Management of self-care includes preventive measures important for avoiding burnout or compassion fatigue. Helpers

15 Sep Management of self-care includes preventive measures important for avoiding burnout or compassion fatigue. Helpers

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Management of self-care includes preventive measures important for avoiding burnout or compassion fatigue. Helpers can struggle with keeping a balance between care for others and care for themselves. Review Exercise 14.2, the Self-Care Worksheet, in your textbook.

In your initial post, discuss one of the items in each domain (physical health, social connections, psychological domain, affective domain, inner life, professional domain) that you engage in regularly and explain how that activity helps you maintain balance in your professional and personal life.

Chapter14.pdf

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C H A P T E R 14

Competence and the Ethics of Self-Care

I don’t know if it is I’m just overworked or whatever. I’m having trouble sleeping, don’t want to do anything or go out with friends, and truthfully, I look at my appointment schedule and start hoping clients cancel. I’m not sure what’s up, but I sometimes wonder if it’s time to simply get out of this profession?

T he experience being described by the human service provider who opened this chapter is sadly neither unique to this profession nor that unusual. For all who work as human service providers, the

mental fatigue and emotional exhaustion that accompany the intense work we do can be destructive to our health, mental well-being, and ability to provide ethical and effective service to our clients.

Table 14.1 highlights the fact that our professional codes of ethics are clear in their mandating of professional competence as a primary ethical requisite to providing service.

As suggested in the codes posted (see Table 14.1), the primary focus rests on competence as defined by one’s knowledge, skill, and experience. While these are clearly essential to effective, ethical practice, they are not the only considerations that should be made when assessing one’s ability or one’s competency to perform professional service.

Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from capella on 2021-09-12 17:41:50.

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Table 14.1 Addressing Competency

Professional Organization Principle

American Counseling Association (2014)

C.2.a. Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience.

American Psychological Association (2010)

2.01.a. Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

American Association for Marriage and Family Therapy (2015)

Standard III. Marriage and family therapists maintain high standards of professional competence and integrity.

International Association for Group Psychotherapy and Group Processes (2009)

Principle 3. Group psychotherapists who are members of the IAGP should have either completed formal education in group psychotherapy or be presently receiving supervision in an ongoing educational program by an established training organization that meets specific requirements.

National Association of Social Workers (2008)

1.04. a. Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

The current chapter reviews the ethical principles of provider compe- tence with special emphasis on the threats to competency emanating from the experience of burnout and compassion fatigue.

● OBJECTIVES

As such, the current chapter will help you to

• Describe what is meant by burnout and compassion fatigue • Explain the difference between burnout and compassion fatigue • Describe the ethical challenges burnout and compassion fatigue pres-

ent for the human service provider

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Chapter 14. Competence and the Ethics of Self-Care –●–349

• Identify ways a human service provider can reduce the possibility of burnout and compassion fatigue

• Articulate a personal wellness plan

COMPETENCY: MORE THAN KNOWLEDGE AND SKILL ●

In their book, Field Experience: Transitioning From Student to Profes- sional, Zhang and Parsons (2016) introduced the concept of self-care with an Anton Wildgans’s (1881–1932) quote, which has been made famous by Viktor Frankl, the author of Man’s Search for Meaning (1963): “What is to give light must endure burning.” While Wildgans’s quote is clearly reflective of his own experience as a provider of care and support to self and others during the Holocaust, the simple quote speaks volumes for all human service providers who have been engaged in providing care and support to others.

Perhaps, you are just starting your training in the field or are coming to the end of your training. In either case, it is likely you have already experi- ence the awesome gift and responsibility of serving in the role of human service provider. Being invited to journey with another, especially during a time of turmoil and challenge, demands knowledge and skill of the helping process, awareness of that which constitutes “best practice,” and the physi- cal and emotional energy to engage in a dynamic and challenging therapeu- tic relationship. They are responsibilities that provide light, while at the same time opening the provider to the possibility of emotional “burning.”

Helping: Being With, Not Doing To

Unique to the role and function of a human service provider is the fact that we are required to “walk with” our clients and not simply do for them. Our clients are not cogs on a conveyor belt needing to be assembled, nor are we simply information providers to those requesting direction. Our cli- ents are those navigating through a challenging time in their lives, for whom support, emotional, social and physical, is required.

