Identification, Effects & Prevention of Stress and

slide1. Identification, Effects & Prevention of Stress and Burnout Frank Röhricht, MD FRCPsych
Consultant Psychiatrist
Honorary Professor of Psychiatry

Developed with materials from:
Renos K Papadopoulos - CTAR, University of Essex<br>
slide2. Introduction and setting the scene<br>
slide3. The Over-involvement- Under-involvement Continuum 'Crusader' approach Doing it all oneself Trying to fix everything Excessive responsibility for people's feelings Excessive accommodation of people's difficulties Wanting to know more Empathy Responsibility for one's behaviour and the reaction of others Developing strategies Advocacy for intervention Professional detachment Maintaining boundaries Involvement in a range of activities Preoccupation with efficiency Cynicism Minimising contact No responsibility for people's reactions Insufficient allowance for problems Blaming survivors Displacement onto other issues MOVING AWAY FROM WORKING WITH SURVIVORS IDEAL RANGE UNDER - INVOLVEMENT OVER - INVOLVEMENT TOWARDS WORKING WITH SURVIVORS<br>
slide4. One has to “burn” for something in order to burn out<br>
slide5. Inter- /intrapersonal Risk Factors (Working with) clients with traumatic histories
Experiences of own personal trauma
High work ethos, enthusiasm, helping-attitude
Unrealistic expectations of self / perfectionism
Inability to attend to own needs
Too high demands from others and/or the situation / high work volume
Lack of resources and time
Lack of control over own work / tendency to work outside work place (can’t shut off)
Lack of support and appreciation<br>
slide6. Work related risk factors Team too big
Inadequate Team composition
Bad reputation of work place
Lack of success
Lack of feed-back
Culture of envy, competition, betrayal
Mobbing
Incompetent management<br>
slide7. General impact All phenomena (concepts) refer to the way we are affected by the specific nature of our contact with specific clients
The way we are affected can vary in terms of
Intensity
Duration
Type (cognitive, emotional, motivational, etc)
The area it affects us (work, relationships with family, friends, etc)
Being visible or invisible (noticeable)
It can be said that this type of work may have a transformative effect on us
However, transformation may be either (predominantly) positive or negative<br>
slide8. Workers Become Stressed As workers we are less effective when under extreme stress.
The purpose of this training is to identify how we respond as professionals in dealing with migrants…
…and how stress can have a negative and positive impact on staff. I will then offer some ways to manage this.<br>
slide9. Stress and its related responses (Definitions, different concepts etc.)<br>
slide10. Counter-transference In Psychoanalysis, all the feelings an analyst has in response to the analysand’s transference to the analyst
More generally, all feelings therapists or professionals have about their own clients
More specifically, that are generated from the interaction with the clients, the client’s own condition, their stories, and the impact they have on the professionals who attend to them<br>
slide11. What is Stress? An adaptive set of response to a situation that is perceived as challenging or threatening to the person’s well-being
There is “good” and “bad” stress<br>
slide12. Stress Reactions Brain, body, and mind are inextricably linked...Alterations in any one of these three will intimately affect the other two."—Bessel van der Kolk, M.D., Traumatic Stress<br>
slide13. All systems involved Sensory system
Motor system
Hormonal system
Emotional system
Cognitive system<br>
slide14. Negative Stress Reactions<br>
slide15. Work
Stressors

Physical
environment

Role-related

Interpersonal

Organizational Stressors and Stress Outcomes<br>
slide16. Stress response – clue to burnout: Three Stages Initial Response – Alert/Alarm Stage
Activation/ Resistance Stage
Exhaustion Stage<br>
slide17. Defining Terms… There are a number of terms out there as they relate to negative stress reactions…

Vicarious Trauma
Secondary Traumatic Stress
Compassion Fatigue
Burnout<br>
slide18. Vicarious Trauma Vicarious Traumatization (VT) refers to harmful changes that occur in professionals’ views of themselves, others, and the world as a result of exposure to graphic and/or traumatic material.
K. Baird & A. C. Kracen<br>
slide19. Vicarious Trauma VT can be seen as a normal response to ongoing challenges to a helper’s beliefs and values but can result in decreased motivation, efficacy, and empathy.

