Compassion Fatigue and Mental Health Disaster Response Education

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Title:
Compassion Fatigue and Mental Health Disaster Response Education
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1 online resource (61 p.)
Language:
english
Creator:
Vutsinas,Steven
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
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Thesis/Dissertation Information

Degree:
Master's ( M.A.E.)
Degree Grantor:
University of Florida
Degree Disciplines:
Mental Health Counseling, Human Development and Organizational Studies in Education
Committee Chair:
West-Olatunji, Cirecie
Committee Members:
Smith, Sondra
Griffin, Wayne D

Subjects

Subjects / Keywords:
compassion -- counseling -- disaster -- fatigue -- response -- satisfaction -- trauma
Human Development and Organizational Studies in Education -- Dissertations, Academic -- UF
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Mental Health Counseling thesis, M.A.E.
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theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
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Electronic Thesis or Dissertation

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Abstract:
In responding to natural or human made disasters, mental health counselors and responders put themselves at great risk for developing Compassion Fatigue. Compassion Fatigue is a major issue affecting the effectiveness and sustainability of mental health disaster responders, but it is far less researched than related terms such as burnout, secondary traumatic stress, or posttraumatic stress disorder. Some research has been done exploring the causes, warning signs, and associated protective factors of Compassion Fatigue. Little research has been done on Compassion Fatigue prevention or education. The purpose of this study was to examine the relationship between Compassion Fatigue education prior to mental health disaster responder deployment and levels of Compassion Fatigue and Compassion Satisfaction after deployment. The study used the Professional Quality of Life Scale, Version 5, the Stressful Life Experiences ? Short Form, and a series of demographic questions. These instruments provided information on the levels of Compassion Fatigue and Compassion Satisfaction of participants, their trauma history, and basic demographic information. The results of the study suggest that individuals without Compassion Fatigue education prior to deployment had higher levels of Compassion Fatigue, and that individuals who did have Compassion Fatigue education prior to deployment had higher levels of Compassion Satisfaction. These findings are important for responders, relief organizations, and academic institutions because it highlights the importance of Compassion Fatigue education as a needed component in responder training. Ensuring that Compassion Fatigue education is vital component of any formal or informal training model may help to protect responders from Compassion Fatigue and sustain them with higher levels of Compassion Satisfaction. For graduate institutions, this highlights the need for more thorough training on Compassion Fatigue as part of disaster response training, thus promoting the graduation of better equipped and prepared counselors, ready to respond to disasters anywhere in the world.
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In the series University of Florida Digital Collections.
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Includes vita.
Bibliography:
Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Steven Vutsinas.
Thesis:
Thesis (M.A.E.)--University of Florida, 2011.
Local:
Adviser: West-Olatunji, Cirecie.

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Applicable rights reserved.
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lcc - LD1780 2011
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UFE0043497:00001


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1 COMPASSION FATIGUE A ND MENTAL HEALTH DISASTER RESPONSE ED UCATION By STEVEN MARK VUTSINAS A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN EDUCATION UNIVERSITY OF FLORIDA 2011

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2 2011 Steven Mark Vutsinas

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3 To my mom, for the encouragement when I needed it the most

