Compassion fatigue is a negative effect of trauma and emotional care, which can adversely impact the professional and personal life of any counselor. Despite an urgency and importance of the issue, burnout and secondary traumatic stress are not often discussed and taught in counseling training and academic courses in Nepal. The causes, consequences, screening and ways of managing compassion fatigue are elaborated and discussed. This document is deemed to fulfill the gap in research and understanding of compassion fatigue into the academic, researcher, and counseling practitioners in Nepal.

Compassion Fatigue (CF) is can be defined as the burden in emotional and physical aspects of life felt by a counselor out of their service to the people in need. The counselor has to listen, witness and experience the suffering of survivors of trauma in daily life.¹ It is a negative consequence and occupational hazard associated with the service to the trauma-affected clients, which impacts the counselor through a reduction in interest in and the ability to be empathetic to people in need.² Additionally, the cumulative effects of secondary exposure to trauma through the transformation wrought in a counselor by experiencing traumatic exposure vicariously through the client.³ Nepali mental health communities lack evidences on such negative impact of the trauma and emotional care to the clients. The academic and training courses in counseling and applied psychology have not covered issues of the compassion fatigue and addressing such a burden to the counselors. This article brings an attention to the academic, researchers and practitioners to provide an importance on negative aspects of the emotional care and discussing the ways to address such challenges.

Historically, the Mental Health and Psychosocial Support (MHPSS) to trauma-affected individuals in Nepal was started during the Eighties. However, a broader attention on the mental health and psychosocial needs of the people were brought to attention during the Nineties when more than one hundred thousand Bhutanese refugees were temporarily kept in camps at the Southeast belt of the country.^4,5 Notably, ten years long protracted internal armed conflict in Nepal, which was ended in 2006, also intensified the need for MHPSS services to the people affected by the conflict. The disaster and other traumatic incidences are also massively covered by the media, and often many more people are vicariously exposed to trauma.⁶ The traumatic situations, both the conflict and post-conflict, increasingly demanded the support of MHPSS professionals to address the psychological, social, and mental health impact on the people affected by the traumatic incidences.^7,8 The impact of the mega-earthquake in 2015 has further increased the demand for MHPSS professionals to address the traumatic effects of the disaster on the general populations.⁹

Nepali post-conflict situation had a higher prevalence of mental health and psychological cases. A mega earthquake struck in April 2015 killing nearly 9000 people; more than 2000 Nepali citizens became injured, and around 650 thousand families were displaced. The Earthquake has further traumatized the people and brought tragedies and uncertainty that prolonged without proper assistance. There were numerous other types of violence and outcomes as a result of these earthquake after-effects increased the cases trafficking in persons, domestic violence, sexual abuse and substance abusers. The disaster and other traumatic incidences are also massively covered by the media, and often many more people are vicariously exposed to trauma. The conflict and post-conflict situations increasingly demanded the support of counselors to address the psychological, social, and mental health impact on the people affected by the traumatic incidences.^7,8,10 The impact of the mega-earthquake in 2015 has further increased the demand for counselors to address the traumatic effects of the disaster on the general populations.⁹ Traumatic events and incidences have mental health, psychological, social and cultural impacts on that survivor which impair their daily functionality, increases the level of anxiety, psychosomatic complains, depression and often lead to the situation of self-harm.¹¹ The mental health professionals offer the support to heal the wounds of the people and encounter with the stories of difficulties in life, fear, sufferings and distressful memories of victims, it impacts the psychological, emotional and cognitive aspects of their personal and professional life. Consequently, the exposure to the stressful situation of the client affects their professional quality of life, which constitutes both the effect of burnout and secondary trauma.¹²

