© suzanne matson, ma, phr, lpc, ncc team care: 4 top management challenges coping with conflict,...
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© Suzanne Matson, MA, PHR, LPC, NCC
Team Care: 4 Top Management ChallengesCoping with Conflict, Burnout, Compassion Fatigue and Depression in Animal Caregivers
Matson Practice Management & Consulting, LLC
Suzanne Matson, MA, PHR, LPC, NCCPractice Management Consultant
Professional in Human Resources
Licensed Professional Counselor
© Suzanne Matson, MA, PHR, LPC, NCC
Team Care:Coping with Conflict, Burnout, Compassion Fatigue and Depression in Animal Caregivers
IntroductionWelcome
Bathrooms
Breaks
Lunch
Evaluation
© Suzanne Matson, MA, PHR, LPC, NCC
Overview of Today
ConflictThe Emotional BrainNeuropsychology of Conflict
BurnoutSymptomsStress and the BrainNeuropsychology of Burnout
Compassion FatigueSymptomsCoping Strategies
DepressionSymptomsTreatment Strategies for Depression
© Suzanne Matson, MA, PHR, LPC, NCC
My BackgroundExperience
Charles Schwab - 6 YearsStock BrokerTraining in Leadership & Management
– Schwab University - Leadership Development, Finance & Management– “Six Sigma” Management of Productivity
Tuition Reimbursement Program – Master’s In Counseling PsychologyMA with Honors, in Counseling Psychology and Pastoral Care from Denver SeminaryTraining Department – Training ManagersHuman ResourcesMaster’s Certificate in Human Resource Management, Villanova UniversityDesignation of Professional in Human Resources (PHR)
Practice Manager/Consultant – 3 YearsConifer Veterinary Hospital Platte Canyon Animal Hospital
Practice Management Consultant – Professional in Human Resources (PHR) – 4 YearsMountain Paws Veterinary PracticeCoal Ridge Animal HospitalDenver SeminaryOther Small Businesses & Churches
Licensed Professional Counselor – 7 YearsPastoral Care & Counseling – Pastoral Connections Counseling MinistriesMountain Community Counseling Associates
© Suzanne Matson, MA, PHR, LPC, NCC
Let’s Talk Conflict!
What are the Top 3 things about Conflict that you hate?
What are the Top 5 Conflicts that arise in your workplace?
© Suzanne Matson, MA, PHR, LPC, NCC
The Sources of Conflict
Most Difficult People Characteristics and Problems to Manage in Veterinary Medicine – Animal Welfare?
Time ManagementInefficiencyPosition of Non-responsibilityFailure to Think/Failure to CommunicateConflict & EmotionsRefusal to Share KnowledgeUnprofessionalismEmployee Simply Doesn’t CareResistant to Change
Each of these are a direct result of… How the Brain Processes Conflict andHow the Brain Processes Emotion
© Suzanne Matson, MA, PHR, LPC, NCC
The Science of Conflict and Emotion: “The Emotional Brain”
The Limbic System A group of interconnected structures that mediate emotions, learning and memory.
People with Problems & Problem People•Seem to be disconnected from what is going on around them•Display Negative Emotions or is often times “Over Emotional.•Frequently Slow to Learn new things.
Why is this?•Let’s look to a scientific understanding of how the brain works. •I think you’ll be surprised at how much sense there is to the nonsense of conflict in the workplace.
© Suzanne Matson, MA, PHR, LPC, NCC
How the Brain Works Under Stress
Function of Three Main Understandings:
First: The Anatomy of the Brain’s “Limbic System”
– The Limbic System is a Contained, Circular Structure
– There is a reason for this structure…
Second: Designed for Fight-Flight-or-Freeze Survival Response
– Fight-Flight-or-Freeze – Explains the standard reactions of
many employees: » Argumentative (Fight)» Unavailable (Flight)» Zombie/Unresponsive
(Freeze)
© Suzanne Matson, MA, PHR, LPC, NCC
How the Brain Works Under Stress
Function of Three Main Understandings:
First, Limbic System StructureSecond, Fight-Flight-or-Freeze
Third:Neurotransmitters – “Toxic Fumes” of the Workplace“Stress Hormones”
Increase in stress-related neurotransmitters/hormones
– Result: Increase in Limbic System Activity (emotion/respiratory) and
– Decrease in Neocortal (thinking) Activity
Then it makes sense that Good Thinking becomes impaired when working under stress.
