By Maurice Fenton
Maurice Fenton has worked at all levels in residential care, trainee to director, within the statutory, voluntary and private sectors. He founded Empower Ireland in 2009 to support care leavers in Ireland, and is an independent advisor and researcher with a particular interest in mentoring and social justice.
He is scheduled to complete his doctorate at Queens University, Belfast in 2016. He is the author of ‘Social Care and Child Welfare in Ireland: Integrating Residential Care, Leaving Care and Aftercare’ . His most recent book “The Stolen Child” adapted from articles Maurice wrote for the goodenoughcaring Journal is reviewed by Simon Blades in this issue of the Journal.
Relationship-Based Self-Care in Social Care – The SOS Model
The most protective and empowering factor is social care work is, in my opinion, beyond doubt the worker themselves. Therefore, how workers make use of ‘self’ in their work is of critical importance. There are many aspects to the use of self and in this article, I intend to address vicarious processes inherent in the work with regards to two of these self-processes – the importance of self-awareness and self-care. I will then outline a model of Relationship-Based Self-Care which identifies three relationships the worker must engage with and manage to optimally promote their self-care. These relationships are with Self (S), Others (O), and the care System (S).
Key concepts identified within this article are:
Vicarious Trauma, Vicarious Resilience, Vicarious Vulnerability; Compassion Fatigue, Self-Compassion and Compassion Satisfaction; Trauma, Post-Traumatic Growth and System Trauma.
Bearing witness to another’s vulnerability can be an uncomfortable and challenging experience, which can evoke our own vulnerability, emotions, feelings and past experiences. We can also experience some of the other’s pain if we connect to and ‘therapeutically hold’ them (Winnicott, 1975), or ‘hold the child in mind’ (Ruch, 2005), during these times of distress. By recognising that we ‘hold’ something it can then be seen that some degree of possession is implied on the part of the carer. This means we also can become affected by their trauma and pain and we can experience Vicarious Trauma, what Hatfield et al., (1994) describe as a form of emotional contagion that causes the carer to ‘catch the emotions’ of those they care for. Vicarious Trauma can also be referred to as Compassion Fatigue (Figley, 2002) which, although with different causation, is sometimes associated with Secondary Traumatic Stress (Pryce et al., 2007). Secondary Traumatic Stress is more closely associated with Post Traumatic Stress except that the stress is experienced through another person, i.e. vicariously, rather than first hand. It is important to recognise that these concepts are contested (Sabin-Farrell & Turpin, 2003) and that “the actual causes of vicarious traumatization have not yet been established” (Bloom, 2003:459). Consequently, there is no certainty regarding which workers will, if any, or to what degree, experience these conditions. However, what is incontestable is that working with others can and does have an impact on the worker and that this needs to be acknowledged and managed.
In my experience, Vicarious Vulnerability is an appropriate terminology to use. Trauma implies harm, which in turn could be said to imply that the young person has caused harm to the worker, even if unintentionally. Equally, Compassion Fatigue could be seen to imply that the needy or demanding young person invokes fatigue on the part of the worker thus casting the young person as the cause of this fatigue. This, then, could lead to the young person becoming perceived as the cause of the harm, the problem, when clearly, they are not. It is the harm that has been caused to them by others that is the cause of the problem.
During, and after, many of the incidents and daily life events I have been involved in over my years of social care practice very often I was not traumatised or fatigued but I did connect with and re-experience some of my own vulnerability through connecting with the vulnerability of the children and young people (and occasionally my colleagues). This concept of Vicarious Vulnerability allows for recognition of workers’ own pre-existing vulnerability to be recognised as part of this condition and thus the young person is not solely responsible for workers’ experiences. This is a perspective I find helpful in my practice as it lessens the tendency towards judgement and blame. I have found that reflective process have become part of my self-care regime which, together with supervision and talking to trusted colleagues, enables me to process the feelings arising from such encounters with vulnerability.