As human service providers, we are engaged in a service that requires our personal, emotional engagement with the client (Bakker, Van der Zee, Lewig, & Dollard, 2006). The very process of engaging with others who are suffering can pose a threat to the human service provider (O’Brien, 2011). The work we do is fertile ground for stress. The fact that we work in situa- tions of physical and social isolation, where we often encounter unexpected and unpredictable schedules and demands and by definition immerse

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ourselves in intense personal interactions, provides the conditions to make this work stressful and emotionally demanding (Bakker et al., 2006). The stress of taking on the responsibility for assisting one in crisis, especially when work conditions are such as to add to that stress or, conversely, fail to provide the essential support necessary for providing ethical, effective service, can accumulate and will negatively impact the provider’s ability to perform competently. Research would suggest that those engaged in the helping professions are vulnerable to effects of enduring stress (Lee et al., 2007).

Given the nature of our work it is not unexpected to find that many find it difficult to maintain their own health and well-being. According to a study by the American Counseling Association (ACA, 2010), of those surveyed, over 63 percent reported knowing a colleague whom they would consider impaired. The magnitude of the finding moved the ACA to develop a task force for the sole purpose of decreasing impairment and enhancing wellness among its members.

The impact of enduring stress and the toll it can take on both the pro- fessional and the clients whom they serve makes it a clear ethical concern. While the impact of enduring stress can take many forms, two—burnout and compassion fatigue—are the focus of the remainder of this chapter.

● BURNOUT

Burnout has been described as the “gradually intensifying pattern of physi- cal, psychological and behavioral responses to a continual flow of stressors” (Gladding, 2011, p. 24). Burnout is experienced as emotional exhaustion and often manifests in form of apathy, negative job attitude, and perhaps most concerning from an ethical perspective of competence, a loss of con- cern and feeling for the client (Gladding, 2011).

For some practitioners experiencing burnout, the impact is evident in their tendency to withdraw from social contact, become defensive and aggressive in relationships, and when it comes to clients, exhibit a dehu- manizing attitude (Lambie, 2002). That dehumanization often reveals itself in the provider’s identification of clients by a diagnostic label such as “my borderline” or in personal characteristics, for example, the “divorcee,” and serves to distance and detach the counselor from the person of the client and thus his or her suffering (Maslach, Schaufeli & Leiter, 2001). Consider the case of Dr. L., one practitioner for whom burnout clearly impacted her ability to provide effective, ethical service (Case Illustration 14.1).

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Case Illustration 14.1

Dr. L.: A Case of Burnout

Dr. L. is a 48-year-old clinical psychologist working in a community mental health center. She has worked as a clinician for over 19 years and has been employed within this center over the past 8 years. Over the course of the past 8 years, she has experienced a decline in both professional and support staff, while at the same time an increase in both the number of clients seen and the level of severity of the issues being presented. The pressure from external funding sources as well as internal administration placed emphasis on a mandate to see more clients and produce results with fewer sessions. The increased workload resulted in her working late hours, often 10 hour days, and twice a month being required to work a sixth day, Saturday, to increase her “productivity” figures.

The physical exhaustion of the increased workload, the reduction of physical and emotional support, and a general dissatisfaction and discomfort with what she saw as her inability to provide “adequate” service began to take its toll. As one who considered her work more than a job, a true vocation, the situation left her feeling professionally inadequate.

While these changes developed slowly, it became obvious that Dr. L. was experiencing a deep sadness and a lack of interest in engaging in previously enjoyable activities (e.g., racquet ball, golf, etc.). She was finding it difficult to make decisions within her practice, even to the point of failing to develop meaningful treatment plans for her clients. Dr. L. reported a concern that her ability to attend to her clients seemed diminished and that she had on occasion experienced moments when her memory went “blank.” She reported entering sessions in which she brought the wrong case file and even had three occasions where she either could not remember the client’s name or referred to the client by using another client’s name.

She found the experience to be such that she “dreaded” going to work and hoped that clients would cancel. In addition, she began call- ing out and taking sick days, often canceling appointments at the last moment. While her colleagues privately expressed concern, no one reached out to Dr. L. Fortunately, her diminishing level of professional

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As is evident in our case illustration, the experience of burnout is multidimensional. In addition to somatic and cognitive symptoms, burnout can affect a professional’s emotional stability, resulting in conditions rang- ing from annoyance and frustration to more severe presentations, such as depression and anxiety (Maslach, Schaufeli, & Leiter, 2001). For others, burnout results in apathy, fatigue, anger, and conflict (Gladding, 2011). In any presentation, it becomes clear that burnout will impair one’s ability to provide ethical care and service (Maslach, 1993).

effectiveness along with her increased reliance on alcohol as a means of self-soothing led Dr. L to ask for, and receive, medical leave.