After noticing significant changes in mood, attitude and motivation of the emotional support providers in a clinic, Freudenberger explored the term burnout and highlighted the negative impact of the trauma care to the therapists. Maslach, in 1982, brought an understanding of burnout of care providers as a psychological condition that involves emotional exhaustion, depersonalization and diminished feelings of an individual’s professional accomplishments.¹³ Maslach also developed a burnout inventory focusing the measures of exhaustion, cynicism, and inefficacy.¹⁴ A physical, emotional and mental exhaustion due to the care of others affected by stressful life situations is often caused by demanding situations of an extended period of service, often unrewarding and neglected role of the professionals were the causes of burnou.¹⁵ A continuous engagement with emotionally demanding situations and exposure to the traumatic journey of the survivors were further elements of burnout.¹ Challenging working environments and inability to respond to the essential needs of professionals were worrisome factors that were causing burnout of the care professionals.¹⁶ Lately, some theoretical frameworks such as individual, interpersonal, organizational and societal were proposed to explain burnout better. However, those concepts were moreover guided by the severity of burnout. The issue of burnout comes through the imbalances between the individual and the requirement of the job rather than also considering the impact of the secondary trauma of the professionals.^17,18

The effect of secondary exposure to trauma linking with the pain, suffering and trauma was explored by the professionals providing care to trauma survivors. A collective term ‘compassion fatigue’ is termed to define such difficulty that was agreed by many researchers.^1,12,19 The ability in understanding the feeling of the client and conveying genuine empathy is diminished due to the compassion fatigue¹⁶ The cost of emotional care of trauma victims was found burdened due to the exposures to distressed individuals, rigorous desire to help and empathetic attitude of the care providers.²⁰ Different terminologies such as vicarious trauma,²¹ secondary traumatization,²² trauma transmission,²³compassionate witnessing etc²⁴ were interchangeably used to understand the effect of secondary exposure to trauma and its impact. The vicarious traumatization refers to the cognitive change process which changes or alters the thoughts and belief towards the ecological surroundings and viewpoint towards the world, where secondary traumatization affects the outward behavioral symptoms rather than affecting the cognitive changes.²⁵ In summary, burnout (BO) refers to the physical, emotional and mental exhaustion caused or induced by the work and working environment. Whereas, the secondary traumatic stress (STS) or vicarious traumatization is the negative emotional exhaustion transferred from or acquired through the experiences of beneficiaries and clients that are either shared, observed or felt with verbal and non-verbal expositions to the care provider. Compassion fatigue (CF) refers to a collective terminology to refer to the negative effect of emotional care, which includes both burnout and secondary traumatic stress. The symptoms of CF, combining burnout and secondary traumatic effects, includes pains, aches, and impaired decision-making, impaired functionality and withdrawal from social activities providers.²⁰ Sabo²⁶ reviewed the theoretical understanding and literature review on burnout, compassion fatigue and vicarious trauma; and summarized key signs, symptoms and triggering situations that affect the counselors are presented in a tabular form as below (Table 1). In a study of professional quality of life of Nepali Counselors and other mental health support workers, the author explored that Nepali Counselors and other mental health support professionals (N=112) are found to be in low of risks of burnout (mean=19.98), and a moderate level of risks for the Secondary Trauma (mean=21.34). The secondary trauma effects were considerably high in the counselors serving to beneficiaries other than the earthquake trauma survivors and were found to be in higher risks.²⁷ Arguably, the compassion fatigue, both burnout, and secondary traumatic disorder should now be the component of academia, clinical supervision, and management of the work of the counselors in both non-governmental and governmental settings.

Compassion Fatigue (CF) is a serious and ongoing challenge for the counselors globally, and Nepali counselors are also affected. The concern now has to be taken seriously and to be addressed without any delay. The following recommendations may guide the academia, researchers, managers and counselors to overcome the burden of compassion fatigue into the counselors.