It also makes sense that Emotions begin to run high.
What part of the brain is responsible for this?
© Suzanne Matson, MA, PHR, LPC, NCC
How Does the Brain Process Emotion?
Amygdala – Emotion Center/Pleasure-Pain Center
Structure involved in many brain functions including emotion, learning and memory. Part of a brain system that processes “reflexive” emotions and responses.
– Fear and Anxiety– Size of an Almond– Pleasure vs. Pain –
» Simple “reflexive” responses vs. Complex Processing
» Neuro-pathways are “Reflexive”
© Suzanne Matson, MA, PHR, LPC, NCC
How Does the Brain Process Emotion?
Cingulate gyrus – Required for more Complex ProcessingPlays a role in processing conscious emotional experience.
The distance between the amygdala and cingulate gyrus, the structures in between, and the presence of stress hormones explain how it is that emotional employees can’t see the impact of their emotions on others. Without building the Neuro-pathway…the (thinking) destination can’t be reached.
Explains StagnationResistance to Change
But, How do negative emotions permeate the workplace?
© Suzanne Matson, MA, PHR, LPC, NCC
What about the Emotional Escalation and Deterioration of the Workplace?
Physiology of the Group
Emotion and anger become contagious in the workplace for the same reason that Women’s Menstrual Cycles Synchronize….
The Amygdala and Neurotransmitters play a role, and the “intelligence of the primitive brain.”
The Limbic System along with the Primitive Structures of the Brain Regulate or Excite the Central Nervous System.
How?Our Sympathetic Nervous Systems detect other people’s hormonal levels and respond with either synchronization and/or dis-regulation.Unconscious Process – Olfactory/Visual/Auditory Synchronization – to another person’s level of distress/excitement. Disregulation – swing between two or more states of stress.
Parasympathetic Nervous System is responsible for calming us down.This requires the conscious activity of the Cingulate Gyrus.
© Suzanne Matson, MA, PHR, LPC, NCC
Review
ConflictControlled by the Brain
Structures involved?– LS– A– FFF– CG– AC– CNS– SNS– PSNS– NT– SH
© Suzanne Matson, MA, PHR, LPC, NCC
Activity
The Color of Words Exercise
© Suzanne Matson, MA, PHR, LPC, NCC
The Human Brain and Conflict
Recognized Styles of ConflictAvoidance – “I’ll think about it tomorrow”
Accommodate – “It would be my pleasure”
Compromise – “Let’s make a deal”
Collaborate – “Two heads are better than one”
Compete – “My way or the highway”
© Suzanne Matson, MA, PHR, LPC, NCC
Break
See you back in 5 Minutes
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout & Compassion Fatigue in Animal Care-giving
Let’s Talk Burnout, First!
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout: What you will learn…
What is Burnout?
How Stress is Processed by the brain
Neuro-endocrine dysfunction
Role of Dopamine in the Brain
How Dopamine influences Thinking and Behavior
Symptoms of Burnout
What creates burnout in animal caregivers
Relationship between Burnout and Compassion Fatigue
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout
What is Burnout?
Burnout is the state of extreme dissatisfaction with one’s work.
Symptoms – Five Categories
Poor MotivationWorkplace DreadSense of AlienationAgitation or AggressionHealth Problems
When we understand the impact of stress on the brain, we understand where these symptoms originate from…
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout
Self Reflection Exercise…Symptoms – Five Categories
Do I have Poor Motivation?– In What Areas
Workplace Dread?– In general– Specific people I dread being around
Sense of Alienation– Conscious choice to alienate self– Avoidance of others?
