A Counselor`s Own `Treatment Plan`

Time-limited treatment with multi-problem clients creates work situations that can ignite the fires of unresolved countertransference, and can fan those fires with compassion fatigue and burnout. On a good day, addiction counseling is stressful work. Clients, suffering from the physical and mental ravages of addiction, as well as the traumatic life events that either initiated or resulted from it, seek help. Counselors must accurately diagnose these clients, as well as assess for trauma-related symptoms, all while functioning within stressful work systems.

It is no wonder that countertransference, compassion fatigue, and burn-out can result for the counseling professional. Let's look at a prototypical example. Tom, a seasoned counselor, struggles with the pressures brought on by aging parents, adolescent children, and a job in an addiction treatment center undergoing systemic changes. Tom postpones an overdue vacation to cover for a colleague on emergency medical leave. At the same time, an aging parent with Alzheimer's disease recently has moved in at his home. Also, Tom's son receives a second arrest for driving under the influence and denies that he has a drinking problem. These factors leave Tom particularly vulnerable to countertransference with his younger clients, as well as compassion fatigue and eventually full-blown burnout. A combination of stressful situations at work and at home leaves him with no safe haven.

Defining compassion fatigue

At the heart of effective counseling is the ability to join others in their painful journey and to lend strength to their process of recovery. Professionals' capacity for compassion sets the stage for countertransference, compassion fatigue, and burnout. In a discussion at a Women Healing conference sponsored by Hazelden in 2004, author and presenter Stephanie S. Covington, PhD, defined compassion as “losing ourselves in order to emotionally join with our clients.” Dr. Covington and I have discussed at this conference how counselors' constant surrendering to that “deeper than empathy” level can exhaust them and lead to compassion fatigue.

It is abundantly clear that alcohol and drug counselors must make a conscious decision to protect themselves if they are to survive working in the field, retain their effectiveness with clients, and live a fulfilling personal life. It is likely that counselors such as Tom, who face patients whose lives have similarities to their own, can quickly lose professional detachment if they have not integrated those past experiences. Endless compassion combined with personal and professional stress can destroy a counselor's optimism, diminishing the belief in the human spirit's resiliency. When counselors pull up to park at work, they have to remember that they are entering a danger zone where countertransference, compassion fatigue, and burnout can, if ignored, grow from a tiny acorn into a full-size oak.

Figley defines compassion fatigue as the convergence of primary traumatic stress, secondary traumatic stress, and cumulative stress/burnout.1 It is a state of tension and preoccupation with the individual or cumulative trauma of clients that is manifested by the reexperiencing of traumatic events, avoidance/numbing of reminders of the traumatic events, and persistent arousal. When compassion fatigue is combined with the effects of cumulative stress, burnout results. Counselors with their own personal histories of violence and trauma have an increased susceptibility to compassion fatigue.

Table 1. Creating a personal burnout prevention plan

• Accept that vulnerability to compassion fatigue, countertransference, and burnout is part of a counselor's life.

• Seek to understand the dynamics of compassion fatigue, countertransference, and burnout.

• Become aware of personal countertransference triggers.

• Become aware of personal indicators that compassion fatigue is corrupting the ability to function personally and professionally.

• Have a self-care plan in place.

• Schedule time away from work.

• Seek a spiritual life.

• Seek clinical supervision. If the employing agency does not provide it, purchase supervision from an outside source (it is tax deductible).

• Use agency resources, such as EAP services.

• If necessary, change jobs.

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Post-traumatic stress disorder symptoms of intrusion, avoidance, and hyper-vigilance combined with burnout symptoms of exhaustion, cynicism, and inefficacy deplete the counselor in the throes of compassion fatigue. Tom was particularly vulnerable because his son's behavior was reminiscent of behavior in Tom's adolescence, which opened him up to countertransference. Along with this stress at home, Tom's job situation created fertile ground for compassion fatigue to grow into burnout. Accepting that compassion fatigue must be guarded against, and that self-care is essential to the counselor's prevention plan, offers a step in the right direction.

Defining burnout

Understanding burnout's dynamics and relationship to compassion fatigue and countertransference constitutes a tool in the counselor's burnout prevention plan. According to Maslach and Leiter, burn-out is a prolonged response to chronic emotional and interpersonal stressors on the job.2 Twenty-five years of research have validated that burnout results from the individual's stress within the larger organization. Experts contend that personal isolation, ambiguity surrounding success in treatment, and the emotional drain of remaining empathetic enhance counselor vulnerability.

Dedicated counselors seek to help others. Yet the impact of compassion fatigue and burnout can harm clients. Dropout rate research has indicated that professionals experiencing burnout may exhibit certain behaviors that cause clients to believe that the quality of care received is substandard. This knowledge should motivate counselors to activate and adhere to a prevention plan.

Clear indicators of burnout are exhaustion, cynicism, and feelings of inefficacy. Burnout encompasses feelings of being overextended and depleted of one's emotional and physical resources. Cynicism or depersonalization represents the interpersonal context of burnout. Excessive gallows humor usually offers a clue that staff is burning out. A counselor experiencing reduced efficacy feels incompetent and unable to achieve at work.3

Signs of compassion fatigue

Compassion fatigue drives the engine that results in burnout. It presents as apathy, low personal accomplishment, frustration, boredom, depression, anxiety, and hopelessness. Constant exposure to people suffering from trauma sets addiction counselors up for compassion fatigue. Acceptance that compassion fatigue can catch even the most conscientious and dedicated professional off guard constitutes another tool for prevention. Untreated compassion fatigue develops into full-blown burnout when unrealistic self-expectations of perfectionism clash with stringent organizational demands.

