Taking Care of the Caregiver Angela M. Dean, PsyD Clinical Assistant Professor of Psychiatry University of Pittsburgh Licensed Psychologist UPMC Hillman Cancer Center Center for Counseling and Cancer Support

Learning Objectives To identify signs and symptoms of compassion fatigue, burnout, and work-related stress Including the ability to assess yourself To identify strategies to combat compassion fatigue, burnout, and work-related stress in the workplace To develop a personal self-care plan Be able to discuss and develop self-care strategies with your colleagues

Informal (Friends and family) Who are Caregivers? Professional Informal (Friends and family) The focus of this session is caring for the professional caregiver For information of how to take care of and support the informal caregiver, please contact Dr. Dean!

Vocabulary Compassion Satisfaction (CS) Compassion Fatigue (CF) Positive aspects of working as a helper Compassion Fatigue (CF) Negative aspects of working as a helper Burnout Inefficacy and feeling overwhelmed Work-related traumatic stress Primary traumatic stress direct target of event Secondary traumatic exposure to event due to a relationship with the primary person © Beth Hudnall Stamm, 2009. www.ProQOL.org

CS-CF Model © Beth Hudnall Stamm, 2009. www.ProQOL.org

Compassion Satisfaction The positive aspects of helping Pleasure and satisfaction derived from working in helping, care giving systems May be related to Providing care To the system Work with colleagues Beliefs about self Altruism © Beth Hudnall Stamm, 2009. www.ProQOL.org

Compassion Fatigue The negative aspects of helping related to Burnout Providing care To the system Work with colleagues Beliefs about self Burnout Work-related trauma © Beth Hudnall Stamm, 2009. www.ProQOL.org

Burnout and STS: Co Travelers Work-related hopelessness and feelings of inefficacy Secondary Traumatic Stress (STS) Work-related secondary exposure to extremely or traumatically stressful events Both share negative affect Burnout is about being worn out STS is about being afraid © Beth Hudnall Stamm, 2009. Professional Quality of Life Scale (ProQOL). www.proqol.org. This test may be freely copied as long as (a) author is credited, (b) no changes are made without author authorization, and (c) it is not sold.

Complex Relationships Relationships Are Complex Multiple spheres Work environment “People helped” environment Personal environment Positive (CS) & negative (CF) Altruism CS can override CF Compassion Fatigue two parts Worn out (BO) common Frightened, traumatized (STS) rarer but powerful © Beth Hudnall Stamm, 2009. www.ProQOL.org

Models of Stress Vulnerability- Resilience Model Diathesis-Stress Model Ingram & Price, 2001 Spielman, Caruso, & Glovinsky, 1987 diathesis. : a constitutional predisposition toward a particular state or condition and especially one that is abnormal or diseased.  Trauma experts define CF as sustained knowledge that another person is suffering and wanting to do something to relieve their suffering. Compassion satisfaction (CS) on the other hand involves the personal gratification one receives from caregiving. Although CF and CS are not direct opposites, the two concepts have a definite relationship. Nurses have a good chance of warding off CF by nourishing CS. What Research Tells Us Several scales are available for use in detecting levels of compassion. The Professional Quality of Life Scale is a validated tool that has been used in multiple studies. Data confirm that high CS scores correlate with low scores related to CF. The tool lists negative and positive aspects of compassionate care. Questions about feelings and behaviors can help nurses evaluate how they perceive their job and how it is affecting their work and personal life. Results from a study of mental health professionals indicated that lower levels of CF and higher levels of CS were prevalent among those professionals who practiced self-care strategies. Positive intent is a self-care strategy that has the potential to influence overall well-being. One way to set your intention for the day is by practicing a loving kindness (metta) meditation. This can be done before you leave home and just prior to meeting with any person you encounter at work and throughout your day. This technique works with people you don’t know and people you are familiar with.

General Risk Factors for Distress History of psychiatric disorder Social Problems Cognitive Impairment Family & caregiver conflict Communication barriers Inadequate social support Medical comorbidities Living alone Financial problems Spiritual /religious/ existential concerns Limited access to medical care Having young or dependent children Younger age History of abuse “Because possessing vulnerability places one at higher risk for developing a disorder, vulnerability is probably most accurately seen as a subcategory of risk “ Ingram & Luxton, 2005 Source: NCCN Guidelines for Distress Management, 2018

Medical Professional Specific Risk Factors for Distress Female Gender Isolated work environments Zero Tolerance for mistakes i.e. those not interdisciplinary in nature Pressure for high patient satisfaction surveys Having safety concerns about work environment (for patients and selves) Unbalanced workload Nedrow, Steckler, & Hardman, 2013; Van Bogaert et al, 2017

Protective Factors against Distress High tolerance of negative emotions and uncertainty Skills in communication, planning, and problem solving Strong capacity for self-reflection Strong religious faith Meaning making Feelings of responsibility to family, friends, work, self No prior history of MH concerns or substance abuse Having caring and supportive relationships within and outside the family. A positive self-view Self-efficacy As cancer patients spoke about their need for support four subthemes surfaced. Does any of these themes seem familiar to you? Difficult Emotions: Participants reported on the overwhelming impact the diagnosis of cancer had for themselves as well as for those around them (Nekolaichuk et al., 2013). Family Burden: Cancer patients worried about the effect of cancer diagnosis on the family. Reports ranged from individual family members becoming depressed. Some reported that the whole family was sad. Cancer patients also felt lonely and isolated as a result of not being able to discuss freely cancer-related issues with family members (Nekolaichuk et al., 2013). Breaking Point: Cancer patients sought cancer support groups after reaching a “breaking point” of being emotionally paralyzed or having no one to talk to about cancer before receiving advice (Nekolaichuk et al., 2013). Losing the Safety Net: Participants felt overwhelmed after end of treatment. The loss of the “medical safety net” (p. 597) gave much rise to anxiety and persistent dread of tumor recurrence (Nekolaichuk et al., 2013). Source: American Psychological Association, 2018

Medical Professional Specific Protective Factors against Distress Decision making agency in workplace Good interdisciplinary collaboration & communication Ability to follow individual patients for entire trajectory of care Safe venues to discuss mistakes and concerns for safety Nedrow, Steckler, & Hardman, 2012; Van Bogaert et al, 2017;

Screen yourself!