Agitation or Aggression– In general, directed inward– In general, directed outward– Directed at specific people
Health Problems– Changes in sleep, appetite, weight, energy– Muscle soreness– Headaches– Slow to recover from illness, sick more often
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout, Stress & The Brain
The Brain
Stress Response Neurotransmitters (brain chemicals) activate the HPA-Axis
Hypothalamic Pituitary Adrenal Axis = HPA AxisHPA-Axis: Assesses threat & Triggers a Behavioral ResponseCatecholamines (FFF Hormones) activate the Hypothalamus as the result of Stress.When stimulated, the Hypothalamus secretes CRF (corticotrophin releasing factor)
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout, Stress & The Brain
The Brain
CRF effects brain functioning in several waysIncreases Arousal, Alertness, Attention and ReadinessStimulates the Pituitary Gland to release ACTH (Adrenocorticotropic Hormone)
ACTHStimulates the Adrenal Glands to produce two glucocorticoids: cortisol, and corticosterone.Increase cortisol production helps individual to initiate their behavioral response to the stress or threat by increasing stimulatory glucose to lower fear responseOver time, cortisol lowers immune response, resulting in health problems
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout, Stress & The Brain
The Brain
Neural Endocrine Dys-regulationHPA-Axis should stop cortisol production when the stressor is removed.This does not always happen.
– Neural pathways have been set in childhood– And, our initial conscious management of stress reinforces
these neural pathways and the levels of cortisol in the brain.
Conscious Management of Stress is Critical and Essential to Coping and Changing our Lives
Prefrontal Cortex (PFC)Controls attention, working memory, sorts out sensory inputs, regulates inhibitory responses.PFC has a high concentration of dopamine receptors.
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout, Stress & The Brain
Role of Dopamine in the BrainHelps to Regulate…
Movement as a crucial part of the basal ganglia motor loop in the brain
– Fatigue– Depression
Emotion, Motivation and Feelings of Pleasure (Limbic System)– Fatigue– Depression
Stabilizes brain activity – facilitates brain activity– “brain fog”– Regulates the flow of information to other parts of the brain
(Neuro-cognitive functioning)
Acts on our sympathetic nervous system (blood pressure, heart rate)
– Fatigue– Depression
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout, Stress & The Brain
Role of Dopamine in the Brain
Excessive Levels of Dopamine Deficient Levels of Dopamine Normal Levels of Dopamine
Addictions Addictions (food) Healthy bonding
Anxiety Depression Feelings of well-being, satisfaction
Compulsions Anhedonia – no pleasure Pleasure, feelings of reward in accomplishments
Sexual Addiction Lack of Ambition Healthy libido
Unhealthy Risk-taking Inability to ‘love’ Good feelings toward others
Gambling Low libido Motivated
Compulsive Activities Erectile Dysfunction Healthy risk taking
Aggression No remorse about personal behavior
Sound choices and decisions
Psychosis ADHD Realistic expectations and thinking
Schizophrenia Social Anxiety Disorder Parent-Child Bonding
Sexual Fetishes Sleep Disturbance & Restless Leg Syndrome
Contentment in the ‘little’ things
© Suzanne Matson, MA, PHR, LPC, NCC
The Balance Between…Too much or Too Little?
Martha Stewart
Tiger Woods
1st Date but no 2nd?
“It’s not you, it’s me”
Chocolate cravings?
Cocaine?
Indifferent to your partner/spouse?
Prone to Addiction/Not Prone to Addiction
© Suzanne Matson, MA, PHR, LPC, NCC
The Balance Between…Too much or Too Little?
