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Article 24

When it All Hits the Fan

Helping Counselors Build Resilience and Avoid Burnout

Claudia J. Sadler-Gerhardt and Davia L. Stevenson

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Paper based on a program presented at the 2011 ACES conference, Nashville, TN, October 27.

It costs to care for others. Helping others can be painful for the helper. Hearing stories of pain, sorrow, and suffering on a daily basis is described by Skovholt, Grier, and Hanson as an occupational hazard for members of a “high touch” profession, such as counselors, nurses, teachers, and social workers (2001, p. 168). Counselors work with clients who have experienced all kinds of trauma, including sexual victimization, war, chronic illnesses, violence, earthquakes or hurricanes, and terrorist attacks, to name but a few. Counselors in community mental health experience increased case loads along with decreased resources and funding cuts. Managed care providers authorize fewer billable session hours while mental and emotional disorders are more frequent and more severe. Societal stressors such as unemployment, financial crises, and the vast numbers of returning veterans who may be injured or suffering from mental or emotional disorders are further burdening an already under resourced health care system. In addition, counselors may also have a personal history of their own traumatic life experiences which can increase their susceptibility for emotional arousal to their clients’ stories of trauma (Lawson & Myers, 2011; Lawson & Venart, 2005).

One tenet of counseling practice is the importance of the therapeutic relationship (Wampold, 2001). Counselors are˝ actively engaged and emotionally present with hurting clients and often demonstrate a strong sense of empathy towards their clients. Recognition that the person of the counselor is considered the instrument of change in counseling can compound the felt responsibility experienced by counselors (Lawson & Venart, 2005). Counselors work with more than one client at a time, consequently striving to be fully present with many individuals at once. Supplying such empathic presence over time can diminish the physical and psychological resources of the counselor. Compounding these stressors is a cycle of starting new attachments with clients while ending other therapeutic relationships. Whether ending the relationship is due to completion of counseling goals, reaching the limit of managed care sessions, or as a result of other client variables, there may be feelings of grief and loss which add to counselor stress (Skovholt, 2005; Skovholt et al., 2001). Counselor-client relationships are a one-way helping relationship focused on the client’s needs, (i.e., the “other-care”; Skovholt et al., 2001, p.168) which may lead to depletion and burnout in the counselor. Additionally, the degree and direction of client change and reactions of supervisors to their supervisees are variables not completely within the counselor’s control, adding to the possibility of occupational stress (Skovholt, 2005).

Burnout, Compassion Fatigue, and Vicarious Traumatization

Counselor burnout has been studied, described, and defined in the literature (Lee, Cho, Kissinger, & Ogle, 2010; Morrissette, 2004; Osborn, 2004; Valent, 2002), and risk factors and potential vulnerabilities to burnout have also been explored (Lee et al., 2010; Skovholt, 2005). Burnout has been defined as the cumulative result of that sense of powerlessness in achieving work goals, which may be accompanied by psychophysiological arousal symptoms such as sleeplessness and irritability, decreased work performance, and relational disruptions or avoidance (Valent, 2002, p. 19). Burnout is also described as a state of mental and emotional depletion coupled with physical exhaustion (Osborn, 2004) that results from high work demands and low job satisfaction (Lee et al., 2010).

Physically, a counselor who is burned out will be tired, rundown, and may exhibit robotic actions. There may be some degree of depressed mood or even a sense of hopelessness that anything can change or improve. Additionally the person may be disillusioned with the profession or even with herself or himself. There may be resentment, a sense of entitlement, and low morale (Osborn, 2004).

Other terms that are often used interchangeably with burnout include compassion fatigue and vicarious traumatization. However, burnout can occur in any profession or job, and typically includes the physical and emotional characteristics described above. Compassion fatigue and vicarious trauma refer to a state in the helping professional that results from actions of empathic compassion, caring, and a view of the client as someone who suffers. Caring is evidenced by the counselor’s behavior or emotions and may produce a degree of physical and emotional fatigue or exhaustion. Figley described this state as the “cost of caring” (2002b, p. 2). Initially such a reaction was considered as a countertransference response, which is an emotional reaction to the client by the counselor. However, some authors disagree with that, suggesting that countertransference has little to do with empathy towards the client or the presence of trauma, but more to do with the counselor’s family of origin relationships (Figley, 2002a, pp. 1435-1436) and to unresolved conflicts and reactivated early memories (McCann & Pearlman, 1990).

