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Stress and Grief Reactions Among Rehabilitation Professionals: Dealing Effectively with Empathy Fatigue.

Many rehabilitation counselors are exposed to counseling-related activities in which they must be empathically available to individuals and family members who are survivors of a variety of chronic illnesses, traumatic, and life-threatening disabilities. Professional rehabilitation counselors are compelled by ethical obligation to sometimes sacrifice their own needs for the needs of their clients. The nature of beneficent actions by rehabilitation counselors are clearly pronounced in the Code of Professional Ethics for Rehabilitation Counselors (1987) which reads: "Rehabilitation counselors shall endeavor at all times to place their clients' interest above their own" (p. 27). Regardless of how beneficent rehabilitation professionals may appear, the lack of empathy, when working with persons with disabilities, will greatly diminish the counselor's ability and obligation to act in a manner that promotes the well-being of others (Rubin & Roessler, 1995). Consequently, as rehabilitation counselors are compassionate and empathic in their service to others, there appears to be a state of emotional, mental and physical exhaustion that may occur as the counselors' own wounds are revisited by issues raised concerning their client's life stories and experience of disability.

The concept and phenomenon of "compassion fatigue" was first introduced by Joinson (1992) in the nursing literature. This concept, which was expanded in the psychology and trauma stress literature by Figley (1995), may assist rehabilitation counselors in describing the state of emotional, mental, physical exhaustion, and the secondary stress reaction that occurs during therapeutic interactions with persons who have experienced traumatic life events. Figley's (1995) wellspring of research illustrates how compassion fatigue among professional counselors is identical to secondary traumatic stress disorder (STSD) and is equivalent to post-traumatic stress disorder (PTSD) in terms of its symptomatology. Because compassion fatigue has been recognized as a form of professional burnout, this condition may manifest itself within the helping relationship as a pattern of secondary traumatic stress (STS; Figley, 1993).

To date, the rehabilitation literature has not addressed issues related to compassion fatigue. Rather, this concept, as it relates to rehabilitation counseling and administration, has been discussed in terms of the phenomenon of "burnout." Burnout has been described as a syndrome of cumulative physical and emotional stress that is observed among rehabilitation professionals who work in organizations that serve persons with chronic and several disabilities (Blankertz & Robinson, 1996; Cranswick, 1997; Gomez & Michaelis, 1995; Riggar, Godley, & Hafer, 1984; Vash, 1980). The term "empathy fatigue" will be used in this article because historically, considerable attention has been given to developing the skills of empathy as a fundamental tool and resource for the preparation of masters-level rehabilitation counselors-in-training (Stebnicki, 1998). As Rogers (1980) emphasizes, "the ideal therapist is, first of all, empathic" (p. 146). Empathy as a "way of being" is the foundation for establishing and building the working alliance within client-center models of counseling and is necessary for working with the psychosocial aspects of adjustment and adaptation to disability.

Empathy fatigue transcends the experience of professional burnout. The experience of burnout emerges gradually within the individual and results in cumulative emotional and physical exhaustion. Compassion fatigue (Figley, 1995) or empathy fatigue, as described here, can emerge suddenly with little warning as an unhealthy form of countertransference or STS.

If professional helpers are not empathically available to the persons they serve, then there should be little concern for the influences of STS reactions or compassion fatigue (Figley, 1995). Yet, unavoidably, many rehabilitation counselors will be exposed to some degree of STS depending upon their professional role, organizational setting, and the persons they serve. Consequently, empathy fatigue may be a natural artifact of working at an intense-level of service provision for persons with acquired chronic illnesses and disabilities. Rehabilitation counselors who may or may not be aware of this parallel process must be open and invited to develop healthy coping responses and strategies that lead to a decrease of the secondary stressors associated with empathy fatigue.

A Framework for Understanding Empathy Fatigue

Cultural and social factors (e.g., gender, ethnicity, cultural differences) have an impact on how emotions are expressed. These factors influence the way in which counselors respond emotionally to their work. Thus, knowledge of the client's cultural and social norms for expressing emotion is critical in working with persons who are culturally different.