Oxytocin & ProlactinOxytocin
Encourages Closeness & AttachmentTrust hormoneDrops in Dopamine & Oxytocin result in increased levels of prolactin.The more oxytocin you produce, the more receptive nerve cells are to oxytocin. The more dopamine you produce, nerve cells shut down to protect themselves from overstimulation and are not as receptive to dopamine the next time. Therefore it takes more dopamine to stimulate them.Calming effect on other individuals (pheremonal quality)
Prolactin (excessive)Increases hostility and anxietyIncrease of testosterone levelsAssociated with despairIncreases desire for one’s own space
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout, Stress & The Brain
The Brain
Under-Communication by the PFC to the HPA Axis and Amygdala– Amygdala continues to assign high emotional valence to the stressor– Setting the entire process back in motion – negative feedback loop.
Long Term Effects of Stress
Pre-Frontal Asymmetry – Left Frontal Brain Impairment– Increased levels of cortisol cause
» damage to the hippocampus» PFC to shrink
– Neuro-chemical Dysregulation – Maladaptive Feedback Cycle– The frontal brain is the last area of the brain to develop, as an individual develops.
Limbic System– Structures: Thalamus, Hypothalamus, Amygdala and Hippocampus– Threat stimulates the locus coeruleus to produce noradrenaline (primary stimulatory
neurotransmitter of the Limbic System.– Amygdala responds to stress by releasing CRF– Prolonged elevated cortisol levels burn out neurons in the hippocampus and
amygdala and these areas have been shown to be smaller in individuals impacted by long-term stress, and traumatic stress.
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout in Animal Caregivers
Revisit Symptoms and Characteristics of Burnout in Animal Caregivers in light of the Brain…
Excessive distancing from ClientsImpaired competenciesLow energy and dissatisfaction Increased irritability with othersDepression resulting from individual, social, and work environmental factors
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout in Animal CaregiversBurnout is Cumulative over Time
Gradual build-up of dissatisfaction often related to several competing external factors
Demands of the jobDealing with Clients and the PublicDemands of Time Pressures in Medicine Line of Responsibilities Clearly Defined
– Lack of clarity around responsibilities– Responsibility Overload
Relationship Stress– Poor Relationships– Personality Incompatibility– Lack of Respect, Displays of Disrespect
Stress caused by Management– Bullying Bosses – Supervisors
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout
Questions…?
Is Burnout a Predictable and Foreseeable Process?
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout – Thinking Question?
What is the difference between…A frog placed into a pot of boiling water
And a frog in a pot of cold water that is gradually brought up to a boil?
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout
Burnout is often a “Solvable Problem”Actions can be taken to prevent
Taking a vacation usually restores
Change of job is often beneficial, if necessary
Changes in Work-Life Balance are helpful
Level of external support and connections has been shown to impact burnout.
© Suzanne Matson, MA, PHR, LPC, NCC
Working Lunch Together
Enjoy!!!
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion Fatigue…
What you will learn…
The difference between Burnout and Compassion FatigueWhat is Compassion FatigueThe context of Compassion Fatigue: Traumatic Stress DisordersHow to think about How Compassion Fatigue may be Impacting your life or those you work with.Your Potential for Compassion SatisfactionYour Potential for Compassion FatigueYour risk for Burnout
© Suzanne Matson, MA, PHR, LPC, NCC
Burnout & Compassion Fatigue
Burnout
A state of extreme dissatisfaction with one’s work.
Not necessarily associated with manifestations of trauma.
Compassion Fatigue
A prolonged state of tension and preoccupation with the cumulative traumatic aspects of working in animal-care and veterinary medicine.
Natural consequence of stress resulting from caring and helping traumatized or suffering animals or people.
