Compassion fatigue, secondary traumatic stress, and coping strategies of mental health professionals

Abstract

Background:

The prevalence of compassion fatigue (CF) and secondary traumatic stress (STS) has been studied with a predominant focus on medical care professionals, indicating a significant presence of STS and CF among them. The present study has identified a dearth in the representation of mental healthcare professionals (MHPs), grouped by psychiatrists, clinical psychologists, psychiatry nurses, and psychiatric social workers within the Indian context.

Aim:

To assess the degree of CF and STS and the subsequent coping mechanisms adopted by MHPs.

Materials and Methods:

This study followed a cross-sectional research design. There were 75 participants selected using purposive sampling and administered scales that measured CF, STS, and coping strategies adopted by the participants.

Results:

There is a strong presence of CF in MHPs along with problem-focused coping as the preliminary approach to STS. Participants with average or higher scores in STS had higher intrusion scores. Higher STS scores tend to have avoidant coping styles in comparison to the larger sample. Female participants indicated higher levels of CF and STS than their male counterparts.

Conclusion:

The study emphasizes on the immediate requirement to address and manage CF levels among the MHPs and focus on the factors that continue to aggravate STS.

Over the years, studies have focused on the impact of work experiences among medical practitioners further identifying detrimental effects on the psychological health of the medical practitioners.[1] While a large aspect of compassion fatigue (CF), secondary traumatic stress (STS), and burnout have been linked to the traumatic experiences that are witnessed by medical professionals within their practice, fewer studies have shifted focus into identifying if similar psychological impacts may be witnessed among the mental health practitioners.[2] “Living in an ocean of stressful emotions” is how Skovholt and Mathison describe the burnout that mental health professionals (MHPs) experience.[1] MHPs have been grouped as clinical psychologists, psychiatric nurses, psychiatric social workers, and psychiatrists within the context of the present study.[3] CF was introduced to define the mental exhaustion experienced by direct interactions with an individual’s suffering.[4,5] The present study applies the standard definition of CF – “the deep physical, emotional, and spiritual exhaustion that can result from working day to day in an intense caregiving environment”.[5] CF has four broad symptom categories: cognitive symptoms are lesser attention, lethargy, inflexibility, confusion, obsession with shock, and perfectionism. The emotional symptoms are hopelessness, apprehension, remorse, annoyance, lack of feeling, fright, vulnerability, grief, dejection, exhaustion, over-sensitive, and sudden and involuntary recalling of frightening experiences while working. The behavioral symptoms are irritability, withdrawal, mood swings, poor sleep, nightmares, change in appetite, hypervigilance, isolation, accident-prone, and loss of things. The spiritual symptoms are an inquiry into the meaning of life, loss of intention, and deficiency in self-righteousness. The somatic symptoms are sweating, increased heart rate, breathing difficulty, dizziness, headaches, and lethargy.[5,6]

MHPs who allocate time toward sustaining relationships and practicing self-care tend to be at lower risk for the negative effects associated with their work in the helping profession.[7] Existing literature discusses a significant correlation between lower levels of burnout and CF.[8] In a systematic review, Indian MHPs were identified to have severe STS and moderate to high degrees of burnout.[9] A prior history of trauma would contribute to increased risk of STS, and the presence of emotional intelligence and self-compassion are protective variables in the development of STS.[10] STS can negatively impact work performance and family connectivity and high levels of depersonalization with aging among MHPs.[11] Therapists with increased caseloads, lesser professional experience, and increased interaction with child abuse-related clients and youth populations have a greater risk of STS.[12]

There is a constant demand for extended applications of soft skills such as empathy and compassion from professionals leading to extended periods of mental exhaustion, with a greater risk among MHPs who treat severely ill patients.[13,14] While research focuses on the impact of CF, STSS, and burnout, some works extend the understanding into gender-based differences, indicating that female practitioners experience more STS than male practitioners.[15] While several studies elaborate on the positive influence of effective coping strategies to combat STSS, there is a dearth of research on coping mechanisms adopted by MHPs to combat CF and STS.[16] Professionals must conduct mental health interventions to enhance psychological care and lower stress levels.[15] The present study attempts to meet this research gap. The present study aims to assess CF, STS, and coping strategies adopted by MHPs. The focuses on the following objectives: Identify the levels of CF in MHPs and assess the level of STS among the MHPs. Inquire the type of coping strategies adopted by MHPs and evaluate the relationship between CF, STS, and coping strategies among MHPs.