Provide education and awareness

Those, who go through the training process like Post Graduation Diploma (PGD) in Counseling Psychology, Master’s degree in Counseling Psychology and Master’s degree in Clinical Psychology, has to be given enough knowledge and awareness on the negative cost of care and serious effects of the compassion fatigue. Learning the signs, and symptoms of compassion fatigue may help the counselors to seek for support and advanced care. The academia, supervisors and researchers can use Nepali version of Professional Quality of Life Scale (N-ProQOL-5) translated and culturally adapted by the researcher to promote the awareness and screening of burnout, secondary trauma and compassion satisfaction among the counselors. The tool is available at: http://proqol.org/uploads/Final_Nepali_PROQOL-5_in_Preeti.pdf

Regular clinical supervision

In most of the non-clinical settings, counselors provide care and support to the client without any provision of clinical supervision. Clinical supervision is a process and support activity which allows the counselors to present their doubts, share frustrations and fears, and get support for the encountered difficulties in the therapeutic services carried out by the counselors. Unavailability of clinical supervision or ineffective clinical supervision practices further harms the motivation and enthusiasm of supporting the client of any counselor.

Training on dealing with trauma and care for caregivers training

Trauma management and addressing the emotional consequences of various types of trauma have no often empathized in the training and curricula. The counselors feel exhausted and frightened to face the trauma victims with inadequate practical skills.²⁸ A specific training in dealing with trauma survivors and care-for-caregivers workshops are to be part of the curricula and supervision practices.

Self-care, positive coping, and develop hobbies

Figley CR¹ outlined that the compassion fatigue is also a component that contributes through the chronic lack of self-care. Self-care Compassion fatigue: Psychotherapists' chronic lack of self-care. Self-care techniques vary from person to person, nevertheless a nutritious diet, regular exercise, a restful sleep, making a balance between work and leisure, the practice of self-compassion, and being aware of the emotional needs are mostly representing actions in all the counselors.²⁹Positive coping and hobbies out of work help to overcome the emotional hardships and secondary trauma. The positive coping practices differ from persons to person, however practicing mindfulness, yoga, listening to music, reading books and outdoor games requiring group engagement are often the choices of many.

Practice resilience

Being resilient is a matter of choice. Resiliency practices are the actions which help any human being to overcome the stress and bounce back into the stress-free situation. Resiliency can be enhanced through being in present, understanding the limitations, managing irrational thoughts, effective management of time, setting priorities and learning the skills to sensor the reactions of an unprecedented situation. Helping others in need, religious activities for those who believe in faith and engaging in social activities are other actions, which promote the resilience. Resilience practices can be taught or learned; nevertheless practicing it into the daily life is crucial.³⁰

Look at the emotional boundaries and address it

Counseling is a profession in which the counselor works in providing compassion, empathy and address the emotions of the client with unconditional positive regard. Putting self into the client’s situation in every situation has the impact of counter transference and transference. Setting emotional boundaries can provide a chance to look at the counselor is a separate person and is there in helping the client.³¹ Often the emotional boundaries should be the part of the supervision process, nevertheless, the therapeutic alliances and organization of helping relation within the ethics and boundary are neglected in the training and curricula.

Enhance workplace mutual support

Counselors often spend time in the workplace. Self-help techniques among the counselors and other staff members provide stress reduction opportunities. Regular breaks, peer-gatherings, outdoor activities and flexible working hours are few out of many to manage the workplace related burnout and enhance the compassion satisfaction.

Seek for help

Counselors are also the human being and are equally vulnerable to the emotions and mental health. Seeking help when they feel overstressed, exhausted or broken does not mean that they are mentally ill or unstable.³² The counselors are should be equally encouraged to seek individualized counseling or therapy support if they are in need.

Compassion fatigue, a combination of both burnout and secondary trauma, has a serious effect on the professional and personal life of any counselor. The signs, symptoms, and triggers of the compassion fatigue, were discussed above in detail. These references can provide an outline of the problem to the trainers, researchers and practitioners in providing urgency in addressing these negative aspects of emotional care. Compassion fatigue can be better prevented and treated, however, the efforts at Nepali context are found to be very minimal. Some actions such as education on the compassion fatigue, regular clinical supervision and promoting self-care can be immediately started. Work settings are better places to enhance peer support, making a balance between work and life, and promoting the counselors to seek for emotional support. An urgent action of implementation of combating the compassion fatigue through training, practice and supervision is in need. This article may help to fulfill these gaps in addressing the compassion fatigue concerns of Nepali counselors.

None.

Author declares that there is no conflict of interest.

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