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PTSD Questions & Answers
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Joyce Boaz & Dr. Frank Ochberg, M.D.

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Professionals: Compassion Fatigue.

Here is a recent correspondence between Dr. Ochberg and a mental health professional helping low income and vulnerable client populations.

Q: Dear Dr. Ochberg, I happened onto your website The Gift from Within by accident from an NASW webpage. I was curious about the title because for the past 6 months I have worked as a mental health therapist (the only one for 3 of those months) in a facility with one of the nation's highest adolescent suicide rates. I used the metaphor of a gift to reframe the traumatizing event and subsequent recovery process for my clients. I really enjoyed my work and had surprisingly positive results for a new counselor but unfortunately, I ran into several ethical dilemmas with the agency's increasing administrative directives that I felt put my client's lives at risk needlessly and I resigned, but not before a state senator's aid contacted me for information. Now I am being blacklisted by the agency for essentially whistle-blowing.

When I applied to a position in another facility the interviewer told me that I was suffering from compassion fatigue and no doubt there is some of that, especially since I was on my own here with a caseload of actively suicidal kids and grief stricken parents/families in a PTSD overloaded community and no clinical supervision or support. But I felt that I'm more stressed from my anger than compassion, anger about the lack of appropriate services here. Since I was told this by a competent therapist I am also a bit concerned about taking my anger back into clinical work if I am still struggling with compassion fatigue. How can I tell the difference between what I thought was simply healthy and appropriate anger towards a gross social injustice and compassion fatigue where I might need to get some help for myself?

A: Hello, What interesting, introspective questions! While I can't advise you from an email sketch, I can define terms and suggest a legal resource. Compassion fatigue means two entirely different things to authors Charles Figley and Susan Moeller. Charles, a psychologist and a pioneer in trauma science, uses the term to signify too much compassion --and fatigue from empathic overwork. Susan, a journalist and professor of media studies, means that compassion itself is fatigued, leaving the reporter cynical after covering too many tragic and traumatic human events. Susan's definition resembles our term, burnout. Burnout, to me, to Charles, and to most workplace consultants, means you no longer like your work and you aren't particularly effective. You have no sense of humor, your passion is gone, you are out of touch with the values and the optimism that brought you into the field in the first place.

If you have your humor and your spunk and spirit, but you are legitimately angry at administrators who may be burnt out and callous, or may be unqualified and blind, you don't need therapy -- you need a lawyer to help you fight for your own job rights and for rights of others. If you are emotionally damaged, suffering with signs of stress such as insomnia, substance abuse, poor health, or interpersonal tension, you would benefit from therapy. A good therapist would enjoy working with a highly motivated but stressed individual. The diagnosis would probably be adjustment disorder with anxious mood.

Finding a good therapist is not always easy, but you do have a background in the field and can find one by asking colleagues you respect. Don't settle for less than the best in commuting distance. A mediocre therapist is worthless. A good lawyer who cares about abuse of clients is even harder to find.

Try the NCVBA website (National Crime Victims Bar Association) for assistance. You are not a victim of crime. But if you or your clients faced anything approaching abuse of authority, reckless indifference, and commission of torts (civil rather than criminal wrongs), there may be legal redress and this group of lawyers are the ones who have the sensitivity and the experience to address such torts. I'm not recommending either course of action (retaining a therapist or a lawyer). That is up to you. Good luck no matter what, and thank you for caring enough about vulnerable people to get angry!

Professionals: Compassion Fatigue.

Q: Dear Frank, Here is a question from one of the people who attended your recent workshop on Compassion Fatigue.

"I attended your day-long workshop in Wausau, WI last week, and found that as days go by, the information shared continues to inform me - some big pieces falling in place about CF, especially how it relates to PTSD, and can be distinguished from burnout." I am a hospice chaplain working on a Doc/Ministry degree, and conducting my own research (pilot project at this point) on Compassion Fatigue among hospice staff (using ProQOL) as it relates to spiritual development.