MATERIALS AND METHODS

Study design

The present study attempts to test the hypotheses through a cross-sectional research design. The levels of STS, CF, and coping strategies were independently assessed through measures before testing out the correlation between them. The research was approved by the NIMHANS Institute Ethics Committee (Ref No: NIMH/DO/BEH. Sc. Div./2021-22, dated 29.06.2022). Potential participants were briefed about the study and Informed Consent Form was supplemented for their voluntary participation in the study. The present study hypothesizes that: H0: there is no correlation between CF, STS, and coping strategies. H1: a high level of STS and CF is present among MHPs. H2: there is a significant correlation between STS, CF, and their subsequent coping strategies.

Sample

The universe of the study was MHPs (clinical psychologists, psychiatric nurses, psychiatric social workers, and psychiatrists) from three major hospitals in Bengaluru, Karnataka. The data were collected via a purposive sampling technique. The final sample consisted of 75 MHPs. The data were collected from the period July 2022 to September 2022.

Inclusion and exclusion criteria

The following were considered for inclusion: MHPs (clinical psychologists, psychiatric nurses, psychiatric social workers, and psychiatrists) working in NIMHANS Hospital, St. John’s hospital, and Victoria hospital, Bengaluru. Minimum 1 year of clinical experience in their profession, and directly involved in the care of psychiatrically ill patients. Other health workers working in these three major hospitals were excluded from the study.

Tools

Sociodemographic proforma: A semistructured proforma was developed to capture sociodemographic details such as age, gender, clinical experience, working in a mental health sector, engaged in caring of a family member, and engaged in offering mental health services.

Professional Quality of Life Scale (2005): The PROQOL 5 scale, developed by Hudnall Stamm in 2005,[14] is a 30-item, five-point Likert rating, self-report questionnaire developed to measure compassion satisfaction (CS) and CF among health professionals. The scale has three subscales: compassion satisfaction, STS, and burnout. The validity of each domain was identified as 0.88 for CS, 0.81 for CF, and 0.75 for burnout.[15] The first domain measures CS, defined as the ability to function well in the workplace. Increased satisfaction levels of the caregiver are identified through higher scores. The second domain measures burnout, hopelessness, and inhibition of optimal working capacity. High scores indicate high levels of burnout. The third domain measures CF/STS, with high scores representing more significant levels of CF/STS. The participants select the score that relates to the frequency with which each statement was experienced by them during the past 30 days. A five-item Likert scale ranked as (1= never, 2= rarely, 3 = sometimes, 4 = often, and 5 = very often). Each domain is computed independently. Five items (1, 4, 15, 17, and 29) are reverse scored before cumulating the scores. This scale was used in Indian studies.[16]

STS Scale (2004): The scale was developed by Bride et al., in 2004.[17] The scale was designed to measure the reactions that professionals working through stressful and traumatic experience display. The 17-item scale is designed to measure intrusion, avoidance, and arousal symptoms emerging from professional experience.[17] Participants indicate on a five-point Likert rating (1 = never, 2 = Rarely, 3 = Occasionally, 4 = Often and 5 = very often), the frequency of symptoms during the week. Scores below 28 are identified as no STS, and between 28 and 37 as mild STS. A score range between 44 and 48 is identified as high levels of STS and severe STS is categorized above 49.[17] The study has a reliability of 0.956 and a validity of 0.7.[18] The scale has been used in Indian studies.[19,20]