Carl Jung (1875-1961) theorised that many carers and helpers are motivated to enter caring professions because of their own ‘wounds’ from prior life experiences. He coined the term ‘wounded healers’. Jackson (2001) identifies the ‘wounded healer’ not as a flawed professional rather one whose past experiences can be utilised to better attune them to caring for others. She cites Gothe (1749-1832): “Our own pain teaches us to share in the suffering of others” (2001:17) and makes explicit that the ‘wounded healer’ is not a victim of burnout rather the healer’s own suffering and vulnerability. She identifies how both Freud and Jung were themselves ‘wounded healers’. Research by Maeder (1998), Regehr et al. (2001) and Rizq & Target (2010) identified that high percentages of workers in social work, counselling, and psychotherapy professions had experienced prior ‘wounding’ experiences which motivated them to enter these professions. From this research, we can see the magnitude of the potential for workers’ having pre-existing vulnerabilities that may be impacted on by children’s and young people’s vulnerabilities but that correctly managed this need not be a negative phenomenon. This, then, confirms the absolute imperative for workers to be aware of their own vulnerabilities and to manage them.
In the event that the worker does experience vicarious trauma it “is important to recognise that neither clients nor the negligent helpers are responsible for VT. Rather it is an occupational hazard, a cost of doing the work” (Pearlman & Caringi in Courtois & Ford, 2009:205).
It is also important to recognise that none of these conditions, vicarious trauma, compassion fatigue or secondary traumatic stress are the same as burnout. However, they can be antecedents to, and therefore may develop into, burnout if not dealt with appropriately.
The potential for the evoking of our own vulnerability and past experiences as well as potentially experiencing vicarious trauma or compassion fatigue makes clear the imperative for workers not just to be self-aware but also to have good self-care practices (Newell & MacNeil, 2010). Good self-care practices are vital to aid workers to process their emotional responses and not alone to take care of themselves but also in this process to be more effective in their role of caring for the distressed child or young person.
“We propose here that helpers’ personal distress and emphatic responses, if processed adequately, can result in growth for both client and helper.” (Pearlman & Caringi in Courtois & Ford, 2009:205)
It is important to recognise that vicarious trauma and compassion fatigue are very treatable conditions and can be resolved successfully with good self-care practices and/or professional support should the worker experience them. The role of supervision is critical within this area.
However, these vicarious processes all present with varying degrees of negative implications for workers. Whilst I have experienced many, if not all, of the symptoms of these processes over the years I have also had many positive experiences through vicarious processes with children and young people in care. Vicarious Resilience (VR) has only relatively recently been acknowledged by academia with Hernández et al. (2007) first identifying the concept with regards to psychotherapists working with traumatised clients. They argue that “this process is a common and natural phenomenon illuminating further the complex potential of therapeutic work to both to fatigue and to heal” (2007:237). They also highlight that vicarious resilience offers a mechanism to counterbalance vicarious trauma and, crucially, that practitioners’ awareness of the potential of vicarious resilience boosts its potential benefits for these practitioners.
“Both processes can be managed: VT can be identified and decreased, and VR can be identified and increased, by developing awareness, purposefully cultivating and expanding it.” (Hernández et al., 2007:239)
Silveira & Boyer (2015) found that in addition to experiencing vicarious resilience counsellors of traumatised children were also imbued with increased levels of optimism which they attribute to the vicarious mechanisms of engaging with children overcoming trauma. They also identify how professionals who are familiar with vicarious resilience can look for it within the children and young people and share findings with the children’s families thus affording the families opportunities for experiencing vicarious resilience and enhanced optimism also. This, they point out, could potentially transform family dynamics in positive ways “and contribute to better therapeutic outcomes for clients” (2015:523). They recommend, and I concur, that vicarious resilience be brought into discussions within supervision and professional development workshops.
With regards to the concept of compassion and trauma, there are also positive constructs identified that warrants inclusion from a self-care perspective. These include Self-Compassion (Thompson & Waltz, 2008) which has been gaining purchase in the social profession in recent years for its potential to enhance practitioners’ mental health within a framework that avoids the self-evaluation and self-judgement that is inherent in many other models. This then enables the person to be less judgemental of others. The person balances concern for themselves with concern for others. Kristin Neff (2003) identifies how people are apt to be much harsher and unkind towards themselves than they are to others they care about or even strangers.