I gather it makes sense to anticipate PTSD among certain populations: Vietnam vets, those who experience a natural or induced disaster of crisis proportions, victims of rape. But what about hospice patients? Do you think there would be an increased likelihood of PTSD among people (and their loved ones) who are told - usually in a doctor's office setting - that they probably have 6 months or less to live? (That's the primary Medicare criterion for hospice benefits, so it's often the yardstick that docs use and articulate.)

We as hospice workers, then, are the first group of people to step into the situation and begin processing it with patients, many of whom are numb, some of whom are really quite terrified. In any case, then we walk with them through their own process, which ends in death most of the time but not always, and sometimes painful death, but mostly not.

I'm just wanting to make sure: do hospice patients sound to you like people who would likely be traumatized, and would we as workers be vulnerable then to CF? The hospice experience sounds pretty gentle compared to rape or war, but it is SOOO primal - culminating in death. Like being slowly nudged off a cliff with your eyes open. And yet, not outwardly violent, either.

Up until now I have just ASSUMED entry into hospice as traumatic - now less sure.

Thank you for any reflections you might offer on this - or for any leads about how we as hospice people might informally or gently/easily identify PTSD in our patients - long term effects being irrelevant because of their life expectancy."

A: Dear Joyce, Thank you for this articulate and challenging email about hospice and PTSD. I'll do my best to reflect upon the questions raised. Of course hospice patients are shocked to hear the news about mortality and to know they will die. Loved ones are shocked as well. We all know we are going to die, but to absorb the news when it is real, finite, imminent -and associated with the risk of pain, isolation, stigma, dependency is traumatic, in the general sense of that word, "traumatic."

PTSD experts would limit the use of "traumatic" to the experience of a life circumstance that is not only shocking and stressful, but that evokes a particular image in the mind. To qualify as PTSD, that image must be unnatural, transforming the whole human into body parts, or the dignified and secure self into a helpless animal at the mercy of a predator -- or a home and community that was once traditional and harmonious into a shambles after an earthquake, with splinters and smoke and no solid earth under foot.

Natural death can be absorbed by the dying person as a stage of life - frightening but not "traumatic" in the special sense that defines PTSD. I suppose it is your job to help every member of the hospice family, including the patient and the next of kin, but also the co-worker, to accept this final chapter of life for what it is. If there are components of the PTSD diagnosis involved (because trauma imagery has occurred for any reason, and people have nightmares, flashbacks and haunting memories) then you and others can and should do everything possible to ameliorate these disturbing echoes of the past.

But if the real issue is overwhelming fearful anticipation of the future, then the PTSD model does not really pertain. The challenge is to find the best path through the present, knowing that "death, a necessary end, will come when it will come" (Julius Caesar, Act II, Sc ii).

My personal hope for my final chapter is that experts like yourself will do everything possible to assure minimal pain, reasonable dignity, and opportunity for communication with loved ones on MY terms -not having my preferences subordinated to those of institutional authorities or well-meaning relatives. In that regard, the hospice worker must be an effective advocate for the patient, not for the "system."

If I am haunted by the past (the day of receiving a "death sentence" in the form of a diagnosis) I will need help in freeing my mind of that obsessive rumination. Several of the techniques we discussed, based on post-traumatic therapy, would be worth consideration. But if I am frightened of the future, I would be best reassured by knowing the details of effective pain management, and of protocols assuring dignity and self-determination. If I requested some form of spiritual companionship, I should have that provided --but my religious beliefs are all about humanity and personal relationships, not about any organized religion. So I would need my form of religious freedom, which is freedom from the rituals of others (as much as I respect the rights that others have to practice as they believe).

My regard for hospice work and hospice workers is very, very high. I consider it a demanding and emotionally hazardous occupation. Compassion fatigue, vicarious traumatization and burnout are to be expected. But drawing strength from one-another and gaining gratification from assisting fellow human beings negotiate the final passage makes all the risk worthwhile.

Webcast: What is Compassion Fatigue?

In this webcast Dr. Frank Ochberg explains the causes, symptoms and
methods for coping with compassion fatigue.

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Page created on 9 Febrruary 2010
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