burnout and cumulative stress have shown us in long-term studies of emergency services personnel that they are more susceptible to trauma, particularly when the trauma involves children. We are now only becoming aware of the implications of the effects of secondary traumatic stress (i.e. secondhand exposure to traumatic material which transforms the inner world of the helper) and vicarious trauma on service workers who deal with children and trauma on a day-to-day basis, particularly those in child protection and child abuse services. The nature of the empathic relationship can create a higher risk for the induction of symptoms of secondary traumatic stress (see Table 1)
5.
Vicarious Traumatization
In their book Trauma and the Therapist12, Pearlman and Saakvitne state that "Vicarious traumatization differs in its conceptual basis from secondary traumatic stress disorder and compassion fatigue." Their definition of vicarious trauma is "a process through which the therapist in her experience is negatively transformed through empathic engagement with the client's trauma material; that is, that vicarious traumatization focuses specifically on the negative aspects of the worker as a witness to the client's trauma through their vivid description of the traumatic events, their reports of intentional cruelty and abuse, and their experiences of reliving their terror, grief and yearning. The worker is both a witness and a participant in the traumatic re-enactment within and outside of the therapeutic relationship."
They also state that vicarious traumatization refers to the cumulative effect (i.e. the cumulative stress) of doing trauma work with clients and to its pervasive impact on the self and can thus result in profound disruption in the worker's frame of reference, that is, basic sense of identity, world view and spirituality. Multiple aspects of his life are affected including affect tolerance, fundamental psychological need, deeply held beliefs about the self and other interpersonal relationships, internal imagery and experiences of his body and physical presence in the world.
Compassion fatigue is described by Figley5 as a state of tension and preoccupation with the individual or cumulative trauma of clients manifested in 1 or more ways: that of re-experiencing the traumatic event, avoiding, numbing or reminders of the traumatic event and through persistent arousal. Figley also points out that when the professional is suffering trauma, as opposed to burnout, he usually experiences a faster onset of symptoms and faster recovery from symptoms – a sense of helplessness and confusion, isolation from supporters – symptoms often disconnected from real causes and symptoms triggered by past or current traumatic experiences (which could also be former critical work-related critical incidents).
The main difference between these two definitions as stated by Pearlman and Saakvitne12 appears to be a difference in the conceptual basis. Secondary traumatic stress and compassion fatigue have their foundation in a symptom-based diagnosis, and thus focus primarily on a constellation of symptoms. Vicarious traumatization has its foundation in a constructivist personality theory: it emphasizes the role of meaning and adaptation rather than symptoms.
"Given our understanding of psychological trauma and the self and of the interpersonal therapeutic process from a theoretical perspective, vicarious traumatization is inevitable. It is unique to trauma work and its effects are specific, pervasive, and predictable according to its theoretical foundation and the psychology of the individual therapist. The effects are widespread, its costs are immeasurable… it will inevitably affect all of our relationships – therapeutic, collegial and personal."
Pearlman and Saakvitne12
The authors also state that unaddressed vicarious trauma can lead to the worker leaving the field, whether because it sets the stage for burnout or because of the worker's lost sense of identity as an effective helper or because of demoralization and soul sadness that characterizes the spiritual damage of vicarious traumatization.
Determining the Degree of Vicarious Trauma
Pearlman and Saakvitne13 have developed an assessment tool to determine the contributing factors of vicarious trauma. Assessing the following questions can help determine the degree of vicarious trauma experienced by the caregiver or the helping professional.
The nature of the work
- How much choice and control do I have over my work?
- Is my work short-term crisis or long-term?
- Am I doing the kind of work I like, for which I feel I like, for which I feel well suited, at which I feel competent and talented?
- Does this work match my values and beliefs?
The nature of the clientele- With what populations do I work?
- How many clients do I see each day / each week?
- Is there balance and variety in my caseload and work?
- Are there certain clients with whom I especially enjoy working? Why?
- With which clients do I struggle the most? Why?