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4 ACKNOWLEDGMENTS I thank Megan, for being the extra push I always needed to get anything done. I my committee chair, Dr. Cirecie West Olatunji, for her mentorship, her scholarship, and her support. I thank Jeff Drayton Wolfgang and Cheryl Ricciardi, for their assistance in the thesis process. Finally, I thank the other members of my committee: Dr. Sondra Smith and Dr. Wayne Griffin, for their understanding, support, and assistance throug h the thesis process and through the course of my graduate education.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 ABSTRACT ................................ ................................ ................................ ..................... 8 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 10 Rationale for the Study ................................ ................................ ........................... 11 Significance ................................ ................................ ................................ ............ 12 Assumptions of the S tudy ................................ ................................ ....................... 12 Definition of Terms ................................ ................................ ................................ .. 13 2 REVIEW OF THE LITERATURE ................................ ................................ ............ 14 Definition ................................ ................................ ................................ ................. 14 Causes of Compassion Fatigue ................................ ................................ .............. 17 Measurements of Compassion Fatigue ................................ ................................ .. 17 Compassion Satisfaction ................................ ................................ ........................ 18 Related Terms ................................ ................................ ................................ ........ 19 Burnout ................................ ................................ ................................ ............. 19 Vicarious Trauma and Sec ondary Traumatic Stress ................................ ........ 21 Compassion Fatigue Resilience: Positive Effects and Protective Factors .............. 23 Protective Factors and Prevention ................................ ................................ .......... 2 4 Need for Preparation of Disaster Mental Health Responders ................................ 25 Counselor Training and Preparation for Crisis Response and CF Prevention ........ 27 Organizational Compassion Fati gue Training ................................ ......................... 28 Academic Compassion Fatigue Training ................................ ................................ 29 3 METHODOLOGY ................................ ................................ ................................ ... 31 Participants ................................ ................................ ................................ ............. 32 Instruments ................................ ................................ ................................ ............. 33 Protocols ................................ ................................ ................................ ................. 35 Data Analysis ................................ ................................ ................................ .......... 35 Limitations ................................ ................................ ................................ ............... 36 4 RESULTS ................................ ................................ ................................ ............... 37 Demographics ................................ ................................ ................................ ......... 37 Results of the Data Analysis ................................ ................................ ................... 38 Hypothesis 1 ................................ ................................ ................................ ..... 38

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6 Hypothesis 2 ................................ ................................ ................................ ..... 39 Hypothesis 3 ................................ ................................ ................................ ..... 39 5 DISCUSSION ................................ ................................ ................................ ......... 44 Significance Of Findings ................................ ................................ ......................... 44 Recommendations for Counselors ................................ ................................ .......... 45 Future Research ................................ ................................ ................................ ..... 47 APPEN DIX A INSTITUTIONAL REVIEW BOARD DOCUMENTS ................................ ................ 49 B STRESSFUL LIFE EXPER IENCES SCREENING SHORT FORM ..................... 52 C PROFESSIONAL QUALITY OF LIFE SCALE, VERSI ON 5 ................................ ... 53 D DEMOGRAPHIC QUESTION S ................................ ................................ ............... 54 LIST OF REFERENCES ................................ ................................ ............................... 56 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 61

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7 LIST OF TABLES Table page 4 1 Age ................................ ................................ ................................ ..................... 42 4 2 Gender ................................ ................................ ................................ ............... 42 4 3 Race an d ethnicity ................................ ................................ .............................. 42 4 4 Profession ................................ ................................ ................................ .......... 42 4 5 Compassion Fatigue education ................................ ................................ .......... 42 4 6 Education level ................................ ................................ ................................ ... 43 4 7 Descriptive frequencies for deployment length ................................ ................... 43 4 8 Descriptive frequencies for categorical individual variables ............................... 43 4 9 Deployment status ................................ ................................ ............................. 43 4 10 Analysis of covariance tests with CS (Dataset with missing data) ..................... 43

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8 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts in Education COMPASSION FATIGUE A ND MENTAL HEALTH DISASTER RESPONSE ED UCATION By Steven Mark Vutsinas August 2011 Chair: Cirecie West Olatunji Major: Mental Health Counseling In responding to natural or human made disasters, mental health counselors and responders put themselves at great risk for developing Compassion Fatigue. Compassion Fatigue is a major issue affecting the effectiveness and sustainability of mental health disaster responders, but it is far less researched than related terms such as burnout, seco ndary traumatic stress, or posttraumatic stress disorder. Some research has been done exploring the causes, warning signs, and associated protective factors of Compassion Fatigue. Little research has been done on Compassion Fatigue prevention or educatio n. The purpose of this study was to examine the relationship between Compassion Fatigue education prior to mental health disaster responder deployment and levels of Compassion Fatigue and Compassion Satisfaction after deployment. The study used the Profe ssional Quality of Life Scale, Version 5, the Stressful Life Experiences Short Form, and a series of demographic questions. These instruments provided information on the levels of Compassion Fatigue and Compassion Satisfaction of participants, their tra uma history, and basic demographic information. The results of the study suggest that individuals without Compassion

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9 Fatigue education prior to deployment had higher levels of Compassion Fatigue, and that individuals who did have Compassion Fatigue educat ion prior to deployment had higher levels of Compassion Satisfaction. These findings are important for responders, relief organizations, and academic institutions because it highlights the importance of Compassion Fatigue education as a needed component i n responder training. Ensuring that Compassion Fatigue education is vital component of any formal or informal training model may help to protect responders from Compassion Fatigue and sustain them with higher levels of Compassion Satisfaction. For gradua te institutions, this highlights the need for more thorough training on Compassion Fatigue as part of disaster response training, thus promoting the graduation of better equipped and prepared counselors, ready to respond to disasters anywhere in the world.