K. Baird & A. C. Kracen<br>
slide20. Secondary Traumatic Stress STS, also called the “cost of caring,”
In effect, it is like an actual Traumatic Stress syndrome, e.g. PTSD but which is activated as a result of being exposed to persons who are themselves traumatised
includes: nightmares, flashbacks, intrusive thoughts, avoidance of people, places or activities that remind one of the event, numbness, lack of interest in things, hyperarousal<br>
slide21. Compassion Fatigue Compassion fatigue is experienced by caregivers who are overly focused and upset by the cumulative trauma of those they are trying to help.
Again: The symptoms might be similar to those of post traumatic stress disorder (PTSD).<br>
slide22. Compassion Fatigue Compassion Fatigue is the cumulative outcome of caring – caring too much and for too long with no end to be seen.
You are absorbing the trauma from the eyes and ears of your clients.
A natural consequence of working with people who have experienced extremely stressful events (Figley, 1995).<br>
slide23. Burnout The state which occurs when stress reactions reach a crisis point. More commonly experienced by staff and caregivers in response to continual exposure to other peoples pain.
It grows over time and unlike CF, burnout is caused by stress and hassles, rather than over-empathizing with the trauma of those you work with.<br>
slide24. Stages of Burnout-Development Enthusiasm & Engagement (energy, involvement and efficacy)
Feelings of too high demands
Feelings of guilt
Distress
Defeat
Helplessness
Exhaustion
Burnout (exhaustion, cynicism and inefficacy)<br>
slide25. Burnout: General psychological stress as a result of working with difficult clients
Feeling of being overloaded due to working with clients with chronic and complex problems
Progresses gradually as a result of emotional exhaustion
May result in various symptoms, e.g. physical, emotional, behavioural, interpersonal, etc.
Can affect the motivation and quality of our work<br>
slide26. Epidemiology Maslach and her colleague Jackson first identified the construct "burnout" in the 1970s
40-60% amongst nurses in intensive care, cancer and HIV centres
15-30% of doctors (mainly GPs)
35% of teachers with another 30% in at-risk stadium
Migration professionals?????<br>
slide27. Stress vs. Burnout Burnout is a defense characterized by disengagement.
Stress is characterized by over engagement.

Burnout produces a sense of helplessness and hopelessness.
Stress produces a sense of urgency and hyperactivity.
Dr. Archibald D. Hart<br>
slide28. Learned helpless Wikipedia.org: “means a condition of a human person or an animal in which it has learned to behave helplessly, even when the opportunity is restored for it to help itself by avoiding an unpleasant or harmful circumstance to which it has been subjected.”
Biological and behavioural model for depression<br>
slide29. Learned helpless experiments(American psychologist Martin Seligman, University of Pennsylvania in 1967) In the learned helplessness experiment an animal is repeatedly hurt by an adverse stimulus which it cannot escape.
Eventually the animal will stop trying to avoid the pain and behave as if it is utterly helpless to change the situation.
Finally, when opportunities to escape are presented, this learned helplessness prevents any action. The only coping mechanism the animal uses is to be stoical and put up with the discomfort, not expending energy getting worked up about the adverse stimulus.
The good news: not all of the dogs in Seligman's experiments became helpless.<br>
slide30. The General Adaptation Syndrome (GAS) First described by Seyle in 1956
A Three-Stage physiological response to stress.
Sometimes also known as the “Fight or Flight” response.
Occurs several times a day.
Occurs every time a stressor is introduced into our environment.<br>
slide31. Job Burnout Process Interpersonal and
Role-Related Stressors<br>
slide32. Who Suffers From Burnout Anyone can suffer from burnout.
It is not a sign of weakness, mental illness or inability to cope with life.
Burnout can be treated, overcome, and prevented in the future.<br>
slide33. Cost of Compassion Fatigue (CF): Stress and Burnout Job performance decreases in terms of productivity
Mistakes increase
Office morale drops
Work relationships suffering
Personal life suffers, increased risk for substance abuse
Can lead to problems with health<br>
slide34. Cost of CF: Stress and Burnout Isolation from support networks
Decreased sense of self esteem and confidence
High staff turn over (£)
Increase use of sick leave (£)
Lack of collaboration with other offices<br>
slide35. The scale of the problem: Structured Assessments<br>
slide36. The Secondary Traumatic Stress Scale The STSC is a 17-item, self-administered
instrument which can be completed in under ten
minutes, designed to measure intrusion, avoidance and
arousal symptoms associated with indirect exposure to
traumatic events via one’s professional relationships
with traumatized people.<br>
slide37. Copenhagen Burnout Inventory (CBI) The CBI is a self-administered, 19-item survey
assessing frequency of symptoms with a five-point
scale; it requires five to ten minutes to fill out, and has
three subscales: personal burnout, work-related
burnout, and client-related burnout.31<br>
slide38. Our own examples/experiences: taking stock<br>
slide39. Self-assessment with STS & CBI<br>
slide40. My best stress-minimising thought? Phrase (what does it say?):