“Self-compassion entails seeing one’s own experiences in light of the common human experience, acknowledging that failure, suffering and inadequacies are part of the human condition, and that all people – oneself included – are worthy of compassion”. (Neff, 2003:87)
Neff identifies the three elements of self-compassion as:
“(a) self-kindness – extending kindness and understanding to oneself rather than harsh judgements and self-criticism, (b) common humanity – seeing one’s experiences as part of the larger human experience rather than seeing them as separating and isolating, (c) mindfulness – holding one’s painful thoughts and feelings in balanced awareness rather than over-identifying with them.” (Neff, 2003:89)
Additionally, there is another concept relating to compassion that warrants consideration here, this being Compassion Satisfaction. According to Phelps et al. (2009) Compassion Satisfaction refers to the positivity involved in caring for others and it is often gauged by the Compassion Fatigue and Satisfaction Test (Stamm, 2005). Simply put, Compassion Satisfaction involves “the ability to receive gratification from caregiving” (Simon, Pryce, Roff, & Klemmack, 2006:6). Compassion satisfaction has the potential to counter-balance Compassion Fatigue, Secondary Trauma and Burnout.
DIAGRAM OF PROFESSIONAL QUALITY OF LIFE (Stamm,2010:6)
In the event the professional does experience trauma it is not alone possible that this trauma can be resolved by following the actions outlined above but, in fact, following such recovery the professional may grow both personally and professional from the experience of the effects of this trauma, by both its endurance and remedy. This has been identified as Post-Traumatic Growth by Calhound & Tedeschi (2013:6) who define it as “The experience of positive change the individual experiences as a result of the struggle with a traumatic event”. There is no guarantee that Post-Traumatic Growth will occur yet for those where it does the paradox is they may be more vulnerable, yet they are stronger. They have experienced adversity and survived so whilst they are more aware of the potential for adversity to revisit them they are also more confident, based on their experience, that they will survive it should it re-visit them.
“It is not necessarily an experience that leads people to feel less pain from tragedies they have experienced, nor does it necessarily lead to an increase in positive emotion”. (Calhoun & Tedeschi, 2013:8,23)
Workers may experience Vicarious Post Traumatic Growth from their experiences working with children and young people who have been impacted by adverse childhood experiences (Horell, Holohan, Didon & Vance, 2011).
Furthermore, by understanding and learning form vicarious traumatisation workers can experience vicarious transformation.
“Listening to the life stories that clients tell them may change clinicians in a variety of positive ways” (Calhounn & Tedeschi, 2103:141).
As the African proverb states: Smooth seas do not make skilful sailors
We have seen that vicarious resilience offers the worker the potential to counterbalance the effects of vicarious trauma and that self-compassion and compassion satisfaction offer the worker the potential to a counterbalance the impacts of compassion fatigue and therefore potentially avoid secondary post-traumatic stress and burnout.
Consequently, workers’ awareness of the potential of vicarious resilience and compassion satisfaction as well as the potential for opportunities to enhance levels of optimism coupled with the practice of self-compassion can enhance practitioners’ wellbeing. In the event the worker does experience vicarious trauma or compassion fatigue, as it is after-all an occupational hazard and not an individual failing or weakness on the part of the worker, there is the potential for the worker to experience Post-Traumatic Growth following these events.
It is important to recognise that self-care is a critical component of professional competence in social care.
To have the capacity and capability to care for others we must first take care of ourselves.
However, we must also recognise that systems which facilitate practices such as the expectation of individual accountability without sufficient resources can be seen to be dysfunctional in terms of providing basic support for both workers and children and young people. It is entirely plausible to perceive of such systems as posing a real threat of harm to workers. Here, the risk of what can be termed ‘System Trauma’, where the lack of support, resources and services afforded by the system of care, is equally, if not more of a risk for workers than vicarious trauma. Children and young people are equally exposed to such ‘System Trauma’ within a system which, for example, in The Republic of Ireland in 2014 had 405 children waiting for an appointment within our Child and Adolescent Mental Health Service (CAMHS) for longer than 12 months (Children’s Mental Health Coalition, 2015).
Systems which operate residential child care services as placements of last resort, what is termed as residualised, as is the case in the UK and Ireland, can clearly be seen to cause harm to children in care. Within such systems, children must first be placed in other ‘less restrictive’ settings, such as foster care, and this must be evidenced as not working, in other words, this placement must evidence that it is not capable of meeting the child’s needs, i.e. there must be placement breakdown before a child can be placed in residential care. Often this must occur multiple times before a child is placed in residential care by which time the trauma which led to them being taken into care, as well as the trauma of the entry into care process, has been compounded.