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10 CHAPTER 1 INTRODUCTION Compassion Fatigue (CF) is often referred to as the cost of caring experienced by counselors working with trauma victims ( Figley & Kleber, 1995). In modern times the world has experienced natural and human made disasters that have necessitated unprecedented numbers of qualified mental health providers to give support to survivors (Kennedy, 2006). Whether responding to the a ftermath of the World Trade Center attacks of 2001 or the Haiti earthquake of 2010, counselors and other mental health workers are tasked with providing aid not only to the victims of the disaster but also to the first responders (Creamer & Liddle, 2005). Individuals who work with trauma survivors are susceptible to compassion fatigue, burnout, secondary traumatic victimization/stress, and, in some instances, post traumatic stress disorder. Compassion Fatigue needs to be clearly defined and understood in o rder for counselors to better prepare themselves for the stress that they often experience when working with trauma survivors. Disaster relief counselors need training that includes not only self care strategies, but also compassion fatigue education. Cluk ey (2010) suggested that preventative education for disaster response workers could help them to be better prepared for the emotional reactions that they may experience as a result of caring for trauma survivors. The purpose of this study was to see if th ere was a relationship between the level of Compassion Fatigue education an individual has prior to their crisis response deployment and the subsequent levels of Compassion Fatigue that the individual reports following the end of their deployment. The stu dy utilized a survey comprised of demographic questions, the Professional Quality of Life Scale 5, and the Str essful Life Experiences Screening Short Form The population sample consisted

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11 of members of the Florida Crisis Response Team (FCRT); all of the se individuals were voluntary participants. Rationale for the Study Mental health counselors in disaster response settings often have trouble continuing to do their work effectively due to Compassion Fatigue. Mental health counselors who work in disaster relief scenarios with trauma survivors and first responders are often subject to the Secondary Traumatic Stressors that accompany this work. Among these stressors, Compassion Fatigue is one of the most debilitating because it directly impairs a counselor 2004). The importance of understanding and preventing Compassion Fatigue is not only for the benefit of the counselor but also their ability to continue serving populations in crisis. Preventing Compa ssion Fatigue is important because if these counselors are not sustained there will not only be fewer counselors to serve, there will be fewer counselors, able or willing, to train the future ranks of trauma counselors (Clukey, 2010). When compared to oth er forms of traumatic stress such as Secondary Traumatic Stress, Vicarious Trauma, or Burnout, Compassion Fatigue has a much smaller presence in the literature. Scholars agree that specialized training in crisis work can reduce the likelihood of developin g Compassion Fatigue, but there is no mention in the literature of CF components in this specialized training (Craig & Sprang, 2010). There is little in the literature that examines the relationship between Compassion Fatigue specific preventative educati on prior to deployment with levels of Compassion Fatigue following deployment. The author seeks to determine what if any relationship exists between Compassion Fatigue education and post deployment Compassion Fatigue levels in disaster response mental hea lth workers.

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12 Compassion Fatigue is a serious problem given its potential to inhibit the ability of disaster response counselors to empathize with survivors. Literature relating to CF delineates the issues pertaining to the different ways it can impede th ability to assist their clients, but there is less literature relating to prevention techniques. Some literature cites specialized crisis training as a protective factor against CF, but it does not necessarily include education about CF and its effects (Craig & Sprang, 2010). Finding ways to protect and sustain disaster response counselors is vital to ensuring that the entire crisis response effort is able to fully meet the needs of survivors. The purpose of this study was to look at the ro le of Compassion Fatigue education as a protective factor against the likelihood of developing CF. Significance It is hoped that the findings of this study will contribute to the literature on Compassion Fatigue. By utilizing the Professional Quality of L ife Scale, Version 5, the researcher advances knowledge about a specific population of individuals that work in disaster response. Though this study may not be generalizable to the population as a whole, it is a first step in looking at how education abou t Compassion Fatigue may act as a protective factor. The ultimate purpose of this study is to impact the sustainability and well being of all individuals that work as disaster relief mental health counselors. Assumptions of the Study The researchers of th is project made three assumptions regarding the study participants. The first assumption was that t he Florida Crisis Response Team members who completed the survey understood the questions presented to them. The second assumption was that the FCRT member s who completed the survey answered honestly. The third and final assumption was that the FCRT members who completed the survey

