A rather unsettling fact about American society is that within it there exists a high rate of violence and abuse. According to Kessler et al (1995), 60.7% of men and 51.2% of women will experience at least one traumatic event in their lifetime. Given this fact, Kessler et al also state that of this group, the rate of those who will develop symptoms of Post-Traumatic Stress Disorder (PTSD) is high. Therefore, it is very likely (statistically) that many staff in agencies serving people with mental illness will have experienced some sort of trauma themselves. Couple this with the fact that the populations of people served experience trauma in ranges of 60% to 100%, there is a strong possibility of challenges in staff managing their own wellness and self-care. This article addresses one agency’s model for helping staff to work in this demanding environment.
The Institute for Community Living, Inc. (ICL) is a behavioral healthcare network serving over 8,000 people with mental illness and developmental disabilities per year. Offering programs in Brooklyn, Manhattan, Queens, The Bronx, and Willow Grove, Pennsylvania, ICL is a comprehensive care consortium that offers housing, rehabilitative and habilitative services, outreach, assertive community treatment, healthcare, outpatient, day treatment, vocational, case management and linkages services to individuals and families experiencing, or who are at risk for, mental health or development disability concerns. ICL now operates over 100 programs in congregate settings, shelters, schools, apartments, clinics, and the community.
ICL primarily receives funding from public entities, such as The New York State Office of Mental Health and The New York State Office of Mental Retardation and Developmental Disabilities. Funding sources such as these expect that ICL will accept and serve populations who are underserved or not present in private settings. Therefore, ICL works with young adults, individuals who have had contact with the criminal justice system, long-term shelter inhabitants, dually (e.g. MICA or MR/MI) or triply diagnosed (homeless, mental illness and chronic medical conditions) individuals, institutionalized consumers, and many individuals who have fallen out of traditional systems of care. Therefore, it is quite common that the average person served at ICL will have a homeless history, have used substances at some point in his or her lifetime, may have poor impulse control problems, have had contact with the criminal justice system, be at risk for a serious medical condition (or already be living with one) and have experienced a “revolving door” of treatment rather than consistency.
All these factors contribute to our client’s vulnerability to stress and its management. Persons served at ICL have a high need for intervention, natural supports such as family, and friends are not available, and as a whole they are at an economic disadvantage. These precipitating factors often lead persons served to express frustration towards staff that, due to their disempowerment, they cannot express easily towards the real source of their stress or anxiety. This naturally takes a toll on staff, and makes them vulnerable to secondary traumatic stress (STS), compassion fatigue (CF) and even burnout.
According to Pulido (2006), STS is a normal response for direct support professionals who are exposed to painful traumatic material as listed above. STS is different from basic trauma, in that the actual trauma is experienced by one person (the client), and it affects the helper in some other way. In secondary trauma, the worker exposed to the traumatic “stories” of the client develops reactions (signs and symptoms of trauma exposure) that mimic the reactions experienced by the person served. STS can change the way the worker thinks and feels about her or himself. Some of the signs and symptoms of STS can include increased vigilance, nervousness, intrusive dreams, and depersonalization (feeling like one’s life is not real) — all of which can impact a staff worker behaviorally, physically, psychologically, cognitively, spiritually, and socially. A common STS anecdote is that a worker who listens to stories of rape and violence begins to feel very edgy and worried when they are walking down an empty or darkened street. An important point to reiterate about STS is that it is a normal reaction to the exposure of working with traumatized persons; however, it is also a warning sign that the professional should seek support through personal therapy or counseling.
Similar to secondary traumatic stress is Compassion Fatigue (CF). According to Hudnall Stamm (2009), CF is also about work-related, secondary exposure to traumatic or extremely stressful events. Workers in the field of mental health often hear stories about the traumatic events that have occurred to other people, commonly called Vicarious Traumatization. Like STS, CF may include being afraid, having difficulty sleeping, having images of the upsetting event pop into one’s mind or avoiding things that remind the worker of the event. CF, like STS, is another warning sign that the worker must seek support. The risk in both symptoms is burn-out.
Burn-out is one of the elements of compassion fatigue, according to Hudnall Stamm (2009). It is associated with feelings of hopelessness and difficulties in dealing with work or doing one’s job effectively. These negative feelings usually have a gradual onset. They can reflect the feeling that one’s efforts make no difference, or they can be associated with a high workload or a non-supportive work environment. Signs and symptoms of burn-out include anger about coming to work, avoiding work altogether, physical ailments, frustration, increased anger, low morale, anxiety and stomach upset. If untreated, STS and CF can lead to burn-out which in turn can truly affect the worker to the point of needing to take a leave of absence or quitting his or her job.
ICL recognizes that in working with a traumatized population, the risk for employee STS, CF and even burn-out is high. This is why the agency has embraced a model of staff wellness and self-care. A core element of this model is a training module offered to all direct support professionals during their first six months of hire. Staff attends a 1.5 hour course that focuses on descriptions of STS, CF and burn-out, and walks staff through stress management techniques that include deep breathing, muscle relaxation and guided imagery. Staff is taught to use these techniques on a daily basis, and the importance of self-care is emphasized. The concept behind self-care is that as caregivers, mental health professionals are often better at caring for others than for themselves. Therefore, each attendee of this training makes a commitment to do a self-care activity for themselves every day beginning with the training date and forward. This can include anything from a daily walk, deep breathing, exercise, getting one’s nails done, a massage, watching a comedy, or reading something funny, to getting enough sleep and having a proper diet. The course instructor follows up with the trainees a few weeks later to check on how the self-care is going, whether they are keeping up with it, what obstacles are getting in the way of completing self-care and what the instructor and others in the person’s life can do to help maintain self-care.
The training ends with an assessment scale entitled the Professional Quality of Life Scale (ProQOL), developed by Hudnall Stamm (2009). The scale helps trainees measure their compassion satisfaction (e.g. the pleasure they derive in being able to do their work well), their level of burn-out and their compassion fatigue. Respondents are told the scale is meant to reflect how the person feels in the last thirty days. They are also told that the scale is but one piece of assessing these areas and that the respondent should not take the answers as “gospel.” They should, however, be mindful of scores that evidence burn-out and compassion fatigue and should, as a consequence, seek support (e.g. The Employee Assistance Program, supervisory or collegial support, and/or other means). Respondents are also encouraged to use this tool again at a later date to assess if their scores have changed.
“Staff Wellness and Self-Care” training has been in effect at ICL for eight years. It consistently receives marks of “excellent” to “good” on training evaluations, and qualitative data reports that staff members feel it really helps them to understand they are not alone and that they can experience STS and still do their jobs. Respondents report that they use the stress management techniques long after the training has been completed.
The realities of working in the mental health field are that the direct professional’s job is demanding and stressful. Clients are traumatized, and it is statistically likely that staff has been too. It is essential in caring for the caregivers that more classes like “Staff Wellness and Self-Care” are offered to personnel who are employed in mental health programs. Such classes are a solid cure for burn-out, and they help educate workers on their own vulnerabilities. As it is often said, if the mental health worker does not care for themselves, how can they care for others?