Vicarious traumatization (VT) is that state which results from secondary exposure to traumatic events (i.e., listening to a client’s story of trauma exposes the counselor to the knowledge of the trauma), a “function of bearing witness to the suffering of others” (Figley, 2002a, p. 1435). As such it is a secondary traumatic stress reaction producing both emotional and physical reactions in the counselor as a result of hearing the client’s report. VT can occur in counselors, emergency medical workers, first responders, crisis counselors, or other providers of care for trauma survivors (Trippany, White Kress, & Wilcoxon, 2004, p. 32). Vicarious traumatization alters the worldview of the counselor as an aftereffect of repeated exposure to trauma stories over a period of time. The results can include disruption of the counselor’s cognitive schemas in terms of personal identity, memory, and beliefs; altered sense of trust and safety; exacerbated feelings of loss of control; and triggered intrusive thoughts or images within the counselor. Possible irrational and pervasive cognitive schematic changes may develop as a cumulative effect to additional traumatized clients (Trippany et al., 2004).

Counselors’ Risk Factors for Compassion Fatigue and Vicarious Traumatization

Every counselor and every client is different with differing stories. Each counselor will react to individual clients and their stories in varying ways. Counselors often hold the belief that they should be able to overcome their own personal difficulties without help, and that they can be immune to the effects of vicarious traumatization or compassion fatigue due to their training and skill (Lawson & Venart, 2005). Figley (1995) stated that counselors are vulnerable to stress because of the nature of their work, and that they are at high risk of compassion fatigue as a result. The “high touch” risks described by Skovholt and colleagues (2001) include external factors, such as the difficulty of the work, unsolvable client problems, or paucity of client resources, and certain intrinsic factors, such as a counselor’s inability to say no, the need for provision of constant empathy, and the uni-directional aspect of caring from counselor to client (pp. 169-170). Additionally, insufficient support resources, large case loads, inadequate supervision, long work hours and exhaustion, burnout conditions, and poor self care also increase vulnerability (Lee et al., 2010; Trippany et al., 2004).

Physiologic Response to Secondary Stress

Since there can be a physiological arousal response in hearing trauma stories from clients, similar to actually experiencing a threat or a danger, a review of the body’s response to perceived danger is helpful. The autonomic nervous system triggers the body’s initial response to stress with the fight, flight, or freeze reaction, evidenced by faster heart rate, dry mouth, and increased muscular tension. Simply hearing about a client’s traumatic event can activate the counselor’s autonomic nervous system (Rothschild, 2006). The autonomic nervous system includes two branches: the parasympathetic and the sympathetic nervous systems. The sympathetic nervous system is stimulated by threat or stress while the parasympathetic is activated during rest and relaxation. The two work similarly to a balance scale, with one activated and elevated and the other more suppressed. In extreme threat however, both may activate, eliciting “full throttle” response of all systems and the resultant body freeze state of “tonic immobility” (Rothschild, 2006, pp. 99, 101) in which the body is stopped by paralysis and a state similar to dissociation.

The limbic system’s amygdala is the controller of emotional response. When it perceives danger and trips the body’s alarm, the sympathetic nervous system is activated, causing the adrenal glands to release epinephrine, norepinephrine, and cortisol (Rothschild, 2006). Persistent threat results in prolonged hyperarousal of the sympathetic nervous system with flooding of the body by the stress hormones. If an activated counselor can learn to become aware of her or his own body’s state of arousal, that person can begin to manage or even halt the threat responses. Relaxation transfers the control of the sympathetic nervous system to the parasympathetic nervous system. Parasympathetic dominance in turn then produces increased bodily comfort, maximal motor and cognitive function, improved self regulation, with increased effectiveness. Parasympathetic relaxation is enhanced by relaxation of the large Kegel and Psoas muscle groups (those muscles in the lower pelvic region). Progressive muscle relaxation and deep breathing can also assist the individual in returning to parasympathetic dominance (Gentry, 2005).