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13 had either completed a deployment or had not been deployed at all to a disaster response situation. Definition of Terms COMPASS ION FA TIGUE A function of bearing witness to the sufferi ng of others (Figley, 2002), an occupational hazard of psychological work with trauma survivors (Bride, 2007) that results in a reduced capacity or interest in being empath etic (Boscarino, 2004), and is related to the emotional and behavioral aspects of the symptomology of the afflicted therapist (Sabin Farrell, 2003). C OMPASSION S ATISFACTION The sustaining aspect of trauma work, Compassion Satisfaction is the sense of professional satisfaction th at a counselor gains from helping others (Stamm, 2002). B URNOUT A syndrome of emotional exhaustion, depersonalization, and a lack of personal accomplishment (Maslach & Jackson, 1981). Other definitions focus on 2006) and the process of physical and emotional depletion caused by work conditions and stress (Osborn, 2004). SECONDARY TRAUMATIC S TRESS A syndrome of symptoms almost identical to Post Traumatic Stress Disorder (Figley, 1995). Some theorists also consi der Secondary Traumatic Stress and Compassion Fatigue to be synonymous, with CF being the more pleasant term to use (Figley, 1995). V ICARIOUS T RAUMATIZATION A n all encompassing term that includes Secondary Traumatic Stress according to Sabin Farrell (2003). Vicarious Trauma is the cumulative transformative effect experienced by the counselor as a result of working with the survivors of traumatic life events (P earlman & Saakvitne, 1995).

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14 CHAPTER 2 REVIEW OF THE LITERA TURE Compassion Fatigue is often referred to as the cost of caring experienced by counselors working with trauma victims (Figley & Kleber, 1995). In modern times the world has experienced and is experiencing natural and human made disasters that have necessitated unprecedented numbers of qualified mental health providers to give support to the survivors (Kennedy, 2006). Whether responding to the aftermath of the World Trade Center attacks of 2001 or the Haiti earthquake of 2010, counselors and other mental health workers are tasked with providing aid not only to the victims of the disaster but also to the first responders (Creamer & Liddle, 2005). Individuals who work with trauma survivors are susceptible to compassion fatigue (CF), burnout, secondary traumatic victimization/stress, and, in some instances, post traumatic stress disorder (PTSD). Compassion fatigue needs to be clearly defined and understood in order for counselors to better pr epare themselves for the stress that they often experience when working with trauma survivors. Disaster relief counselors need training that includes self care and compassion fatigue education. Definition Charles Figley (2002) was one of the first researc hers to study compassion fatigue as a chronic lack of self care and specifically defines it as: A state of tension and preoccupation with the traumatized patients by re experiencing the traumatic events, avoidance/numbing of reminders persistent arousal (e .g. anxiety) associated with the patient. It is a function of bearing witness to the suffering of others. (p. 1435)

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15 The term, compassion fatigue, was initially used instead of Secondary Traumatic Stress Disorder because surveys among nurses and emergenc y responders suggested that compassion fatigue was a friendlier and favorable term. However, it has been argued that Compassion Fatigue and Secondary Traumatic Stress Disorder are identical and that they are the equivalent of Post Traumatic Stress Disorde r with the exception of the direct exposure to the trauma (Figley, 1995). The terms, Secondary Traumatic Stress, Vicarious Traumatization, and Compassion Fatigue, are generally viewed as synonymous and equally hazardous for those working with trauma surviv ors (Bride, Radey, & Figley, 2007).), Defining CF as a reduced capacity or interest in being empathic, Boscarino, Figley, and Adams (2004) focus more on therapist empathy than on any cognitive schema change or behavioral symptoms. Other researchers propos e that the term Vicarious Traumatization encompasses the term Secondary Traumatic Stress (Sabin Farrell & Turpin, 2003). The issues differentiating these terms are illustrated well by Sabin Farrell and Turpin (2003) who purport that Vicarious Trauma refers to cognitive changes while Secondary Trauma reflects symptomology. Yet, other trauma researchers have identified these terms inversely. The muddled terminology, the overlap of terms, and the interchangeability of these related words have made it extremel y difficult to distinguish the differences between the terms. In defining Compassion Fatigue, Sabin Farrell and Turpin (2003) suggest that CF and Secondary Traumatic Stress (identified as interchangeable terms) focus on the symptoms and emotional response s resulting from work with trauma survivors but do not take into account the specific cognitive changes that vicarious trauma encompasses. Compassion Fatigue from this perspective is being defined as a

