Introduction
In this article, I discuss my experience as a Trauma Center Trauma Sensitive Yoga (TCTSY) Facilitator and a volunteer crisis counsellor with Crisis Text Line (CTL) and my recommendation of using the Polyvagal Theory principle of co-regulation as a resource for compassion (empathy) fatigue, especially for those of us working and perhaps considered on the periphery of trauma care. In my work, I often bear witness to deep suffering endured and ongoing, without the cushions of support perhaps embedded in other mental health professional fields. Compassion fatigue deeply affects trauma care providers, and oftentimes, self-care practices are suggested. I also propose we-care practices, as a relational resource. We need to feel cared for as we care for others.
What is trauma, and who are considered trauma care providers:
As mentioned in SAMHSA’s Trauma and Justice Strategic Initiative, “trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.” (Delphin-Rittmon, 2022) The impact of trauma on a person’s life oftentimes leads a person to seek out support and care. Having access to care in the United States is difficult to navigate and costly. Mental health providers are often out of network, making out-of-pocket costs a barrier to entry. (The Doctor Is Out, n.d.)
In the western medical model, mental health providers include psychiatrists, psychologists, counselors, clinicians, therapists, social workers, mental health nurse practitioners, primary care physicians, peer specialists, and pastoral counselors to name a few. (Types of Mental Health Professionals, 2020) These professionals hold varying credentials, depending on the state. Access to these providers is dependent on insurance and the ability to pay high out-of-pocket costs. Therefore, many people are searching elsewhere for alternative care on their healing journey.
Complementary and Alternative Medicine (CAM) in the western medical model:
Complementary care is practices that are used alongside more traditional pathways of medical support and alternative care practice in lieu of those traditional supports. “The National Center for Complementary and Alternative Medicine (NCCAM) has proposed a five-category classification system for CAM therapies:1) natural products (e.g., herbal dietary supplements);2) mind-body medicine (e.g., meditation, acupuncture, yoga);3) manipulative and body-based practices (e.g., massage, spinal manipulation);4) other alternative practices (e.g., movement therapies, energy therapies); and 5) whole medicine systems (e.g., traditional Chinese medicine, Ayurvedic medicine).”(Strauss & Lang, 2012)
Scope of Practice:
Within the healthcare field, a person’s scope of practice describes the procedures, actions, and processes allowed with keeping within the terms of their professional license. (Scope of Practice Determinations for Health Professions, n.d.) I’m a TCTSY Facilitator, which is a 300-hour yoga teacher training accepted by Yoga Alliance (YA) certification standards. YA is the largest non-profit organization representing the yoga community. (Yoga Alliance, 2020) TCTSY also has its own good standing requirements as well as ongoing research utilizing this modality as a clinical intervention for complex trauma and chronic treatment-resistant PTSD. In addition, I’m trained as a volunteer crisis counselor with Crisis Text Line, an organization providing 24/7 free mental health support and crisis intervention through texting. Both organizations provide continuing education and community-building opportunities, supervision, and ways to give and receive feedback. Although I’m embedded in trauma care, I’m considered complementary or alternative care. My work is very often a solo enterprise and until I reach out for care, it would be hard for those in these organizations to notice when I’m suffering from compassion fatigue.
Compassion Fatigue (CF):
In 1992, Carla Joinson, a registered nurse, first coined the term Compassion Fatigue (CF) in response to the distress and isolation felt by some nurses in emergency care departments. (Lee et al., 2014) In 1995, Figley further described this phenomenon as a secondary traumatic stress disorder, a “cost of caring.”(Boyle, 2011) It is helping that hurts. Research is often done with those mentioned above that are characterized as trauma care providers, those on the front lines in hospital and health settings, and even some will mention stay at home caregivers.
In a small study out of The University of Minnesota’s Mind-Body Trauma Care Lab, TCTSY Facilitators participated in a study on compassion fatigue and coping. In the presentation given to the TCTSY organization, there was an acknowledgment that TCTSY facilitators are under recognized as trauma care providers even though they provide trauma care and utilize knowledge like many trauma care providers. Utilizing as a reference point, the Adams, Figley study on social workers in New York City after the 9/11 terrorist attack (Adams et al., 2007) the results found that TCTSY Facilitators have similar to and much greater levels of compassion fatigue than the social workers in the study.
Figure 1:
Compassion Fatigue through the lens of Polyvagal Theory (PVT):
“Polyvagal Theory is a science-based theory that provides explanations of how our autonomic nervous state influences and is influenced by the dynamic challenges of life.” (PVT Background + Criticism, n.d.)
Through this lens perhaps we can reframe this phenomenon of the cost of caring. According to PVT, this “science of safety,” when our system is overwhelmed, there is a predictable and hierarchical pathway of response that takes us out of our sense of the present moment of safe connection and regulation towards mobilization of flight or fight. If that doesn’t resolve the moment and lead us back toward a sense of homeostasis, then we continue toward collapse and disconnection. This happens all in the service of survival. Our nervous system feeling the effects of compassion fatigue, will adapt to protect us, so some of the telltale signs of CF (as shown in figure 1) can be tenderly attributed to our bodies trying to adapt to the distress. On repeat, we become highly sensitive to these cues of danger.
The other two principles of PVT include neuroception, the safety or danger cues coming from our environment, internally, and between nervous systems (often below consciousness), and co-regulation, “the sending and receiving of safety signals.”(Infographic: The Organizing Principles of Polyvagal Theory, n.d.) PVT is offering us a way to be in ally ship with our own nervous system, a system built for connection. CAM trauma care providers, oftentimes unrecognized in systems of care, are providing this connection for others without perhaps the deserved support, recognition, and connection.