Cultural Empathy

The multicultural counseling literature addresses the relevance of client-centered models of counseling using empathy as a therapeutic approach. This literature suggests that cultural and social factors have an impact on how emotions are expressed and perceived. These factors also influence the way in which counselors respond empathically to their clients. By the very nature and use of empathy in client-centered interactions, the focus should be on the individual's frame of reference (Freeman, 1993), thus allowing an opportunity for the counselor's cultural values not to be imposed which may hinder the working alliance.

Some multicultural counseling theorists describe the concept of "cultural empathy" as a skill that is pancultural or universal (Ponterotto & Bensesch, 1988; Ridley, Mendoza, & Kanitz, 1994). However, other authors (Hamilton Usher, 1989; Pedersen, 1987) have criticized counseling approaches that place a heavy reliance on empathic communication. It is suggested that by stepping inside the private world to understand the feelings and personal meanings that the client is experiencing may be too intrusive or offensive in some cultures. Thus, counselors who value verbal expression of emotions as the primary goals for counseling are likely transmitting their cultural values (Sue & Sue, 1990). Further, if the emphasis in session is to facilitate client autonomy, individuality, or independence, this approach may also be a source of cultural bias. The person's dependence on the family must also be an important consideration. Accordingly, the skill of conveying empathy in a culturally sensitive manner will help facilitate the therapeutic relationship and enhance positive outcomes (Ibrahim, 1991).

Although definitions of cultural empathy vary widely (Ponterotto & Benesch, 1988; Scott & Borodovsky, 1990), the application in cross-cultural counseling settings must focus on client needs and values. Counselors' increased awareness and knowledge of their clients' cultural and social norms for expressing emotion are critical in working with persons who possess a different cultural identity and worldview. Ultimately, a counseling approach that recognizes both the individual's uniqueness and human commonalities will assist rehabilitation counselors to respond effectively to issues that arise in the rehabilitation counseling process (Stebnicki, Rubin, Rollins, & Turner, 1999).

Rehabilitation Counseling as an Occupational Choice

Dealing effectively with the experience of empathy fatigue is important for occupational survival in the field of rehabilitation counseling. Because many persons are drawn to the profession of helping as a result of their empathic concern for others (Figley, 1995), it is important to understand precipitating factors that may trigger the experience of empathy fatigue. As Super (1994) points out, individuals choose occupations that will allow them to function in roles consistent with their self-concepts. Hence, work and the person's self-concept are interrelated and occupations are a way for individuals to express their talents and value systems. Specific to counselors-in-training, Corey and Corey (1993) and several others (D'Augelli, D'Augelli, & Danish, 1981; Egan, 1998; Rogers, 1980) have noted that persons enter the profession of helping for several reasons. Individuals may have a need to: (a) satisfy certain emotional or security needs in their lives, (b) feel as though they are making an impact for humanitarian reasons, (c) discover or gain insight into their own personal issues, (d) care for others because they have been in a caregiving role at a very early age and it feels natural, or (e) unconsciously be a "rescuer" and save others from the chronic emotional and physical pain, as well as the stress experienced in loss and grief.

Working with issues of grief, loss, and suffering touches us emotionally in many different ways. Our ability to deal effectively with empathy fatigue may be dependent on our emotional and intellectual understanding of why we entered the profession of rehabilitation, as well as an increased awareness of our adaptive resources and coping mechanisms. Thus, professional counselors' emotional and psychological needs must be met early-on in the helping relationship. Otherwise, the professional helper may be at-risk for increased levels of anxiety, depression, and substance abuse behaviors. Additionally, they may alienate themselves from colleagues and friends or engage in premature job changes (Figley, 1995).