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16 caregiver response to working with trauma survivors. However, the focus is on the emotional and behavioral aspects of the symptomology rather than actual changes in the way the therapist thinks or views the world. Thus, compassion Fatigue is not viewed as specific to trauma work, as Secondary Traumatic Stres s and Vicarious Traumatization are. Rather, CF and burnout can be experienced in a variety of therapeutic areas. Research in the area of Compassion Fatigue (Sprang & Clark, 2007) has suggested that all of the related terms found throughout the literature are referring to secondary trauma. Overall, scholars appear to agree that counselors and other mental health workers experience secondary trauma when treating trauma survivors. Yet, there is little agreement as to which terminology is correct or if it even matters if the terms are used interchangeably. For the purposes of this study the definition of CF used will be a combination of the Figley, Bride, Boscarino, and Sabin Farrel definitions. CF is: (a) a function of bearing witness to the suffering of o thers (Figley, 2002), (b) an occupational hazard of psychological work with trauma survivors (Bride, 2007) that results in a reduced capacity or interest in being empathetic (Boscarino, 2004), and (c) related to the emotional and behavioral aspects of the symptomology of the afflicted therapist (Sabin Farrell, 2003). This definition serves to highlight the spirit of the term as a reflection of the suffering of the therapist while maintaining a distance from the aspects of VT, Secondary Traumatic Stress, an d burnout that are specific to those terms. Above all other definitions, it appears that the focus on caregiver empathic incapacitation is at the heart of differentiating CF from similar terms.

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17 Causes of Compassion Fatigue To fully describe CF, it is also necessary to investigate the factors contributing to the development of CF in a therapist. According to Figley (2002), there are eleven factors that contribute to the development or preventi on of CF. These factors include (1) empathic ability (2) empathic concern (3) exposure to client (4) empathic response (5) compassion stress (6) sense of achievement (7) disengagement (8) prolonged exposure (9) traumatic recollections (10) life disruptions and (11) compassion f atigue Compassion Fatigue is made up of at least two components that include Burnout and Secondary Trauma that can contribute then to CF (Adams, Figley, & Boscarino, 2008). Another explanation for how counselors and other mental health workers develop C F involves the actual transmission of the trauma from client to counselor. Boscarino, Figley, and Adams (2004) ield of literature regarding CF is not only vague on how to define CF, but also on what its contributing factors and causes are. While there is not a thorough and encompassing definition of CF available from the research literature, there are numerous mea surements of CF that may help contribute to the understanding of the concept. The manner in which the tools conceptualize CF may give further evidence to how CF may be differentiated from similar terms. Measurements of Compassion Fatigue Though the rese arch does not reflect one clear and universal definition of Compassion Fatigue, there are several assessments and instruments that can be utilized in identifying levels of CF or levels of risk for developing CF (Bride, 2007). These instruments may help in understanding what components contribute to

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18 developing CF. Five instruments have been selected for discussion based upon a Compassion Fatigue Self Test (CFST) that fo cused on levels of CF and burnout in respondents (Figley, 1995). Stamm and Figley further developed this scale producing the Compassion Satisfaction and Fatigue Test (CSFT) that added the positive component of Compassion Satisfaction (CS) (Stamm, 2002). Gentry, Baranowsky, and Dunning (2002) designed a modified version of the CFST called the Compassion Fatigue Scale Revised (CFS R). This instrument still measured CF and burnout but used a different number of questions and scoring procedures. A further refined version of the CFS R focused on measuring burnout with a secondary trauma subscale (Adams, Boscarino, & Figley, 2006). Stamm and Figley collaborated to modify the CFST thus producing the Professional Quality of Life Scale (ProQOL) that adds the c omponent of Compassion Satisfaction. The ProQOL has three discrete subscales that measure CF/Secondary Traumatic Stress, Burnout, and CS (Stamm, 2005). Compassion Satisfaction For counselors and other mental health workers who respond to the victims of catastrophic events, there are psychological difficulties that they must face for themselves. Yet, there are also positive and professionally sustaining aspects of trauma work that allow them to cope. This sense of professional satisfaction that is derive d from helping others has been labeled as Compassion Satisfaction (CS) (Stamm, 2002). Figley (1995) places Compassion Satisfaction, Compassion Stress, and Compassion Fatigue on a spectrum that starts with compassion satisfaction, then moves to Compassion Stress, and ends with CF. However, Stamm (2002) described compassion satisfaction as being in balance with CF. This suggests that counselors can suffer from