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion Fatigue
Compassion Fatigue
Display of outward signs and stress resulting from giving care to others.Secondary Traumatic Stress Disorder (STSD vs. PTSD)
“The Stress of Caring….too Much”Beyond what is healthyNot just Emotional, Physical, but characterized by Trauma Responses
Manifestations– Re-experiencing the traumatic events– Avoidance/numbing or reminders of traumatic experiences– Persistent Arousal - Hyperarousal
Internal Emotional Conflict (CF) vs. External Conflicts (BO)– Set of Symptoms – Not a disease.– Prolonged exposure can result in Clinical Depression
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion
“a feeling of deep sympathy and sorrow for another who is stricken by suffering or misfortune, accompanied by a strong desire to alleviate the pain or remove its cause”
“To suffer with…”
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion Fatigue
Field of TraumatologyPrimary Traumatic Stress
PTSD – Post Traumatic Stress Disorder
Secondary Traumatic Stress“the cost of caring…”Being witness to
Other TermsVicarious Trauma (VT)Emotional ContagionCumulative Trauma Compassion StressRepetitive Stress InjuryRepetitive Emotional Self Injury – Repetition Compulsion
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion Fatigue Self-Test
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion Fatigue Facts…
Compassion Fatigue, Burnout and Compassion Satisfaction are not significantly different for male and female veterinary professionals.
Compassion Fatigue, Burnout and Compassion Satisfaction are not significantly different for those who are involved in performing Euthanasia and those who are not.
Scores for all members of veterinary practice teams are similar, although veterinarians and office staff reported different sources of stress and satisfaction.
Healing animals and the opportunity to work as a team are major sources of satisfaction for all staff.
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion Fatigue
Primary Traumatic StressThe traumatic event is persistently re-experienced in one (or more) of the following ways:
Recurrent and intrusive distressing recollections of event, including thoughts, images or perceptions *Recurrent distressing dreams *Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). *Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. *Physiological reactivity on exposure to trauma cues. *
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion
Primary Traumatic StressPersistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by three or more of the following:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma.Efforts to avoid activities, places, or people that arouse recollections of the trauma.Inability to recall an important aspect of the traumaMarkedly diminished interest of participation in significant activities.Feeling of detachment or estrangement from othersRestricted range of affect/emotions (unable to feel one’s own emotions.Sense of foreshortened future (cannot feel a sense of the future, uncertainty).
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion
Primary Traumatic StressPersistent symptoms of increased arousal (not present before the trauma) as indicated by two or more of the following:
Difficulty falling or staying asleep * Irritability or outbursts of anger *Difficulty concentrating *Hyper-vigilance *Exaggerated Startle Response *30 days of ongoing duration, or more *Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning: Evidenced by increase in family conflict, sexual dysfunction, poor interpersonal communication, less loving, more dependent, reduced social support, poor stress-coping methods. *
© Suzanne Matson, MA, PHR, LPC, NCC
Examples of Compassion Fatigue Symptoms
Seven Categories of FunctioningCognitive
Emotional
Behavioral
Spiritual
Inter-personal Relationships
Somatic
Work Performance
© Suzanne Matson, MA, PHR, LPC, NCC
Examples of Compassion Fatigue Burnout Symptoms
Seven Categories of FunctioningCognitive
Lowered Concentration
Decreased self-esteem
Apathy
Rigidity
Disorientation
Perfectionism
Minimization
Preoccupation with Trauma
Thoughts of self harm or harm to others
© Suzanne Matson, MA, PHR, LPC, NCC
Examples of Compassion Fatigue Burnout Symptoms
Seven Categories of FunctioningEmotional
PowerlessnessAnxietyGuiltAnger or rageSurvivor guiltShutdownNumbnessFearHelplessnessSadnessDepressionEmotional instabilityDepletedOverly sensitiveSelf Esteem
© Suzanne Matson, MA, PHR, LPC, NCC
Examples of Compassion Fatigue Burnout Symptoms
Seven Categories of FunctioningBehavioral
Self-EsteemInpatientIrritableWithdrawnMoodyRegressionSleep disturbanceNightmaresAppetite ChangesHyper-vigilanceElevated Startle ResponseAccident pronenessLosing things
© Suzanne Matson, MA, PHR, LPC, NCC
Examples of Compassion Fatigue Burnout Symptoms
Seven Categories of FunctioningSpiritual
Questioning the meaning of life.Loss of purpose.Lack of self-satisfaction.Pervasive hopelessness.Anger at God.Questioning of prior religious beliefs.Loss of faith in GodGreater skepticism about life and God.