Bearing witness to the suffering of children and colleagues due to System Trauma can also cause trauma to the worker and in this context, the term ‘Vicarious System Trauma’ can be located. It is also plausible that caring within a system deficiently resourced to support both children and workers can accelerate compassion fatigue. In my experience, whilst less well recognised and understood, these traumas invoked by the system of care can be a major factor underpinning burnout in professionals within the social professions.
What is clear is that recognising, and identifying with, the resilience and hope of these children and young people who we care for compassionately, and caring for ourselves with similar compassion, can be the antidote to many of these stresses afflicting workers. They are in fact one of our greatest resources, just as we are one of theirs. With regards to the traumas invoked by the system, in my experience, it is professional solidarity, the sharing with, and support of, trusted colleagues, coupled with professional activism, that are most effective in coping with these system deficiencies. These proactive expressions of agency promote a protective sense of an internal locus-of-control for the worker whereas unchallenged system trauma generates a sense of an external locus-of-control on the part of the already beleaguered worker.
It is well recognised that strengths-based approaches are preferable over deficit-based approaches in social care/work (Saleebey, 2002). It is the same, though less well recognised, with regards to self-care. Traditional approaches to self-care are deficit-based in that they target the harms, the deficits, and put in place actions to ameliorate these. This is a reactive approach analogous to what many, myself included, term our system of care to be, reactive and crisis-led. Such deficit-based mechanisms include many forms of talk-therapies, regular exercise, healthy diet, hobbies and other task orientated strategies that require degrees of self-discipline on the part of the worker. A proactive approach is both preventive and positive. By adopting a strengths-based approach it is the very work itself that becomes the antidote for the stresses invoked by its delivery without always demanding secondary actions on the part of the worker. This is both the simplest and least burdensome mechanism for accomplishing effective self-care, requiring far less effort on the part of the worker that traditional deficit-based mechanisms.
“We are more likely to find something we are looking for that to stumble upon something unanticipated” (Fenton, 2015:41/42)
I have oftentimes struggled to maintain the levels of self-discipline required by traditional mechanisms of self-care and have found that these mechanisms became another task I had to accomplish, and outside of my working hours. This tended to make me experience an increased work-related burden which was counter-productive to the goals of the exercise. It felt uncomfortable and unwelcome to me to have to have a self-care regime that necessitated me having to undertake prescribed actions in what is my own time; increasingly scarce time that I greatly enjoy as unstructured and with my family as much as possible. I began to recognise that I have been consistently more successful in recognising the strength, resilience and hope of those children and young people I have cared for than I have been at following prescribed regimes of self care. This requires little discipline on my part, merely compassion, and, most importantly, it recognises that it is the relationship between worker and child that is the source of greatest strength for both parties. Consequently, this approach to self-care promotes best practice on the part of the worker where, correctly undertaken, the work becomes the antidote. It affords a self-fulfilling mechanism of positive relationships between worker and children and young people where strengths are identified and developed and shared.
However, the relationship-based approach does not preclude employing the techniques identified by traditional self-care approaches as a strengths-based approach does not ignore deficits. Rather, it offers a complimentary approach which if combined with these other techniques affords the professional optimum protection from these traumas.
Thus, it is apparent that traditional approaches to self-care focus on one relationship, that with self, but that these are limited in their efficacy in achieving their intended goals. The SOS Model of Relationship-Based Self-Care incorporates three forms of relationship that the workers must engage with, and manage, to optimally promote their own care. These are:
- relationship with Self;
- relationship with Others;
- relationship with the System.
Yes, it can hurt to care caringly but to deny this hurt is to take the first step towards becoming a task-orientated carer and ultimately burnout. We must accept that pain can be the price of caring and maintaining the motivation to make a difference, to continue to care both for ourselves and the children and young people, is the best antidote.
This article contains extracts from the 2015 book: Social Care and Child Welfare in Ireland: Integrating Residential Care, Leaving Care and Aftercare and has been developed into a training workshop by the author.