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19 CF while simultaneously enjoying their work and gaining satisfaction. Though CF has compassion sa tisfaction as a counterpart, there are various terms related to CF that overlap with it that need to be explored to gather a more accurate picture of how the terms interrelate. Related Terms Burnout Burnout is one of the many terms that is often portrayed in the literature as being comparable to CF. Burnout, like CF, has numerous definitions, but scholars agree on several key components of what comprises burnout. One of the most cited definitions of burnout comes from Maslach and Jackson (1981) who described burnout as a syndrome symptomized by emotional exhaustion, depersonalization, and a lack of being a state of persistent expectation of low reward and high punishment at work due to a lack of valued reinforcement, controllable outcomes, or personal competence. Osborn (2004) portrayed burnout as the process of physical and emotional depletion caused by work con (2006) depiction of the consequences of burnout centered on the therapeutic ineffectiveness, premature occupational attrition, depression, and substance abuse that can be major detriments. La loss of caring and commitment to their clients. According to Figley (2002), burnout is characteristically slow and gradual whereas CF can set in suddenly. The core components of burnout appear to be emotional, physical, and psychological exhaustion caused by job stress.

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20 Measurements The different definitions of burnout have contributed to various instruments utilized in measuring burnout levels. The factors that these instruments measure illustr ate many of the core issues at the heart of burnout. The Maslach Burnout Inventory (MBI) is designed with the view that burnout is a syndrome progressively occurring over time (Arthur, 1990). The MBI measures psychological and affective dimensions and ut ilizes three subscales: emotional exhaustion, personal accomplishment, and depersonalization. The Staff Burnout Scale for Health Professionals (SBS) measures psychological, physiological, and behavioral dimensions and focuses on four factors: dissatisfact ion with work, psychological and interpersonal tension, physical illness and distress, and unprofessional patient relationships (Arthur, 1990). These two scales suggest a focus on job dissatisfaction, psychological impairment, and a disconnection from cli ents. Sang (2010) cites that the MBI, while providing some insight into counselor related burnout, does not adequately address issues of burnout that directly affect counselors. Sang (2007) suggests the use of the Counselor Burnout Inventory that focuses on five factors: exhaustion, incompetence, negative work environment, devaluing of the client, and deterioration of personal life. Risk Factors and Prevention In his research delineating the types of burnout that counselors experience, Sang (2010) sugg ested that counselor burnout is primarily Contributing factors have included: budget cuts, managed care constraints, and high caseloads while still providing high levels of ther apeutic service. Lambie (2006) found that while counselor empathy was essential in forming an effective therapeutic

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21 lead to cynicism and detachment and eventually burnout. Counselor empathy, selflessness, long hours, and emotional pressures at work are all cited as contributing factors in developing burnout. Further risk factors cited by Lambie include unrealistic pr ofessional expectations, wanting to feel in control in counseling relationship, and incongruence between professional values and burnout shows overlap with the literature that suggests empathy is a key risk factor for developing CF. (2006) work explored the need f or education in the area of self care as counselors are at risk for burnout because they often focus exclusively on client care rather than self care. Outcomes from research in this area suggests that structured supervision for counselors wherein they are able to discuss their concerns about burnout may in itself act as a protective factor against developing counselor burnout. Vicarious Trauma and Secondary Traumatic Stress According to Sabin Farrell (2003) Vicarious Trauma actually encompasses Secondary Traumatic Stress in what the terms describe. It has been theorized that there is a cumulative transformative effect upon the trauma therapist from working with the survivors of traumatic life events and that this change can be called Vicarious Trauma (Pea When working with trauma survivors, counselors need to understand that the meaning making proce ss is an ongoing and active process in which new information is constantly