The Risk of Counselor Impairment

In 2003, the American Counseling Association (ACA) created the second Task Force on Impaired Counselors in order to help identify and develop strategies and resources for intervention to help impaired counselors (ACA, 2010). One finding indicated that most states do not distinguish impaired professionals from unethical professionals (see the Task Force report for the three exceptions), nor do states identify intervention programs to help counselors in this condition. Further, after polling practicing counselors, the Task Force discovered that most indicated that they knew a colleague who would have been considered impaired by supervisors and colleagues, but that the professional had not received any specific therapeutic intervention for impairment. Counselors also reported that they were unaware whether or not their state had any intervention programs available for counselors.

The Task Force was careful to state that impairment did not imply unethical behavior, but that questionable ethical acts may be a symptom of impairment. An additional finding was that counselors are likely to fall anywhere on the continuum from wellness to impairment at any given time. What the Task Force recognized as important was the need for counselors to understand their own personal risk variables and what they could to promote their state of resilience and health. There are several helpful tools on the ACA website, including the ProQOL – R III (Stamm, 1995-2002), an instrument designed to score an individual’s current levels of compassion satisfaction, burnout, and compassion fatigue/secondary trauma; a Self-Care Assessment Worksheet (Saakvitne, Pearlman & staff of TSI/CAAP, 1996) to assess practices of self-care maintenance; and several other self-care tools for possible use by individual counselors (ACA, 2010).

Building Resilience

Osborn (2004) suggested that it is more beneficial to focus on cultivating and building resources to promote counselor resilience, rather than to focus on the idea of stress and the state of depletion. Preventing burnout or compassion fatigue/vicarious traumatization is a reactive response rather than a proactive focus on counselor wellness. It can hurt to care, to hear the stories from people who are hurting, to be empathic and present, and to want to help (Gentry, 2005). The following activity was conducted by Gentry (2005; shared with permission) in a workshop for workers who deal with trauma survivors. It can be helpful for recognizing that everyone has stresses in the counseling work realm, many of which are similar, and for reinforcing that one is not alone in this work. Participants wrote on cards three negative effects from their work and then silently showed their cards to one another. As the silence continued, attendees experienced an increased sense of community, a lesser sense of isolation, and increased identification with one another. This is an excellent activity that could be used within an agency or practice and has been used with positive reviews by the authors.

Building resilience does not happen by chance (Lawson & Myers, 2011), but instead is based on active practice of decisions that lead to wellness and health. Many believe that the key to prevention of compassion fatigue is discovery and reinforcement of “compassion satisfaction,” those activities that yield a sense of satisfaction from working with clients (Figley and Stamm, 1996, cited by Lawson & Myers, 2011, p. 164). Further, Lawson and Myers defined “career sustaining behaviors (CSBs)” as “personal and professional activities…to extend, enhance, and more fully enjoy their work experiences” (2011, p. 165) and suggested that counselors must be intentional about building specific CSBs into their daily lives.

Osborn used the term stamina as an acronym of seven beneficial factors which form a construct opposite to the deficit model of burnout (2004, p. 319). Stamina represents a dynamic movement towards growth and health (Osborn, Petruzzi, & Paez, 2002). The emphasis of stamina is endurance in the process of working within challenges facing today’s counselors. Osborn et al. (2002) supported the need for counseling professionals to be selective and intentional, to be aware of time restrictions, to be accountable, and to conserve resources of skill and energy as part of enhancing stamina. One aspect of conserving resources is the need for counselors to give themselves permission to say no and set limits in order to protect what is truly important to them. Another factor identified is the ability to negotiate and to collaborate within a multidisciplinary team. Being curious and inquisitive accompanied by a sense of the intrinsic motivation of agency are also other positive traits that help to build resilience (Osborn, 2004; Osborn et al., 2002).

A good starting point is for the counselor to inventory and identify his or her own resources in the physical, emotional, intellectual, behavioral, social, and spiritual domains. One of the helpful resources provided by the ACA Task Force on Counselor Impairment is Nugent’s (2004) “Pie of Life” exercise for examining how one allocates time and resources. Nugent’s instructions were to draw a circle and divide it into pie slices with each slice representing parts of life such as work, family, friends, fun, self care, or spiritual practices. From the pie, the person could determine if her or his life were in balance with values and priorities (ACA, 2010). Regular self-monitoring is an important but easily overlooked practice in the busy life of the counselor (Lawson & Venart, 2005).