While her break from work was brief, only two weeks, it was a time when, with reflection and discussion with a supervisor, Dr. L gained insight into what she was experiencing and the steps she needed to take to engage in her own healing. After this break, during which time she returned to a regimen of healthy eating, regular exercise, engage- ment with friends, and getting 7 to 8 hours of sleep each night, her symptoms diminished and she found not only a desire to return to her clients but also an energy and enthusiasm to advocate organizational changes in order to bring their services in line with that expected of an ethical, effective center.

(Continued)

● COMPASSION FATIGUE

A hallmark of the both the helping relationship and the role of the human service provider is our ability to enter into the other’s phenomenological field, experiencing their world as they do, sharing their feelings, and better understanding their world and self-views. This ability to experience deep empathy is both a gift and a potential risk. Sharing in the pain, the anxiety, the sadness, or the sense of hopelessness often presented by our clients can challenge our ability to balance professional objectivity and distance while at the same time truly walking with our client. For clinicians lost in the lived experience of their clients, the result can be quite destructive, leading to increased stress and an inability to continue to feel and convey the compas- sion so characteristic of the helping professions.

Compassion fatigue has been defined as a “state of exhaustion and dysfunction—biologically, psychologically, and socially—as a result of

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prolonged exposure to compassion stress (Figley, 1995, p. 253). Compassion fatigue differs from burnout in that it occurs suddenly, rather than gradually as is the case with burnout, and presents often with symptoms that mirror post-traumatic disorders (Trippany, Wilcoxon, & Satcher, 2003). As such, it is often referred to as secondary post-traumatic stress disorder.

The impact of compassion fatigue is both broad and deep. Compassion fatigue can result in mental fatigue and an inability to concentrate, a deterio- ration of one’s ability to work effectively, a change in a person’s fundamental values and beliefs, and an increase in feelings of sadness, anxiety, and guilt (Zhang & Parsons, 2016). In addition, for some, compassion fatigue results in excessive emotional numbing and, like those with post-traumatic stress syndrome, the experience of intrusive images and thoughts of their cli- ent’s traumatic material. This experience can reduce the clinician’s ability to empathically engage with a client and thus presents a very real threat to one’s ability to provide competent, ethical service.

THE ETHICAL CHALLENGE ●

Burnout and compassion fatigue must be recognized and accepted as real threats to ethical practice. Consider the following case (Case Illustration 14.2) as reflecting the unethical decisions and behavior that result from compassion fatigue.

Case Illustration 14.2

Compassion Fatigue: Undermining Ethical Behavior

While serving as a middle school counselor for 18 years, Mr. E. had spent the last 2 years working in the capacity of crisis interventionist. In that role, he engaged with students who were physically and sexu- ally abused, those exhibiting suicidal ideation and behavior, and oth- ers with depression and debilitating anxieties. Now, halfway through the academic year, he began experiencing a reduction of energy and a loss of enthusiasm for his job. He began to exhibit attitudes and behaviors that could best be described as atypical for him and clearly unprofessional.

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It would be easy to dismiss both compassion fatigue and burnout as things that happen to those who have worked “too long” in the field. How- ever, failing to embrace the reality of burnout and compassion fatigue as real possibilities for ourselves, regardless of our tenure within the profes- sion, positions us to engage in unethical behavior (Everall & Paulson, 2004). These conditions not only attack the professional’s physical stamina but also as detailed above result in psychological exhaustion, emotional distress, and potential exploitation of clients (Norcross, 2000), and they can occur at any stage of our professional life.

A Challenge to Core Values

A review of the core values that serve as the foundation of our codes of ethics, values such as autonomy, beneficence, nonmaleficence, and justice

Whereas students historically sought out his service and support and parents spoke highly of his effectiveness and real care for the students, it was clear by student complaints about his lack of availability and tendency to be sarcastic when interacting with them that something was changing. Even faculty began to report on the apparent changes in his demeanor and professional behavior, noting that something was negatively impacting his ability to function in his role as crisis intervention counselor.

Faculty reported experiencing his increased venting and complain- ing about the students he was seeing. They noted that he often referred to the students and their life conditions as hopeless and that he, as one person, was impotent in “rescuing” them from the “hands they were dealt.” While concerned about the apparent heavy heart he exhibited when speaking of some of the students, the faculty were equally con- cerned by what appeared to be his angry, dismissive, and devaluing attitude toward other students. Faculty reported hearing him use inap- propriate terms, such as referring to some students as “diagnosable” or others as falling into the category of “P.I.T.A.” (pains in the ass). The dismissiveness and depersonalization was even experienced by teach- ers seeking consultation who were told to “do their own damn jobs.”