Brief Resilient Coping Scale (2004): The scale was developed by Sinclair and Walston in 2004.[21] The scale measures the participants ability to cope through positively adaptive ways. It consists of 28 items that contain four statements that participants rate “1- I haven’t been doing this at all, 2-A little bit, 3- A medium amount, and 5- I have been doing this a lot”.[21] Validity and reliability were 0.60.[22] The scale has three subscales; they are: problem-focused coping (Items 2, 7, 10, 12, 14, 17, 23, 25), emotion-focused coping (Items 5, 9, 13, 15, 1. 8, 20, 21, 22, 24, 26, 27, 28), and avoidant coping (Items 1, 3, 4, 6, 8, 11, 16, 19). The sum scores lay in a range between 4 and 20; 4–13 is categorized as low resilient coping. Medium resilient coping is categorized as a range between 4 and 16, and high resilient coping is any score between 17 and 20.[21] The scale has been used in Indian studies.[23]

RESULTS

The data were analyzed descriptive and inferential statistics were used to analyze the collected data. Spearman’s rank correlation was applied to analyze the sociodemographic data, and Mann–Whitney U-test and Chi-square test have been applied to check the normality assumptions of the variables, as detailed in the Tables 1-5 below.

Table 1.

Sociodemographic details of mental health professionals (MHP)

Variable	Categories	Frequency (n=75)	Percentage (%)	Median
Age	-	-	-	30 (28, 34)
Gender	Male	31	41.3
	Female	44	58.7
Clinical experience	-	-	-	36 (18, 66) In months
Working in mental health sector	Yes	65	86.7	-
	No	10	13.3
Engaged in offering services	Yes	72	96.0
	No	3	4.0
Engaged in caring of a family member	Yes	26	34.7	-
	No	49	65.3

Table 5.

Relationship between compassion, fatigue, coping strategy, and STS

Variable	STS Median (Q1, Q3)		Mann–Whitney (U-statistic)	P
	Low	Average
Intrusion	7 (5.75, 8.25)	12 (9.50, 13.00)	167.500	<0.001
Avoidance	10.50 (8, 13)	17 (13.50, 21.00)	191.000	<0.001
Arousal	8.00 (6, 10.25)	13 (10.00, 14.50)	229.500	<0.001
Problem-focused coping	2.75000 (2.125000, 3.15625)	2.75000 (2.56250, 2.79167)	589.500	0.267
Emotion-focused coping	2.29167 (1.81250, 1.75000)	2.33333 (2.08333, 2.79167)	529.500	0.080
Avoidant coping	1.375000 (1.25000, 1.75000)	1.87500 (1.50000, 2.12500)	376.000	0.001

Table 1 details the sociodemographic information of the participants. On applying Spearman’s correlation, out of the total 75 participants, 31 were male and 44 female MHPs. Twenty-six (34.7%) of the participants were engaged in caring for a family member and 72 participants (96%) were currently offering active services to clients. The median age of the participants is 30, and the clinical experience median is around 36 months.

Table 2 indicates that the majority (57.3%) of the participants have an average level of compassion satisfaction, 42.7% of the participants have a high level of compassion satisfaction, 69.3% of the participants with an average level of burnout, 30.7% have low burnout, 56% of the participants comes under low levels of STS, and 44% of the participants have an average level of STS.

Table 2.

Compassion fatigue of MHPs with gender-based scores

Domains	Category	Frequency (n=75)	Percentage (%)	Gender (n=75)		χ 2	P
				Male (n=31)	Female (n=44)
Compassion Satisfaction	Average	43	573	16 (51.6%)	27 (61.4%)	0.707	0.400
	High	32	42.7	15 (48.4%)	17 (38.6%)
Secondary traumatic stress	Low	23	30.7	20 (64.5%)	22 (50%)	1.55	0.212
	Average	52	693	11 (35 5%)	22 (50%)
Burnout	Low	42	56.0	11 (35 5%)	12 (27.3%)	0.577	0.448
	Average	33	440	20 (64.5%)	32 (72.7%)

There is no association between CS and gender, CS with gender, [P-value = 0.400]. The CS 61.4% have average compassion satisfaction, and 38.65 have high compassion satisfaction, whereas for males, 51.6% have average CS and 48.4% have high CS. The Pearson Chi-square is 0.707.

