Relationship violence is any form of physical, emotional, spiritual and financial abuse, negative social control or coercion that is suffered by anyone that has a bond or relationship with the offender. In the literature, we find words such as intimate partner violence (IPV), neglect, dating violence, family violence, battery, child neglect, child abuse, bullying, seniors or elder abuse, male violence, stalking, cyberbullying, strangulation, technology-facilitated coercive control, honour killing, female genital mutilation gang violence and workplace violence. In couples, violence can be perpetrated by women and men in opposite-sex relationships (Carney et al., 2007), within same-sex relationships (Rollè et al., 2018) and in relationships where the victim is LGBTQ2SIA+ (lesbian, gay, bisexual, transgender, queer, Two-Spirit, intersex and asexual plus)  (The Scottish Trans Alliance, 2010; Rollè et al., 2018). Relationship violence is a result of multiple impacts such as taken for granted inequalities, policies and practices that accept sexism, racism, ageism, xenophobia and homophobia. It can span the entire age spectrum. It may start in-utero and end with death.

Our service providers put their hearts and soul into their work. We need to care for our workers who work on the front lines so that they do not burnout. This chapter is about caring for those who care.

Caring for the caregiver

It is recognized that survivors of abuse can suffer emotionally, financially, spiritually, mentally and physically all of which can impact their safety and health and the well-being of their families. Survivors can develop medically-unexplained symptoms and suffer from chronic health challenges such as asthma, diabetes, anxiety depression, PTSD, drug misuse, etc. (Cocker & Joss, 2016; Ellsberg et al.,2008; Trevillion et al., 2012). Those who provide support for survivors of relationship violence may also suffer from abuse and burnout (Baird & Jenkins, 2003; Kitchingman et al., 2018; Taylor et al., 2019), compassion fatigue or secondary trauma (Cohen & Collens, 2013; Figley, 2002, Ray et al., 2013). Burnout is experienced by many.

According to the International Classification of Diseases,

Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and 3) reduced professional efficacy (World Health Organization, [WHO], 2018).

and it can occur with any occupation.

While burnout can occur with any occupation, vicarious or secondary trauma or compassion fatigue or residual stress and compassion satisfaction, are specific to those workers who address trauma and stress in their jobs such as frontline mental health workers (Figley, 2002, Ray et al., 2013), so it applies to sexual assault and domestic violence staff (Baird & Jenkins, 2003), thus all staff who work with survivors of relationship violence. Compassion fatigue is stress resulting from exposure to a traumatized individual rather from exposure to the trauma itself (Figley, 2002) and when empathy in the service provider changes to stress or compassion, satisfaction with work improves (Lynch  & Lobo, 2012). Compassion fatigue (CF) can impact standards of patient (client) care, relationships with colleagues, or lead to more serious mental and physical health conditions. Compassion satisfaction is defined as the personal fulfillment of a job well done (Figley, 2002, Baird & Jenkins, 2003). CF is the convergence of secondary traumatic stress (STS) and cumulative burnout (BO) that results in physical and mental exhaustion caused by a depleted ability to cope with one’s everyday environment and not being able to handle the stress of caregiving (Cocker & Joss, 2016). In a meta-analysis of 21 studies to measure stress in nurses, Zhang et al. (2018) found the rates of compassion satisfaction (47.55) and compassion fatigue (52.55%) and burnout (51.98%) are about the same and that the presence of higher education is correlated with decreased compassion fatigue.