While certainly unprofessional, the language and labeling was so out of character for Mr. E., a person who had previously been a model of caring and professionalism, that faculty went to the district supervisor to report their concerns.

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(See Chapter 3), illuminates the ethical challenge presented when a practi- tioner is experiencing burnout and/or compassion fatigue.

As ethical providers, we are directed to respect and attend to the welfare of our clients. Respecting the integrity of those with whom we work, committing to serving their welfare, and engaging in competent best practice are principles found across our professional codes of ethics. For example, the American Psychological Association (APA, 2010) notes that psychologists, embodying the values of beneficence and nonmaleficence “strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally” (Principle A). Consider this standard in light of the two previous case illustrations (i.e., Case Illustrations 14.1, 14.2). Certainly, meeting this ethical standard and the similar standards expressed by the other professional human service organization is difficult, if not impossible, when one is experiencing burn- out and/or compassion fatigue.

A Challenge to Developing and Maintaining an Ethical Therapeutic Relationship

As noted by Everall & Paulson (2004), a counselor who is having diffi- culty meeting her personal needs appropriately may violate boundaries and become more deeply enmeshed with her clients. The physical, psychologi- cal, and emotional exhaustion that accompanies burnout and compassion fatigue can result in the human service provider disengaging from the client to a point of negating the client as person and not only demonstrating the inability to maintain a sense of empathy but even a basic respect for the client. Since responsible caring requires professionals to actively demon- strate a concern for the welfare of individuals, the practitioner’s diminished ability to function as a result of burnout or compassion fatigue may con- stitute a serious violation of a fundamental principle of ethical practice. Further, with a personal sense of exhaustion, a human service provider not only runs the risk of failing to engage and maintain a therapeutic alliance but also runs the risk of aligning with a client’s feelings of frustration, anger, and hopelessness to the point of conveying a doubt in the effectiveness of their service. Under these conditions, the practitioner risks exploiting the client through boundary violations or role reversal in order to meet personal needs.

Disengagement from one’s client or using clients to meet personal needs clearly violates the primary directive to respect the dignity and promote the welfare of our clients (e.g., ACA, 2015, Principal A.1.a;

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AMHCA, 2010, Principle I.A.1.a). The inability to care and respect truly undermines one’s competence to engage in effective therapeutic rela- tionships and as such is a violation of our ethical principles. For those experiencing the inability to perform competently because of burnout and/or compassion fatigue, the directive, as noted the APA, is to “refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner” (2010, Principle, 2.06).

A Challenge to Enacting Ethical, Effective Treatment Plans

Engaging in ethical, effective treatment is a keystone of professional practice. For example, the ACA directs its members to devise treatment plans that offer reasonable promise of success (2014, Principle A.1.c). In support of this principle, other organizations have directed practitioners to continue to seek out on-going training and supervision as a means of maintaining and upgrading competence. For example, social workers are directed as follows:

[to] strive to become and remain proficient in professional prac- tice and the performance of professional functions. Social workers should critically examine and keep current with emerging knowledge relevant to social work. Social workers should routinely review the professional literature and participate in continuing education rel- evant to social work practice and social work ethics. (NASW, 2008, Principle 4.01)

Similarly, psychologists are ethically mandated to maintain competence by undertaking “ongoing efforts to develop and maintain their competence” (APA, 2010, Principle 2.03).

While it is notable that our professional organizations recognize the need for the maintenance of a practitioner’s knowledge and skill as foun- dational to competent service, it is equally important that we recognize the fundamental need and value of maintaining a practitioner’s physical and psycho-emotional well-being as equally foundational to competent service. For example, the ACA not only calls for its members to maintain knowledge of best practice and to devise treatment plans that offer a rea- sonable promise of success but calls for its members to do so in concert

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Chapter 14. Competence and the Ethics of Self-Care –●–357

with their clients (ACA, 2014, Principle A.1.c). One may question how such collaboration is developed and maintained when the practitioner has disengaged and devalued the client as a result of his or her experi- ence of burnout and compassion fatigue. Clearly, the disengagement and devaluing of the client that often accompanies burnout and compas- sion fatigue diminishes a practitioner’s interest and ability to effectively engage with a client to devise, implement, and maintain an …

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