Polyvagal Theory Practices for Compassion (Empathy) Fatigue: We-care
Steven Porges, the founder of PVT, in an article called, “Ancient Rituals, Contemplative Practices and Vagal Pathways,” (Porges, 2017) writes about the difference between empathy and compassion. In this article, he discusses how although the words are often used interchangeably there is a difference on a neurophysiological level. Empathy is feeling someone else’s pain which can mobilize us towards that sympathetic fight or flight state or dorsal collapse and despair state. Compassion is respecting and bearing witness to someone else’s pain-that person owns their experience and perhaps they can feel deeply listened to without the agenda of opinion, fixing, and so forth. “Thus, compassion relies on a “neural” platform that enables an individual to maintain and express a physiological state of safety when confronted with the pain and suffering of others.” (Porges, 2021) In this way, I propose that compassion fatigue is empathy fatigue, the distress felt when we have moved away from our own ventral vagal state and are, as the expression goes, “stepping into someone else’s shoes.”
If we are built for safe connection and co-regulation, the usual prescription of self-care practices may not provide the kind of lasting change our systems may need for the journey back towards a calmer, ventral vagal state. Trauma care providers may feel unrecognized and unsupported and self-care practices may be an unavailable resource when deep in the depths of empathy fatigue. I can spend hours online supporting TCTSY participants and on CTL communicating with texters who are in immediate crisis and danger. Continuing to stay alone and try and self-regulate doesn’t always work. In fact, it can sometimes feel like an added burden or chore.
Even before the awareness that I need to self-regulate reaches cognition, I also need to be aware of my nervous system when first entering trauma care spaces. Understanding compassion as a planned resource can be useful. There is a type of pre-planning that can be done but can only be done when we are feeling that safe enough feeling. In that space, we can ask the question, as Deb Dana says, of how can I find my way back to this place when I’m feeling unmoored and pulled into sympathetic or dorsal? (Accessing Self-Compassion During the Covid-19 Pandemic: Deb Dana, LCSW, 2020) Self-care and self-regulating practices can be mapped out here but I would also like to add some we-care practices as well.
Patty Wipler, who created the Hand in Hand Parenting, talks about having an adult listening partner (connection as a form of we-care). Through the PVT lens, a listening partner can be an invaluable resource for compassionate care-the caring for the caregiver. Using her methodology, a listening partner shows respect by believing in the speaker’s intelligence, staying focused on the speaker's thoughts and feelings, encouraging with support and without advice, and confidentiality. (Cynthia, 2014)
Connection to self and connection to others are two ways to find our way back to that safe enough feeling: self-care and we-care. There are two other avenues to mention, which are the environment around us (nature) and more contemplative practices, spirit. (Tami Simon, n.d.)
Conclusion:
People are seeking out the care they deserve, and those avenues are hard to navigate. Trauma care providers include unrecognized providers as well. As noted in the TCTSY study, facilitators are experiencing high amounts of compassion fatigue as well. One way to support and recognize providers could be in reimbursement with insurance companies, which can also be a way to lower those out-of-pocket costs. Other ways that we can support can be through we-care practices, which include co-regulation and connection. To feel alone in our caregiving is hard work and painful to sustain.
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About Author
Mindy Levine is a yoga teacher, TCTSY Facilitator, and Crisis Counselor with Crisis Text Line. Correspondence: https://www.tctsywithmindy.com/
References
Accessing Self-Compassion During the Covid-19 Pandemic: Deb Dana, LCSW. (2020, June 9). Https://Www.Youtube.Com/Watch?v=4ohI-5DjFKA. https://www.youtube.com/watch?v=4ohI-5DjFKA
Adams, R. E., Figley, C. R., & Boscarino, J. A. (2007). The Compassion Fatigue Scale: Its Use With Social Workers Following Urban Disaster. Research on Social Work Practice, 18(3), 238–250. https://doi.org/10.1177/1049731507310190
Boyle, D. (2011). Countering Compassion Fatigue: A Requisite Nursing Agenda. OJIN: The Online Journal of Issues in Nursing. https://doi.org/10.3912/ojin.vol16no01man02
Cynthia. (2014, December 18). PARENT TO PARENT LISTENING GUIDELINES BY HAND IN HAND. Bridges 2 Understanding. Retrieved June 19, 2022, from https://bridges2understanding.com/parent-to-parent-listening-guidelines-by-hand-in-hand/
Delphin-Rittmon, M. R. (2022, June 16). Address Trauma and Mass Violence. SAMHSA. https://www.samhsa.gov/blog/addressing-trauma-mass-violence
The Doctor Is Out. (n.d.). NAMI. https://www.nami.org/Support-Education/Publications-Reports/Public-Policy-Reports/The-Doctor-is-Out#:~:text=Nearly%20half%20of%20the%2060,when%20they%20need%20it%20most.
Infographic: The Organizing Principles of Polyvagal Theory. (n.d.). UNYTE. https://integratedlistening.com/polyvagal-theory-a-primer/
Lee, W., Veach, P. M., MacFarlane, I. M., & LeRoy, B. S. (2014). Who is at Risk for Compassion Fatigue? An Investigation of Genetic Counselor Demographics, Anxiety, Compassion Satisfaction, and Burnout. Journal of Genetic Counseling, 24(2), 358–370. https://doi.org/10.1007/s10897-014-9716-5
68. Smith, J., Nguyen-Feng, V. N., Wheeler, B., & Tola, A. (2021, October). Trauma center trauma sensitive yoga study: Compassion fatigue and coping. Center for Trauma and Embodiment at Justice Resource Institute, Needham, MA, United States.
69. For a more in-depth discussion about the principles of PVT, pleasecheck out my article for Voices Against Torture edition 3 called, “SafeConnection Using Polyvagal Theory: Pathways of Self-Regulation &Co-regulation.” https://bit.ly/3O0ZsGr