Signs of CF include:

• Exhaustion
• Reduced ability to feel sympathy and empathy
• Anger and irritability
• Increased use of alcohol and drugs
• Dread of working with certain clients/patients
• Diminished sense of enjoyment of a career
• Disruption to the world view
• Heightened anxiety or irrational fears
• Intrusive imagery of dissociation
• Hypersensitivity or insensitivity to emotional material
• Difficulty separating work life from personal life
• Absenteeism – missing work, taking many sick days
• Impaired ability to make decisions and care for clients/patients
• Problems with intimacy and personal relationships (Mathieu, 2018)
• Restlessness; irritability; oversensitivity; anxiety; excessive use of nicotine, alcohol or illicit drugs; depression; anger and resentment; loss of objectivity; memory issues; and poor concentration, focus, and judgement (Lombardo & Eyre, 2011)
• Headaches, digestive problems (diarrhea, constipation and upset stomach), muscular tension, sleep disturbances (inability to sleep, insomnia, and too much sleep), fatigue and cardiac symptoms like chest pain or pressure, palpitations and tachycardia (Lombardo & Eyre, 2011)
• Poor resilience (Ray et al., 2013)

The organizational factors that may lead to CF are:

• workload intensity, inadequate rest time periods between shifts, task repetitiveness (Baranowsky & Gentry, 1999)
• low control and low job satisfaction (Kelly & Spencer, 2015)
• lack of meaningful recognition, and poor managerial support (Ray et al., 2013)

The Professional Quality of Life Scale (PROQOL) is a tool that was developed to measure compassion fatigue (CF). You can self-administer the PROQOL and assess your level of CF by clicking here (Stamm, 2009). Once you have self-identified as having compassion fatigue you need to take action, but it would be better if, it could be prevented in the first place.

Effective Programs

It is important that caregivers have resilience as this can not only mitigate the effects of CF but can also prevent CF from developing. It appears that mindfulness interventions and art interventions can increase resilience and decrease CF. Cocker & Joss (2016) conducted a meta-analysis to try to identify effective programs to address CF in nurses. They found the most effective programs were those that focused on increasing resilience. They suggest that employers need to invest in programs such as Accelerated Program for Compassion Relief (ARP) because CF is inevitable in some occupations (Cocker & Joss, 2016). This program helps workers identify triggers and address CF.

Delaney (2018) piloted an eight-step Mindfulness Self-Compassion based program using a pre-post test design and found it significantly increased resilience and compassion satisfaction, and reduced burnout and secondary stress. This is consistent with other studies that find that mindfulness based interventions are helpful in decreasing stress and healing in a variety of situations including caregiving roles (Fortney et al., 2013; Olson et al., 2015; Shapiro et al., 2005).

Dr. Jon Kabat-Zinn developed an eight-week Mindful-Based Stress Reduction Program (MBSR) in his MBSR Clinic that over the years has shown (multiple studies) (more studies) to improve many cognitive, behavioural and self-regulation skills and to decrease stress and improve healing. Listen to a 3-minute synopsis of MBSR studies. It is an internationally accepted program that may also be used with formal and informal caregivers (also offenders and survivors). Access the program based on Dr. Jon Kabat-Zinn’s MBSR Clinic. He is Professor of Medicine emeritus at the University of Massachusetts Medical School (and made his program free upon his retirement).

Philips & Becker (2020) conducted a systematic review of the impact of expressive arts therapy. They found improved outcomes in 13/14 studies reviewed and found that the art format is also relevant – they found greater improvements on well-being from music and art-based interventions than from narrative and storytelling interventions.

In recent years, trauma-informed care (TIC) has become a buzz word in the social sciences and many social workers, nurses and counsellors use this approach. TIC makes an assumption that the likelihood of having suffered trauma is greater than not and that all clients should be approached as if they have suffered a trauma.  It is an approach that does not blame but seeks to understand the experience of the person and the role trauma has played in their life and role of the service provider. A TIC organization will have policies and practices that do not demean or disempower and do not further re-traumatize the survivor and have appropriate and accessible services (The Institute on Trauma and Trauma-Informed Care, n.d.). Schmid et al (2020) found that not only is trauma-informed care the standard for working with youth in the social service sector but it also improves the well-being of the service providers. They also used a biological measure of stress (cortisol levels in hair samples) and found stress levels decreased in the youth and welfare staff who were using TIC. They believe that it is the operational principles of TIC that lead staff to better understand their own stress symptoms and promote self-care so they recommend that all agencies invest resources in using a TIC approach (Schmid et al., 2020).