The range of personal and professional behaviors indicating compassion fatigue can include abusing chemicals, spending less time with patients, being late and absent from work, making professional errors, being hypercritical of others, depersonalizing patients, making sarcastic and cynical comments about patients and the organization, and keeping poor records. Compassion fatigue also can manifest as physical symptoms such as rapid pulse, sleep disturbance, fatigue, reduced resistance to infection, weakness and dizziness, memory problems, weight change, gastrointestinal complaints, hypertension, and head-aches, backaches, or muscle aches.

Because effective counseling de-mands clarity of spirit, compassion fatigue also can erode spiritual development. A counselor might begin doubting his/her values and most deeply felt beliefs. He/she might express anger or bitterness toward God, and begin withdrawing from fellowship. These are clues that the individual must note and address in order to prevent compassion fatigue. Compassion fatigue, if left untreated, can reduce job performance, increase mistakes, lower morale, damage personal relationships, spark a deterioration of personality, and generate a decline in general health.

Maintaining awareness

Management of transference and countertransference is critical to effective counseling and the prevention of compassion fatigue and ultimately burnout. The intensity of my reaction to a client serves as my personal trigger for countertransference awareness. When I really like and enjoy (or dislike and don't enjoy) a client, I realize that this is most likely a countertransference reaction. Experience has taught me to seek supervision when I suspect that countertransference is percolating in the therapeutic relationship.

Powell states that countertransference reflects the unconscious and neurotic conflicts of the counselor toward the client.4 Ongoing clinical supervision that allows counselor honesty offers the best method for addressing countertransference. Countertransference is an inevitable and desired component of the therapeutic relationship and often serves as the vehicle for professional and personal growth for both recovering and nonrecovering counselors. However, these reactions must be addressed, because if they are ignored, they usually reappear more intensely. Unaddressed countertransference can have a destructive impact on the client, the counselor, and the therapeutic relationship.5 Some-times a resolution of the situation requires a break from working with the population that is causing the countertransference. Giving countertransference prominence in a burnout prevention plan is critical to counselor survival.

Countertransference that is not managed via supervision and personal therapy can be acted out in ways that never help the therapeutic process. When the counselor becomes the good parent and tries to rescue the client or is overprotective, mothering/smothering, and enmeshed, the therapeutic relationship is compromised and the client is encouraged to stay dependent. When the counselor forms an alliance with the client, he/she demonstrates countertransference by avoiding negative feelings and protecting the client from confrontation; this ultimately can divide staff members. Whichever way countertransference plays out, it has gone too far and never will encourage client growth.

Table 2. Some questions that are helpful in creating a burnout prevention plan

• What attracted me to this job?

• What attracted me to this field?

• How long have I been involved?

• How do I handle change?

• How much change is going on in my life?

• How is my personal life?

• When did I last take a vacation (not a conference)?

• What do I get out of burnout?

• What do I need to change?

• Why did I choose this situation?

• What can I change on a daily, weekly, monthly, or yearly basis?

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Unresolved countertransference leads to unhealthy client/therapist dynamics. For example, the patient acts out and the therapist defends. The more severe the confrontation, the more severe the acting out; when the counselor is in recovery, this dynamic can result in relapse for either person.

The recovering counselor is particularly vulnerable to countertransference reactions, compassion fatigue, and burnout because of the double-edged sword of personal experience. Counsel-ors in recovery have the strength of knowing that addiction can be managed by significant lifestyle and philosophic changes. However, heightened sensitivity to the issues surrounding addiction can occasionally pierce the protective shell of even the best-trained professional. Because 12-Step programs suggest we are equal and can learn from honest sharing, recovering counselors must establish firm role boundaries for themselves. Hypervigilance to personal reactions to the stories and issues of clients helps counselors improve quality of care.

A list of burnout controls

Alcohol and drug counselors should consider these suggestions for reducing the likelihood of burnout and compassion fatigue:

• Go to Al-Anon to learn how to live with addicts and alcoholics.

• Take regularly planned time off.

• Know yourself—know what triggers you into compassion fatigue or burn-out.

• Have an outside life.

• Make time to exercise.

• Stay spiritually connected.

• Continue to grow professionally and personally.

• Call the EAP.

Even though research has shown that burnout results from conflict between individual preference and organizational demands, the individual is responsible for his/her survival. Accept-ing this responsibility is a step toward preventing burnout from ruining one's career and damaging one's personal life.

Counselors should rate themselves on a numeric scale on how they experience compassion fatigue and burnout, which of the described symptoms fit them and what it would take to alleviate them, how their values mesh with their organization's, and if they can seek supervision on a regular basis.

Questioning oneself and one's behaviors and reactions to work with clients is the first step toward creating a personal prevention plan. Table 1 shows how one could create a “staying healthy” burnout prevention plan that is as thorough as a treatment plan for a client. Table 2 lists questions that can inform the process of creating this plan.

For counselors, opportunities to experience countertransference abound, and compassion fatigue and burnout can result. The challenge lies in deciding how to handle this threat.

References

1. Figley C Treating Compassion Fatigue. New York:Brunner-Routledge; 2002.
2. Maslach C, Leiter MP The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. San Francisco:Jossey-Bass; 1997.
3. Maslach C, Schaufeli WB, Leiter MP Job burnout. In: Fiske ST, Schacter DL, Zahn-Waxler C, eds. Annual Review Psychol 2001; 52:397-422.
4. Powell D Clinical Supervision in Alcohol and Drug Abuse Counseling. New York:Lexington Books; 1993.
5. Forrest GG, Countertransference in Chemical Dependency Counseling. Binghamton N.Y.:The Haworth Press; 2002.