The results indicate no association between gender and CS [P-value = 0.448]. Females have 72.7% have average burnout whereas their male counterparts have 27.3. The Pearson Chi-square is 577. There is no significance between STS and gender (P-value = 0.212). 64.5% of males have low STS scores while 50% have average STS. In comparison to females who have 50% average STS scores and 35.5% low STS. The Pearson Chi-square value is 1.555. The Chi-square was measured as average versus high categories of whole sample as per gender.

Table 3 shows that the median intrusion level among MHPs is 8%, avoidance is 13%, and arousal is 10%. The majority of the participants used avoidance followed by arousal and intrusion. A significance (P-value: 0.045) in intrusion score between the categories of gender at a 0.05 level of significance with higher intrusion scores in females than males. There exists a significant difference (P-value: 0.024) in the arousal score between the categories of gender at a 0.05 level of significance with females having higher arousal scores than male counterparts. There is no significant difference score between the categories of gender (P-value: 0.092) at a 0.05 level of significance in avoidance. Females have higher avoidance scores than males.

Table 3.

Secondary traumatic stress of MHP with gender-based scores

Domains	Median (q1, q3)	Gender (n=75) Median (q1, q3)		Mann-Whitney U-test	P
		Male (n=31)	Female (n=44)
Intrusion	8 (6, 11)	7 (6, 10)	9 (7, 12)	497.000	0.045
Avoidance	13 (10, 17)	11 (9, 15)	14 (11, 17)	526.000	0.092
Arousal	10 (7, 13)	8 (6, 12)	11 (8, 13.75)	472.000	0.024

Table 4 indicates the coping strategies among MHPs. The median of problem-focused coping is 2.75000, emotion-focused coping is 2.33333, and avoidant coping is 1.62500. There is no significant difference score between the categories of gender [P-value: 0.709] at a 0.05 level of significance in problem-focused coping. As for emotion-focused coping, there is no significant difference score between the categories of gender (P-value: 0.957) at a 0.05 level of significance. For avoidant coping, scores between the categories of gender (P-value: 0.420) are at a 0.05 level of significance.

Table 4.

Coping of MHP with gender and strategy scores

Domains	Median (q1, q3)	Gender (n=75) Median (Q1, Q3)		Mann–Whitney U-statistic	P
		Male (n=31)	Female (n=44)
Problem-focused coping	2.750 (2.37500, 3.12500)	2.75000 (2.37500, 3.2500)	2.7500 (2.28125, 3.1250)	647.000	0.709
Emotion-focused coping	2.333 (2.08333, 2.58333)	2.33333 (2.0833, 2.5833)	2.33333 (2.0208, 2.6250)	677.000	0.957
Avoidant coping	1.625 (1.25000, 1.87500)	1.5000 (1.2500, 2.0000)	1.50000 (1.2812, 1.8750)	607.000	0.420

Table 5 shows U-test compared the difference in secondary traumatic and coping strategies between the categories of STS. A P-value of <0.001 in intrusion score between the categories of STS at a 0.05 level of significance indicates a significant difference. Participants who had average scores in the STS had higher intrusion scores and arousal scores. A statistically significant difference was observed between categories of STS score [P-value: <0.001] 0.05 level of significance. Participants in the average STS group had greater avoidance scores than those in the low STS group. A statistical difference [P-value: <0.001] is the arousal score between the categories of STS at a 0.05 level of significance.

For avoidant coping, there exists a statistical difference [P-value: 0.001] in the avoidant coping score between the categories of STS at a 0.05 level of significance. Participants in the average STS group had greater avoidant coping scores than those in the low STS group. The test reveals no significant difference [P = 0.267] in problem-focused coping scores between the categories of burnout and between burnout categories [P = 0.080] in emotion-focused coping scores [P = 0.620].