The Experience of Burnout

It is important to understand the experience of burnout as it relates to empathy fatigue because of the distinct differences and similarities between these two syndromes. Burnout, a phrase first coined by Freudenberger (1974), has been described as a state of physical, emotional, and mental exhaustion whereby the persons who are "burned-out" have negative feelings of themselves, the other professionals with whom they work with, and the clients they serve (Maslach, 1982; Pines & Aronson, 1988). In contrast to burnout, which is a cumulative and sometimes unconscious process, empathy fatigue is perceived to emerge as an acute reaction of physical, emotional, and mental exhaustion. Consequently, rehabilitation practitioners may respond with less compassion, genuineness, or unconditional positive regard for persons they serve if the experience of burnout goes unrecognized or ignored.

The literature on burnout is quite extensive. Recently, Figley (1995) identified more than 1,100 relevant articles and 100 books on the topic of "burnout" in the Psychological Abstracts database. The hallmark of burnout syndrome, as Maslach (1982) notes, is a negative shift in the way professionals view the people they serve. There is a progressive loss of energy, idealism, and personal accomplishment experienced among helping professionals as a result of their working conditions. Pines and Aronson (1988) identified three basic characteristics within the role and function of professional helpers that may contribute to burnout: (a) the work they perform is emotionally draining, (b) they are characteristically sensitive to the individuals they serve, and (c) they typically facilitate a client-centered orientation. These characteristics are similar in nature to the role and function of rehabilitation counselors who work with persons who have acquired or who are survivors of traumatic illness and disability. Rehabilitation professionals who work with these persons may have a similar vicarious experience coping with the psychosocial aspects of adjustment and adaptation to disability (Stebnicki, 1999).

Although there is no current measure to assess the emotional affects of empathy fatigue, the most widely used measure to assess the associated experience of burnout is the Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981; 1986). Three factors have been identified in the MBI: emotional exhaustion (feelings of being emotionally overextended), depersonalization (an impersonal response style to consumers), and reduced personal accomplishment (absence of feelings of competence and success that occur because of job stress). Research using the MBI as a measure of burnout in rehabilitation settings suggests that staff who have continuous contact with clients who are unappreciative, behaviorally challenging, and depressed, often develop to a negative view and have pessimistic attitudes of the persons they serve as well as with the organization they work (Blankertz & Robinson, 1996; Corrigan, McCracken, Edwards, Kommana, & Simpatico, 1997; Gomez & Michaelis, 1995).

Countertransference

Countertransference, a term first described by Freud in 1910, is currently described as a reflection of the counselor's unresolved internal conflicts which encompasses reactions of thoughts, feelings, and emotions as it relates to his or her clients' experience (Corey & Corey, 1993). When this phenomenon occurs, the counselor may exhibit reduced feelings of warmth, acceptance, respect, or positive regard for their clients (Rogers, 1961). Rando (1984) addresses the phenomenon of countertransference that occurs among caregivers who work with persons that have chronic life-threatening disabilities. She suggests that dying persons touch us personally in at least three ways. They may: (a) make us painfully aware of our own losses, (b) contribute to our apprehension regarding our potential and feared losses, or (c) arouse existential anxiety in our personal death awareness. It is suspected that rehabilitation counselors, who are unaware of their unresolved personal issues during client-counselor interactions, experience increased levels of countertransference which may manifest as the experience of empathy fatigue.

Responding empathically to client concerns can either enhance or diminish countertransference within the therapist. Gelso and Hayes (1998) suggest that therapists who convey deep levels of empathy will occasionally experience an overidentification with their clients' issues. Accordingly, therapists who manage countertransference effectively are viewed as having an increased level of insight into their feelings and issues, as well as having a greater capacity for empathy and understanding (VanWagoner, Gelso, Hayes, & Diemer, 1991). The identification and awareness of one's emotional feelings and attitudes toward a client are important issues for rehabilitation professionals because having this information can contribute to an enriched client- counselor relationship (Marinelli & Dell Orto, 1999). Overall, the literature suggests that countertransference in helping relationships must be viewed as a natural by-product of caring for persons who have counseling needs. The rehabilitation professional who has an increased level of self-awareness and insight will likely deal more effectively with the phenomenon of empathy fatigue.