© Suzanne Matson, MA, PHR, LPC, NCC
Examples of Compassion Fatigue Burnout Symptoms
Seven Categories of FunctioningInter-Personal Relations
WithdrawalDecreased interest in emotional intimacy, physical intimacy, or sexual intimacy.MistrustIsolation from othersOverprotection as a parentProjection of anger or blameIntoleranceLonelinessIncreased interpersonal conflicts
© Suzanne Matson, MA, PHR, LPC, NCC
Examples of Compassion Fatigue Burnout Symptoms
Seven Categories of FunctioningSomatic Symptoms
Shock
Sweating
Rapid heartbeat
Breathing difficulties
Aches and pains
Dizziness
Increased number and intensity of medical maladies
Other somatic complaints
Impaired immune system
© Suzanne Matson, MA, PHR, LPC, NCC
Examples of Compassion Fatigue Burnout Symptoms
Seven Categories of FunctioningWork Performance
Low moraleLow motivationAvoiding tasksObsession with detailsApathyNegativityLack of appreciationDetachmentPoor Work commitmentsStaff conflictsAbsenteeismExhaustionIrritabilityWithdrawal from Colleagues
© Suzanne Matson, MA, PHR, LPC, NCC
Break
See you back in 5 Minutes
© Suzanne Matson, MA, PHR, LPC, NCC
Depression…
Presence of 2 or more of the following…
Poor Appetite or Over EatingInsomnia or Hyper-somniaLow Energy or FatigueLow Self-EsteemPoor Concentration or Difficulty Making DecisionsFeelings of Hopelessness
© Suzanne Matson, MA, PHR, LPC, NCC
Coping with…” it all…”
MASTERS Process of Wellness Transformation
MotivationAssessmentSelf-ReflectionTransformationEvaluatingReviewingStudying
•Knowing
•Being
•Doing
© Suzanne Matson, MA, PHR, LPC, NCC
Coping with…” it all…”
MASTERS Process of Wellness Transformation
MotivationIntention is setting your mind to a specific task. Motivation is the force necessary or needed to actually carry out the task.
AssessmentGathering factual and objective information that informs us about where we are now, and where we want to be. And, which may lead us to being happier and healthier.
© Suzanne Matson, MA, PHR, LPC, NCC
Coping with…” it all…”
MASTERS Process of Wellness Transformation
Self-ReflectionRequires honesty, concentration, commitment, and forward reaching vision.
TransformationThe process of shifting from one mind-set that lacks wellness to one that embraces and moves toward wellness.Developing strategies and plans for change.
© Suzanne Matson, MA, PHR, LPC, NCC
Coping with…” it all…”
MASTERS Process of Wellness TransformationEvaluating
Seeking, finding, and learning about those life skills or practices that are tools for achieving success in our Life Plan.
ReviewingReviewing one’s life up to the present.
– Learning from experiences, mistakes, the pastReviewing one’s future life plan for
– Added wellness– New life skills– Desired outcomes for change
Redefining success and failureStudying
Study new thingsStudy your Life Plan Regularly
© Suzanne Matson, MA, PHR, LPC, NCC
Activity
Beck Depression Inventory
MASTER’s Review
Team Handcuffs
© Suzanne Matson, MA, PHR, LPC, NCC
Activity
Team Handcuffs Debrief…
A Metaphor for Remembering what We’ve Learned Today…
© Suzanne Matson, MA, PHR, LPC, NCC
Conclusion…
© Suzanne Matson, MA, PHR, LPC, NCC
References & Credits
Compassion Fatigue in the Animal Care Community
Charles Figley, Ph.D.Robert Roop, Ph.D.
Healthy Caregiving: A Guide to Recognizing & Managing Compassion Fatigue
Patricia Smith, Founder, Compassion Fatigue Awareness Project
© Suzanne Matson, MA, PHR, LPC, NCC
Compassion Fatigue
Primary Traumatic StressDirect experience of an event outside the range of usual human experience that would be markedly distressing to almost anyone.
Car Accident
September 11, 2001
Family violence
Combat