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22 being integrated, both for the client as well as themselves. This concept aligns well with symptoms ne arly identical to Post Traumatic Stress Disorder. Figley and Kleber (1995) further suggested that Secondary Traumatic Stress was a natural consequence resulting from caring between two individuals when one is a victim of primary trauma and the other is in directly affected. Research by Creamer and Liddle (2005) on disaster mental health workers from the 9/11 terrorist attacks in New York found that some of the risk factors that lead to higher levels of Seco ndary Traumatic Stress included h eavier prior traum a case load l ess professional experience t herapist discussion of their own trauma work in their own therapy l onger assignments m ore time working with traumatized children w ork with firefighters who suffered great losses and w ork with clients discussi ng highly morbid material Similarly, Pearlman and Saakvitne (1995) suggested that risk factors for VT included exposure to trauma patients, chronicity of trauma. Seco ndary Traumatic Stress has been distinguished from Compassion Fatigue by Devilly, Wright, and Varker (2009) who suggest that, despite how often the terms are used interchangeably, the differences are that: CF often includes a burnout factor and a compassio n satisfaction protective factor while the focus of Secondary Traumatic Stress is on how its symptoms parallel those of PTSD. Though these terms are forms of secondary stress that counselors experience as a result of caring, CF necessitates its own educat ion and prevention strategies.

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23 Compassion Fatigue Resilience: Positive Effects and Protective Factors As stated previously, literature relating to CF and Secondary Traumatic Stress heavily focuses on the negative aspects of working with trauma survivors. Some of the causes and risk factors related to CF are: having no specialized training, being a younger professional, having a high percentage of PTSD clients in your caseload, and being an inpatient practitioner (Craig & Sprang, 2010). Additionally, prox imity to the crisis situation, duration and intensity of exposure can influence levels of CF (Prati, Pietrantoni, & Cicognani, 2010). Other research focusing on the negative effects of trauma work considered how dysfunctional coping strategies, such as di straction and self criticism, could be correlated to higher levels of CF (Cicognani, Pietrantoni, Palestini, & Prati, 2009). While there are clear risks and consequences to this work, there are also positive effects, protective factors, and reasons why co unselors elect to engage in this work that are not as widely published and discussed in the literature. Leonard (2008) discussed a shift in the literature away from a focus on trauma work as being negative and hazardous to a focus on client strengths. It has been suggested that client strength and resilience (ability to maintain psychological stability in a traumatic situation) can lead to positive psychological outcomes from trauma work. Further, counselor resilience, defined as psychological growth that can be achieved through positive coping in light of adverse circumstances (Leonard). The rewards of working with trauma survivors can also include an increased sense of connection with clients, spiritual growth, an increased respect for the strength of t he human spirit, and learning from witnessing the strength of their clients (Pearlman & Saakvitne, 1995). Compassion Satisfaction (Stamm, 2002) is a protective factor against CF that is comprised of the professional satisfaction that counselors experience from engaging in

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24 their work. Resilience, Compassion Satisfaction, and the various other positive effects of counseling trauma survivors suggest that there are clearly defined advantages to working with this population despite the very real dangers and ris ks. Protective Factors and Prevention Various research suggests different preventative methods and protective factors that can help protect an individual from CF. According to Leonard (2008), lower levels of CF are associated with a greater sense of contro l over work, less paperwork, less disturbed clients, and a more manageable caseload (both in volume and severity). Additional research by Cicognani, Pietrantoni, Palestini, and Prati (2009) highlighted the role of work stress on the quality of life and CF of emergency workers. Their work focused on how CS has been positively correlated with efficacy beliefs, sense of community, and the use of active coping skills. This work goes further in correlating certain worker characteristics that promote higher le vels of CS. The researchers suggested that length of service and level of expertise can lead to higher self efficacy and stronger use of active coping strategies. Feelings of belonging to their community where they live can also be a contributor to counse sense of satisfaction. Thus, for a counselor working in a disaster area where they live and feel a part of the community, there is a protective factor in place in knowing that the work they are doing is as a part thei r own community. Studying volunteers responding to the aftermath of Hurricane Katrina, Clukey (2010) found three themes among the responses of the relief workers that may be pertinent specifically to counselors working in these disaster situations. The t hree themes the research focused on were (a) emotional reactions, such as shock, fatigue, anger, grief, and sleep disturbance, (b) frustration with leadership, and (c) life changing