Secondary and Post-Traumatic Stress Disorders

Caring and serving persons with acquired chronic mental or physical disabilities can carry a significant emotional cost. Counselor stress that is associated with this process has been observed as a STS reaction. As Figely (1995) notes, "the process of empathizing with a traumatized person helps us to understand the person's experience of being traumatized, but, in the process, we may be traumatized as well" (p. 15). Thus, many rehabilitation professionals who maintain a high level of empathy or compassion while helping others who have experienced chronic pain, suffering, trauma, or loss may experience the secondary stressors or parallel feelings of the individuals they serve.

The present literature in STSD regards the phenomenon of compassion fatigue, as equivalent to post-traumatic stress disorder (PTSD; Carbonell & Figley, 1996; Figley, 1995). STSD is the natural consequence resulting from knowing about a traumatizing event (i.e., acquired traumatic brain or spinal cord injury, victims of a crime) that a significant other has experienced. The professional helper can experience similar feelings without actually being physically harmed or threatened with harm. In contrast to burnout, which emerges gradually as a consequence of emotional and physical exhaustion, STSD has a more rapid onset of symptoms. STSD is marked by a sense of helplessness and confusion, a disassociation of the traumatic event itself, and the self-isolation from all support systems.

Specifically in PTSD, there is the underlying premise that persons can be traumatized either directly or indirectly. The DSM-IV (American Psyciatric Association, 1994) notes specific characteristics of PTSD:
 The essential feature of PTSD is the development of characteristic symptoms
 following the exposure to an extreme traumatic stressor involving direct
 personal experience of an event that involves threatened by death, actual
 or threatened serious injury, or other threat to one's physical integrity,
 or witnessing an event that involves death, injury, or threat to the
 physical integrity of another person, or learning about unexpected or
 violent death, serious harm, or threat of death or injury experienced by a
 family member or other close associates. (p. 424)


Given the high incidence of PTSD among consumers of mental health services, it is likely that grief-related reactions of PTSD or STSD among therapists have an emotional impact on their professional behavior and personal lives (Green, 1994).

The Rehabilitation Professional's Experience of Empathy Fatigue

Many rehabilitation professionals just beginning their careers, have little preparation for dealing with the extraordinary experience of having to be empathically available through intensive counseling interactions with persons who have chronic mental and physical disabilities. A reaction of empathy fatigue early-on in one's chosen career may be explained by Super (1994) who believed that most people in their early 20s have insufficient experience to make a career commitment. During the initial years of employment, it is common to experience high levels of stress and anxiety (Corey & Corey, 1993; Cranswick, 1997). In fact, studies suggest that younger, less experienced rehabilitation counselors are prone to higher levels of emotional exhaustion than older, more experienced rehabilitation professionals (Cranswick, 1997; Corrigan & McCracken, 1997). Professional rehabilitation counselors who have a "save the world"-type belief or those who have an enormous capacity for feeling and expressing empathy tend to be more at risk of the emotional and physical exhaustion associated with empathy or compassion fatigue.

Corey and Corey (1993) suggested that many beginning-level counselors reported that they were frustrated and disappointed about their new job's unexpected stressors and demands. The beginning counselors identified the (a) slowness of the organization within which they worked, (b) resistance or reluctance of administrators and peer employees to try new ideas, (c) unrealistic expectations of the beginning counselor, and (d) overall, unanticipated demands of a new job. With the individuals they serve, counselors at varying levels of experience will likely encounter a parallel process of emotional exhaustion due to the grief, loss, or chronic physical and mental impairments. When environmental demands of the job exceed rehabilitation professionals' capabilities for coping with the experience of empathy fatigue, reactions may lead to an increase of alcohol/substance abuse behaviors and increased levels of depression and anxiety (Blandertz & Robinson, 1996; Cranswick, 1997; Gomez & Michaelis, 1995).

Risk Factors

Empathy fatigue among rehabilitation professionals who deal at an intense level of counseling interactions may go unrecognized or may even be denied. If the empathy fatigue response is not dealt with early, these intense level of emotions will likely trigger a STS reaction. Thus, it is important to understand the professional risk factors and be aware of the interplay between various individual, organizational, and environmental conditions that trigger such acute reactions.