Now What? Strategies To Combat Compassion Fatigue, Burnout, And Work-related Stress

Caring for You: Prevent Burn-Out, Compassion Fatigue, Distress, Stress Balance personal feelings with professional duties Prioritize your own physical & emotional well-being Pace your empathy Remember that just your physical presence is helpful to patients and families Learn from your patients Burn Out- Exhaustion of physical/emotional strength or motivation as a result of prolonged stress or frustration Symptoms can include apathy, cynicism, fatigue, depression/irritability, increased use of alcohol/tobacco/drugs, sleep and appetite difficulties, withdrawing from others, relationship problems Health professionals are at risk seriousness of the work increasing job responsibilities fewer rewards smaller staffs non-stop demands balancing needs the ideal of a caring professional

Caring for You: Prevent Burn-Out, Compassion Fatigue, Distress, Stress Maintain a full life outside the hospital Widen your social circle beyond healthcare Limit hobbies and activities that involve caring for people Consider creating a ritual for when you leave work to help the transition Burn Out- Exhaustion of physical/emotional strength or motivation as a result of prolonged stress or frustration Symptoms can include apathy, cynicism, fatigue, depression/irritability, increased use of alcohol/tobacco/drugs, sleep and appetite difficulties, withdrawing from others, relationship problems Health professionals are at risk seriousness of the work increasing job responsibilities fewer rewards smaller staffs non-stop demands balancing needs the ideal of a caring professional

Caring for You: Prevent Burn-Out, Compassion Fatigue, Distress, Stress Nedrow, Steckler, & Hardman, 2013; Van Bogaert et al, 2017;

Let’s Practice! Mindfulness Activity Brief PMR Longer version of PMR is available at https://www.law.berkeley.edu/files/Progressive_Muscle_Relaxation.pdf Brief PMR To get started, find a very comfortable relaxed position. You may want to close your eyes, or feel free to keep them open if you’re more comfortable that way. Let’s begin by focusing on your breathing, following your breath as it comes into your body and goes out of your body. Take 3 slow, full natural breaths in and out, noticing how your energy rises on the in-breath and falls on the out breath. Slow even breaths can help our bodies begin to relax as we start to notice the difference between tension and relaxation. Now, focus on your feet, continuing to breathe evenly and naturally. Tighten the muscles in your feet by clenching your toes and pulling the tops of your feet up towards your shins. Hold the tension, continue to hold… then release and relax, noticing the difference between tension and calm relaxation Next, focus on your lower legs. Tighten those muscles in your calves… tight and tense… hold… then release and relax, allowing the tension to drain away and melt into the ground. Notice the experience of peaceful relaxation in your calves. Continue to breathe naturally and easily as you pay attention to the relaxation in your calves. Shift your awareness now to your upper legs. Tense and tighten the muscles in your thighs, hold them tight, tensing… then release and relax, letting any tightness, discomfort or stress flow away while continuing to notice the difference between tension and tranquility. Stay with that experience while continuing to breathe easily and calmly. Now let’s move your awareness to your stomach and back. Tighten those muscles by pulling your belly button as far as you can towards your back, tight and tense. Hold… tight… then release and relax, making plenty of space in your abdomen for your breath, noticing how it feels to allow your muscles to be still. Gently shift your attention to your hands. Tighten your fingers into tight, tense fists… squeezing as tight as you can…then release and relax, letting any tension or discomfort flow out through your fingertips. Take time for the experience as the tension melts away, replaced by a feeling of calm, peaceful relaxation. Next focus on your arms. Tighten all of those muscle, pulling your arms in as tight as you can into your body… tight and tense… and hold… then release and relax, allowing your arms to settle, noticing the difference between stress and stillness. Take the time to breathe into this experience. Now move on to your shoulders and neck. Go ahead and lift your shoulders up and in, really pulling them into your neck, and hold tight, tensing them… Then release and relax, letting your shoulders fall gently down and back, letting go of any stress and allowing the muscles in your neck and shoulders to be free from tension. Now gently focus your attention on all the tiny little muscles of your face. Tighten those muscles by tightly shutting your eyes, clenching your jaw and stretching your lips up and back. … maintain the tension… then release and relax, letting your muscles be settled and comfortable, paying attention to the difference between the tightness of tension and the comfort of relaxation. And now, imagine looking over your whole body to see if there are any remaining areas of tension or discomfort. Gently breathe into those areas, imagining oxygen is going directly to any areas of tension. Enjoy for a few more moments the comfort and relaxation you feel … knowing that you can return here at any time. Allow your body to continue to feel comfortable and relaxed, even as your attention turns elsewhere. When we are relaxed we are more focused, experience less pain and are more able to be connected to what we are doing. When you are ready, take one more full breath and gently bring your attention to the world around you. Wiggle your fingers and your toes.

Thank you! For complete references or further information, please contact me at: Dr. Angela Dean deana@upmc.edu Center for Counseling & Cancer Support UPMC Hillman Cancer Center 412-623-5888 x 3