Source (where does it come from?):

Context (when did it first occur?):

Effect (how does it help me):<br>
slide41. Stress and adversity: burnout prevention<br>
slide42. Resilience In physics - The ability of a body not to alter after being subjected to different severe conditions
Strength of the person, family, community to withstand pressures
Ability of the person, family, community to resist destructive (not positive, developmental) change
Ability of the person, family, community to retain positive characteristics despite adversity
Resilience not an individual characteristic but a relational process
Existing positive qualities that survive the adversity<br>
slide43. Adversity-Activated Development (AAD) Positive growth developments which are a direct result of the experiences gained from being exposed to adversity
New elements, characteristics which did not exist prior to the adversity
These characteristics can be known or ‘unknown’ to the individual
New positive qualities that were acquired as a result of the exposure to adversity<br>
slide44. The fun part: tension relief and relaxation techniques<br>
slide45. … a short breathing and stress relief exercise<br>
slide46. A quick check-in prevention Relational network: Who is important for me at my work place (mark as RED in Addressbook)
Set boundaries: not accepting ALL demands (think of a recent list of three items)
Switch mobile phone off whilst working on tasks
Recognise your body signals (like red alarms in your car)
Self appraisal (What did I do well last week?)<br>
slide47. Preventing negative stress and burnout in the work place<br>
slide48. Five Steps to Helpfrom: “Paperclip communicationsThe student affairs folk” Recognize the signs of CF and burnout
Assess what you can handle
Seek help from others
Develop prevention techniques
Emotional Restoration<br>
slide50. Recognize the Signs Honestly assess your family life—how are your relationships?
Does your life have a sense of balance?
William Glasser, the founder of Reality Therapy, argues that everyone has 5 basic needs. We are happy when these needs are met and in balance.<br>
slide51. Honest Self-Awareness Be aware of what you can reasonably do and not do.
Identify areas you can let go and let others step in.
Trust your intuition.
Have a realistic tolerance of failure.<br>
slide52. Seek Help from Others Regular professional supervision with an experienced senior colleague.
Developing and maintaining professional networks.
Seek a culture of support (or seek to create this culture in your workplace).<br>
slide53. Prevention Techniques Take time for relaxation and for lunch (scheduled “re-charge” time), and take at least two consecutive weeks for vacation.
Take care of your body, through diet and exercise, mindfulness techniques.
Set boundaries between home and work: Don't play therapist in personal relationships.
Avoid isolation<br>
slide54. Emotional Restoration Create a ‘no-stress zone’ or ‘safe space’ in the office environment such as an outdoor court yard for breaks.
Boredom is extremely stressful and enhances feelings of burn-out. Change up the office routine, move furniture, do more interesting task at ‘low’ points in the day and get the tedious tasks done first.<br>
slide55. Web Resources Website on CF
http://www.breathofrelief.com/

Great resource for Pro-QOL survey
http://www.isu.edu/~bhstamm/tests.htm<br>
slide56. Debriefing Recent studies show that individual single-session psychological debriefing does not prevent and can even aggravate symptoms of PTSD.
High degrees of arousal in the immediate aftermath of a traumatic event are associated with an increased risk for the development of PTSD
Encouraging highly aroused trauma survivors to express their feeling and emotions concerning the trauma might activate the sympathetic nervous system to such a degree that successful encoding of the traumatic memory is disrupted. Moreover, during an emotional debriefing session negative appraisal of one's sense of mastery may be promoted
(Marit Sijbrandij et al, 2006)<br>
slide57. Positive ‘Debriefing’ in group An opportunity to reflect
A possibility to share with somebody – experience of being witnessed
An opportunity to experience support
A space to plan step by step, supportive and group-based actions<br>
slide58. Outcomes? AAD: can you think of one example where exposure to work related stress helped you to develop new skills/perspectives etc. over time?
Change: can you think of one thing that you want to change after attending this workshop?<br>
slide59. In summary: Basic of staff wellbeing Distance: optimal, whilst maintaining professional focus and commitment
Reflection: examining one’s response to situations, maintaining a perspective on experiences & feelings
Digestion: integrating the experiences in the fabric of one’s life
Support: formal and informal, personal and professional, at work and in private life, regular supervision
Complexity: avoiding oversimplification at all levels
Routine: maintaining daily and other functional routines
Continuation: maintaining a time perspective on life, past, present and future<br>