Under the umbrella term of self-care for the counselor are many practices affecting physical, emotional, and spiritual wellness. It is not within the scope of this article to provide an exhaustive list of potential self-care activities, but rather to articulate a few to hopefully springboard idea generation within the reader. One practice that is important, regardless of a person’s spiritual or religious worldview, is the cultivation of sacred moments, that is, “a moment in time imbued with sacred qualities” (Goldstein, 2007, p. 1002). What is viewed as sacred will differ from person to person: it may be sitting by a stream, watching children at play, experiencing a time of meditation, or seeing a sunset. A sacred moment can take a person to a state of transcendence beyond herself or himself and provide a connection with others. It can promote purpose and meaning in life. Individuals have described sacred moments as precious, cherished, compassionate, and full of peace. It is important to find meaning and find ways to be hopeful, which in turn can lower stress (Goldstein, 2007). A sense of gratitude often accompanies a sacred moment and can actually replace that feeling of resentment or entitlement (Gentry, 2005).

Skovolt et al. (2001) described creating a professional greenhouse at work—an environment that would foster growth, with leadership that encouraged a balance of other-care and self-care, provide mentor and peer support, as well as opportunities for fun. The authors recommended further that counselors need to be intentional about creating such an environment, and not to expect that the workplace would act to meet the needs of employees (p. 174).

Also part of self-care is the deliberate meeting of one’s physical needs. Eating right, participating in regular physical exercise, drinking enough water, and getting enough sleep are all aspects of physical balance that help to promote counselor wellness. Investing in important relationships and keeping social contacts with friends who are not counselors are important strategies also. Cultivating hobbies, learning new things, and being involved in meaningful activities or relationships can help promote counselor personal and professional enrichment. Obtaining personal counseling may be an additional helpful aid to development of stamina and resources (Osborn, 2004).

Another important factor already mentioned in Skovholt’s professional greenhouse was play (Skovholt et al., 2001, p. 174), and an accompaniment to play is often laughter. Questions the author (CSG) asks counseling students and professionals are “When was the last time you laughed?” or “When was the last time you really played?” Counselors hear heartbreaking stories of pain, sorrow, and suffering that are saddening and hard to listen to. It becomes increasingly important to maintain a sense of humor (Lawson & Myers, 2011), to look for the comical in life, and to laugh! Perhaps this is a time to recapture childhood, because children laugh spontaneously and often—big belly laughs which are captivating and contagious. Laughter can reduce tension and increase energy (Skovholt, 2001). In fact Skovholt reported that in a study about coping strategies used by psychotherapists, 82% endorsed having a sense of humor as a “career sustaining behavior” (2001, p. 151).

Another suggestion to help promote health is to deliberately include a time of solitude. The work that counselors do is characterized by “people intensity” (Skovholt, 2001, p. 160). In addition to the professional caring work, many lead busy lives with family needs and other demands on their time. Computers, cell phones, social networking, and other internet activities also demand time and attention. Silence can be a disquieting experience, and yet quiet can be refreshing and rejuvenating. Certain spiritual practices such as meditation or prayer promote solitude and a connection with the transcendent, which can restore a sense of balance (Skovholt, 2001).

Conclusions

It is highly unlikely that a counselor deliberately intends to become impaired and unethical in practice. However, counselors and other helping professionals are vulnerable to such risks. In fact, counselors may even be more vulnerable to challenges for impairment than most as a result of inherent qualities of compassion, empathy, and caring (Lawson & Myers, 2011; Skovholt et al., 2001). It is likely that many small steps lead to depletion and on to a state of compassion fatigue over time. The end result might then be poor decision making or unethical choices on the part of the counselor. Without intentional decisions and actions to promote resiliency and wellness, the professional work of counseling can engulf the helper with depletion and exhaustion. A commitment to resilience takes time and effort, but a proactive stance can build endurance and bring about positive and rewarding responses to one’s work with clients (Osborn, 2004). As counselors learn more about building resilience, they can begin to build a supportive community with colleagues, coming along side one another with support and encouragement to reduce isolation and depletion. A focus on building resilience can assist the professional counselor to negotiate the challenging and demanding work environment of the mental health care field, and reduce the risk of ethical mistakes and increase the sense of purpose and mission for the counselor.