Other client-related factors/the nature of the workplace- Do I have enough organizational support?
- Do I have collegial support within my organization, within my profession, among collateral providers?
- Am I getting enough helpful supervision?
Other workplace factors/the nature of the helper self-assessment- Is my training appropriate for my work?
- What are my current life stressors and supports?
- What is my relevant life history?
- What are my familiar coping strategies?
- What are my emotional style and vulnerabilities?
- How is the fit between myself and my work?
- Do I enjoy my work?
Other personal factors/the nature of the social/cultural context- How am I impacted by social obstacles to the work (such as: funding cuts to mental health, managed care, delayed recall controversy)?
- How does the community respond to the type of work I and my organization are doing?
- How does the community view the population I serve?
Work settings have a profound effect on a professional's vulnerability to vicarious trauma. Organizations can increase the risk of vicarious trauma when they do not provide respite for staff, such as:
- shared coverage
- adequate time off
- requiring staff to have unrealistically high case loads
- failing to provide enough qualified supervision
- denying the severity and pervasiveness of the client's traumatic experiences and after effects
- failing to work with staff to identify and address signs of vicarious trauma
- not providing opportunities for:
- continuing education
- sufficient vacation time, and
- personal psychotherapy opportunities for the helper13.
A healthy self-care plan that addresses the worker's professional, organizational and personal realm can help in the healing from the inevitable effects of vicarious trauma.
As seen by the long term debilitating effects of the different types of stress on the professional caregivers, knowledge and understanding of the stresses, and personal, professional and organizational commitment to change are imperative for those suffering from stress. Otherwise the cost of working with traumatized clients can be too high!
References1. Cole, Trevor. All the Rage. February 1999 Report on Business Magazine, pp 5-57. 1998.
2. Edelwich, J. Burnout: Stages of Disillusionment in the Helping Professionals. New York: Human Sciences Press. 1978.
3. Farberon, N & Frederick, C. Disaster Relief: Worker's Burnout Syndrome. Field Manual for Human Services Workers in Major Disasters. Washington, DC, U.S. Government Printing Office. 1978.
4. Faith, K, & Breen, M. To Care for Others: To Care for Ourselves. OASW Newsmagazine; Vol 22#3, pp 1-51. 1995.
5. Figley, Charles. Catastrophes: An Overview of Family Reaction. CR Figley and AI McCubbin (Eds.) Stress and the Family, Vol.11 Coping with Catastrophe. New York: Brunner/Mazel. 1983.
6. Freudenberger, HJ & Richelson, G. Burnout: How to Beat the High Cost of High Achievement. New York: Doubleday. 1980.
7. Hanbury, RF. The Stress Phenomenon of the Field of Psychotraumatology. Trauma Response, Vol. IV#1, pp 17-19. 1998.
8. http://www.stress.org/problem.htm
9. Maslash, C. Burnout: the Cost of Caring. New Jersey: Prentice Hall. 1982.
10. McCann, Lisa & Pearlman, Laurie Anne. Vicarious Traumatization: A Framework for Understanding the Psychological Effects of Working with Victims. Journal of Traumatic Stress, Vol. 32#1, pp 131-149. 1990.
11. Mitchell, Jeff & Bray, Grady. Emergency Services Stress. Guidelines for Preserving the Health and Careers of Emergency Services Personnel. New Jersey: Prentice Hall. 1990.
12. Pearlman Laurie A & Saakvitne, Karen W. Trauma and the Therapist. New York: WW Norton. 1995.
13. Saakvitne, Katen & Pearlman, Laurie Anne. Transforming the Pain. A workbook on Vicarious Traumatization for helping professionals who work with traumatized clients. New York: WW Norton. 1996.
Dr. Barbara L. Anschuetz is a Psychotherapist. This article first appeared in the Journal, the newsletter of the Ontario Association of Children's Aid Societies, Volume 43 #3. It is reprinted with the kind permission of the author.