DISCUSSION

The present study reveals that there is a strong presence of CF in MHPs along with problem-focused coping as the preliminary approach to STS. Participants with average or higher scores in STS had higher intrusion scores. Subsequently, participants with higher STS scores tend to have avoidant coping styles in comparison to the larger sample. Female participants indicated a higher levels of CF and STS than their male counterparts.

The present study has aligned with existing literature on the presence of CF in MHPs. Most MHPs fall within the average scores of CF with over 69.3% of the participants having above average levels of burnout, proving the H1 and H2 hypothesis. When examining the distribution of CF/STS scores among all MHPs, the majority of providers in this study fall within an “average” range. This result is consistent with another study,[19,24,25,26] which examined 491 direct-care registered nurses’ levels of CF and discovered that participants had average levels of the condition. The current study implies that mental healthcare practitioners are not exempt from suffering from STS, burnout, or CF.

Contradictory to the existing literatures, the results indicate that half of the participants do not report experiencing STS symptoms. The existing literature states that there are moderate to severe levels of STS among MHPs.[27] Exposure to problems, trauma history, and role stress positively contributed to secondary traumatization.[28]

A majority of the participants indicate problem-focused coping as the preliminary approach to stress followed by emotion-focused coping-in contrast to existing literature that suggest that a majority of the professionals follow an avoidant-coping mechanism.[26,29] An association between STS and coping strategies was done and the analysis found a significant positive correlation between intrusion and emotional-focused coping, avoidance and emotion-focused coping, and arousal and emotion-focused coping.[21] There is also a positive correlation between intrusion, avoidance, and arousal, with avoidant coping. The participants who reported having higher intrusion, avoidance, and arousal reported higher scores for avoidant-focused coping, which aligns with existing literature.[30]

The difference in secondary traumatic and coping strategies between the categories of STS showed that participants in the average STS group had greater intrusion scores than the low STS group. Participants in the average STS group had greater avoidance scores than in the low STS category. Participants in the average burnout category had greater arousal scores than those in the low STS category. On the other hand, for avoidant coping, participants in the average STS category had greater avoidant coping scores than those in the low STS category. The existing literature aligns with the reported a score between average high in CF and burnout.[31,32,33] For avoidance, participants in the low CF category had greater avoidance scores than those in the average CF category. For avoidant coping, the low CF category had greater avoidance scores than those in the average CF category; females have more intrusion, avoidance, and arousal scores than males.[30]

Limitations and future directions

The present study has limitations. The representation of various categories of MHPs within the study was disproportionate, and the selected participants who were proficient in English language could impact native population. Thus, the generalizability of present study with the sample population may be nonrepresentative.

The present study focuses on the MHPs and the prevalence of STS, CF, and subsequent coping strategies. On the other hand, a large section of the study focuses on the strategies of coping, gender-based differences, and the severity of STS/CF symptoms. The present study would furnish insights that are specific to the Indian demographic of MHPs. Often understudied within the context, the study provides insights into the current mental health crisis among the professionals, which invokes a need to adopt a new system to promote health workspaces for MHPs and a shift in the traditional approach to work.[34,35,36,37] The present study would set path for further research in the management of CF and STS among MHPs. Studies could promote increased research in the estimating the gravity of the mental health crisis and the potential factors leading up to the same.[11,16,17,22] While MHPs provide mental health support, a large group within the population report to a decline in their own mental health. Future studies could focus on interventional models that would suggest optimization of wellbeing and social support in addition to positive coping techniques.

CONCLUSION

The findings suggest that mental health workers may also suffer from mental distress, and adding to the same, there is a drastic change in mental health issues in India. Heavier workloads, fewer trained professionals, and increasingly taxing job demands have aggravated the risk. Many MHPs have been working without receiving any good training to improve their mental health.[34,38] Thus, psychological care or protective interventions are needed to address these issues. On an individual and societal level, the efforts of MHPs must be acknowledged, thereby motivating and providing adequate support for them to continue in their expertise. The availability of routine clinical supervision, professional autonomy, feeling treated fairly, and role clarity are often protective variables. Burnout may be more common among staff members of community mental health teams than employees on specialized community teams.[11]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.