The empathy fatigue risk-factor functional assessment, as proposed by the present author in Table 1, is a practical way of gathering information, identifying problem behaviors, providing a global overall level of functioning, and identifying resources that will assist persons in their ability to cope with the empathy fatigue response. Despite assessments to measure burnout (Maslach & Jackson, 1981) and compassion fatigue among psychotherapists (Figley, 1995), there are no risk factor assessments that provide a means to measure the experience of empathy fatigue among counseling professionals. The items presented in this assessment are grounded in the theoretical assumptions about the nature and phenomenon of burnout, compassion fatigue, and STSD as described by the review of literature presented in this article. Although the validity and reliability of this functional assessment have not been established, the practical value of such a risk factor assessment may be helpful for practitioners. Such a measure may be a fruitful area for further research in the study of empathy fatigue.

Table 1

Empathy Fatigue Risk-Factor Functional Assessment

A. Personality Traits

1. What specific type-A personality traits does the person possess?

2. Does the person have unrealistic high-level expectations for personal accomplishments or productivity?

3. Does the person have difficulty distinguishing between what is realistically accomplishable and what is not?

4. Does the person have a high need for personal recognition?

5. Does the person feel the same level of enthusiasm for their job as they did initially?

6. Does the person alienate him/herself within the organization by becoming cynical?

7. Does the person feel a lack of personal effectiveness or accomplishment in helping others?

B. History of Emotional or Psychiatric Problems

1. Does the person exhibit any underlying pathology that would interfere with their emotional, social, or cognitive functioning while on-the-job?

2. Does the person demonstrate any pathology that would interfere with his/her ethical obligation to their clients?

3. Are there any specific behaviors that the person is exhibiting that would harm their clients or the organization?

C. Coping Behaviors that are Maladaptive

1. Does the person exhibit any of the common characteristics for alcohol or other substance- related disorders?

2. Does the person exhibit increased use of tobacco or caffeine?

3. Does the person exhibit any of the common characteristics for eating disorders?

D. Age and Experience-Related Factors

1. Is the person younger-aged (e.g., 20s) and new to the profession of rehabilitation counseling?

2. Is the person inexperienced in working with chronic or severe types of disabilities?

3. Does the person have experience or training in individual or group crisis intervention?

4. Has the person worked directly or indirectly with individuals or groups in crisis or trauma?

E. Organizational Factors

1. Is the organization or system insensitive to the emotional needs of its employees?

2. Does the person feel unappreciated by their clients or the organization?

3. Does the organization hinder the employee's ability to try new and different things with their job?

F. The Person's Job Duties and Their Position within the Organization

1. How much responsibility for direct-service does the person have?

2. Does the person have a large caseload of clients who are chronically and severely impaired?

3. Does the person have a caseload that is overly demanding and time consuming in proportion with their other job responsibilities?

G. Social-Cultural Factors

1. Does the person have different values or beliefs that are not consistent with either their client's or the organization?

2. Does the person have knowledge of their client's cultural and social norms for expressing emotion?

H. Person's Response to Past Crisis and Stressful Life Events

1. How has the person coped with past crisis events either personally or on-the-job?

2. Does the person demonstrate maladaptive coping behaviors in response to their job?

3. Does the person openly discuss past traumatic events with other peer professionals, support groups, professional counselors, family members, religious or spiritual contacts?

4. Does the person exhibit any detached emotions or disassociate him/herself from past crisis or stress?

I. Level of the Person's Support Network

1. Does the person have a support network of family, friends, religious/spiritual or social groups?

An Adaptive Coping Response to Empathy Fatigue

As the research on burnout suggests (Cranswick, 1997; Corrigan & McCracken, 1997), older more experienced counselors and administrators experience less burnout primarily because they have already learned to cope with the feelings of emotional exhaustion. Also, the older more tenured employee knows how to work more efficiently. Figley (1985) strongly suggests that families and other interpersonal networks (e.g., friendships, client-therapist relationships) are powerful systems for promoting recovery following the experience of secondary trauma. The following strategies are offered to individuals and organizations as an overall approach to cope more effectively with the experience of empathy fatigue.