The Public Health Agency of Canada has a web site for trauma-informed approaches. It can be accessed here. Also to access a report on becoming a trauma-informed organization, click here.

There are many resources to support trauma-informed practice with children, youth and families such as the one developed in BC. It can be accessed here.

Organizations can also create cultures that are safe. They can ensure adequate staffing levels and other resources so staff get breaks and have the resources to provide good care, provide support and recognition, and policies and practices that promote trust. They may also introduce debriefing practices for staff members, including for those doing the debriefing.

References

Baird, S., & Jenkins, S. (2003). Vicarious traumatization, secondary traumatic stress, and burnout in sexual assault and domestic violence agency staff. Violence Vict, 18(1), 71–86.

Baranowsky A., Gentry J. Workbook. (1999). Journal for a Compassion Fatigue Specialist. Psych Ink Resources.

Carney, M., Buttell, B., & Dutton, D. (2007). Women who perpetrate intimate partner violence: A review of the literature with recommendations for treatment. Aggression and Violent Behavior 12, 108 –115. https://www.researchgate.net/publication/222426549_Women_Who_Perpetrate_Intimate_Partner_Violence_A_Review_of_the_Literature_With_Recommendations_for_Treatment

Cocker, F., & Joss, N. (2016). Compassion fatigue among healthcare, emergency and community service workers: A systematic review. International Journal of Environmental Research and Public Health, 13(6), 618. https://doi.org/10.3390/ijerph13060618

Cohen, K., & Collens, P. (2013). The impact of trauma work on trauma workers: A meta-synthesis on vicarious trauma and vicarious posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy, 5(6), 570-580.

Delaney, M.C. (2018). Caring for the caregivers: evaluation of the effect of an eight-week pilot mindful self-compassion (MSC) training program on nurses’ compassion fatigue and resilience. PLoS ONE, 13(11): e0207261. https://doi.org/10.1371/journal.pone.0207261

Ellsberg, M., Jansen, H., Heise, L., & Watts, C. (2008). Intimate partner violence and women’s physical and mental health in the WHO multi‐country study on women’s health and domestic violence: An observational study. The Lancet, 371(9619), 1165–1172. https://doi.org/10.1016/S0140-6736(08)60522-X

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Fortney, L., Luchterhand, C., Zakletskaia, L., Zgierska, A., & Rakel, D. (2013). Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: A pilot study. The Annals of Family Medicine, 11(5), 412-420.

Gurm, B. K. (2004). Understanding the environmental factors that have an impact on employee well-being: A social audit of a university college (T).  https://open.library.ubc.ca/collections/ubctheses/831/items/1.0055797

Kelly, L., Runge, J., & Spencer, C. (2015). Predictors of compassion fatigue and compassion satisfaction in acute care nurses. Journal of Nursing Scholarship, 47(6), 522-528.

Kitchingman, T. A., Caputi, P., Woodward, A., Wilson, C. J., & Wilson, I. (2018). The impact of their role on telephone crisis support workers’ psychological wellbeing and functioning: Quantitative findings from a mixed-methods investigation. PLoS One, 13(12).

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Olson, K., Kemper, K. J., & Mahan, J. D. (2015). What factors promote resilience and protect against burnout in first-year pediatric and medicine-pediatric residents?. Journal of Evidence-based Complementary & Alternative Medicine, 20(3), 192-198.

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Schmid, M., Lüdtke, J., Dolitzsch, C., Fischer, S., Eckert, A., & Fegert, J. M. (2020). Effect of trauma-informed care on hair cortisol concentration in youth welfare staff and client physical aggression towards staff: Results of a longitudinal study. BMC Public Health, 20(1), 21.

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