1. Participate in peer support groups which meet regularly. Peer support groups are critical to allow professionals within the organization or agency to ventilate their emotions regarding the secondary stress or grief reactions felt while working at an intense level of service (Pearlman & Saakvitne, 1995). Structured or unstructured peer groups can be formed during employee lunch breaks or after work. It is recommended that: (a) qualified professionals who do not work directly with a particular unit facilitate the support groups, and (b) the organization's administrators support the total concept. Group issues should focus on developing insight and understanding into one's emotional reactions and coping with the secondary traumatic work- related stressors (Figley, 1985).

2. Offer clinical supervision or mentoring to newer and less experienced counselors. Effective clinical supervision must focus on the counselor's response to empathy fatigue as it relates to issues of personal and professional development (Stebnicki, 1998; 1999). The clinical supervisor should monitor the counselor's emotional hardiness and resiliency and adaptive coping mechanisms for dealing with the secondary stressors. A mentoring system could be implemented within the organization or agency. However, this system must be supported by the organization or agency as a means of embracing persons that are new to the profession as they work through some of the emotionally difficult and intensive job tasks associated with their particular chosen occupation.

3. Shift the focus of rehabilitation treatment Team meetings. The Team (e.g., vocational rehabilitation counselor, psychologist, licensed professional counselor, paraprofessionals) should allow time in the regular meeting structure for counselors to "check-in" emotionally and to communicate and process their feelings, of any job-related stress or anxiety. By encouraging the ventilation of feelings other Team members can validate the individual's experience of empathy fatigue.

4. Decrease the number of demanding and time-consuming clients. Administration should not relegate all the difficult job tasks to the new person as a "rite-of-passage". Instead, administration should balance caseloads across other case managers and counselors.

5. Promote education and wellness programs for employees. Organizations or agencies must promote a wellness approach for job survival. This approach includes, but is not limited to, a focus on the mindfulness and value of physical exercise, diet, nutrition, attitudes and perceptions of the issues related to loss and grief. Group membership rates at a local health and fitness center could be offered to employees as a partial incentive to actively structure a wellness approach to life.

Summary and Conclusion

The experience of empathy fatigue transcends the cumulative emotional, mental, and physical exhaustion typically associated with professional burnout. This is primarily because empathy fatigue emerges more rapidly during intensive counseling interactions with persons and their families who have been traumatized or experienced acquired life-threatening illnesses or disabilities. Many rehabilitation professionals, who by ethical obligation must place the needs of their clients above their own, may experience the secondary stressors associated with having to be empathically available at an intensive level of service. Consequently, the counselor may have parallel feelings of loss and grief or experience some degree of countertransference that results as secondary traumatic stress.

Many persons new to the rehabilitation profession may not be aware of this parallel process and must be open to develop healthy coping responses. It is recommended that the phenomenon of empathy fatigue be addressed early on in rehabilitation counselor training. Programs should educate counselors-in-training to recognize risk-factors and adaptive coping responses that will likely lead to long-term employment in their chosen occupation. The rehabilitation organization or agency should also be mindful of its responsibility and obligation to facilitate its employees' personal and professional growth by addressing issues of secondary stress reactions associated with empathy fatigue. Victor Frankl (1984) believed that it is not necessarily the nature of the trauma itself that most affects one's ability to cope with its consequences, but rather one's own attitude towards the trauma. Perhaps the stress and grief reactions associated with empathy fatigue may call for a defined attitude that exists in the process of adjustment and adaptation.

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Mark A. Stebnicki, Rh.D., CRC, LPC, CCM, Associate Professor, Director of the Master Program in Rehabilitation Counseling, East Carolina University, Greenville, NC 27858-4353.
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Date:Jan 1, 2000
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