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25 t trauma work can positively affect counselors who are providing relief. The impact of disaster work can lead to reflection on life meaning and, in some cases, allow workers to reassess their lives to the extent wherein they value their interpersonal relationships more and worried less about material possessions (Clukey, 2010). Craig and Sprang (2010) illustrated ways that individuals have effectively maintained higher levels of CS in response to adverse situations. According to their research, the us e of evidence based practice is associated with higher levels of CS. Their assertion is that by utilizing evidence based practice, counselors are forced to continuously increase their knowledge base and subsequently have increased confidence in their abil ity to make decisions in crisis situations. The feeling of being capable of performing difficult tasks in a variety of disaster scenarios can serve as a protective factor against developing CF by enhancing CS (Craig & Sprang). However, there are ways to: (a) help alleviate Compassion Fatigue, (b) prevent it in some situations, and (c) increase CS. Though prior research focuses on the negative aspects of trauma work, the benefits are often under emphasized. Given the importance of trauma work, it is nece ssary to understand more fully the need for preparing counselors for this work so that they may be more readily able to address their own CF as well as that of their colleagues. Need for Preparation of Disaster Mental Health Responders Following the Oklah oma City Bombing in 1995, Disaster Mental Health Workers (DMHWs) were deployed to assist the survivors of the traumatic event. In a research study of these workers, a majority of the DMHWs scored as being high in risk for CF on the CF Self Test for Helper s (Moore, 2004). The work that DMHWs do is very different

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26 from that of the uniformed first responder. The uniformed first responder is trained to dissociate and ignore their feelings until the job is done, while the opposite is true for counselors and oth er mental health workers. Counselors have to engage the survivors and provide empathy and containment for the emotional trauma that may be overwhelming them. It is for this reason that counselors are at risk for CF (Ulman, 2008). The training involved i n preparing these individuals for the difficult task of working with trauma survivors is essential for counselor efficacy. The question remains of whether or not more can be done to better prepare disaster mental health counselors for dealing with their o wn emotional responses to the work and subsequently the potential threat of compassion fatigue. While it has been stated that specialized training was a protective factor for those working with traumatized populations (Leonard, 2008), there was no mention of whether or not self care or CF prevention were a part of that specialized training. The idea that trauma counselors need advanced training with a component on their own emotional reactions is endorsed by (Clukey, 2010). The issues pertaining to this n eed for a deeper level of training at the emotional level would have to include education about compassion fatigue. Without an understanding of the potential dangers of CF, disaster mental health workers would have little context in which to understand wh y self care strategies are so important for them. Clukey (2010) identified a need for research investigating the variables that support these workers and keep them supported so that the experienced workers stay s argument was for sustainability; if more is not done to sustain those who are willing and able to be disaster mental health counselors, then these individuals will eventually succumb to CF or burnout. Hence, there would be

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27 fewer experienced authorities t focused on sustaining individuals working with Hurricane Katrina volunteers and centered on predeployment education for workers. Other research suggests that as an adaptive strategy, professional develop ment such as training and education would have benefits beyond simple knowledge gains (Craig & Sprang, 2010). The need for specialized training is serves as a protective factor for disaster mental health workers. Expanding that training to include Compas sion Fatigue education and placing some levels of that training in the core academic training of counselors is endorsed in the literature. Though these authors have recommended these changes, little research has been focused on preventative education with Compassion Fatigue. Research into the interventions for CF illustrates a significant gap in the literature. The research that is available focuses on primary, secondary, and tertiary prevention (Phelps, Lloyd, Creamer, & Forbes, 2010). At the primary level the focus is on identifying and minimizing stressors. The secondary level centers on early detection through self assessment. The tertiary level is meant to minimize the effects of CF and prevent further deterioration when the CF is already firmly in place. Though there is a large knowledge base to inform intervention strategies, the major focus of research into CF has been on definition and recognition rather than prevention and intervention (Phelps, Lloyd, Creamer, & Forbes, 2010). Current liter ature focuses on fixing present problems rather than more proactive approaches that might include CF education prior to being in the stressful situation. Counselor Training and Preparation for Crisis Response and CF Prevention In a study on applying critic al consciousness as a training tool for counselors, Goodman and West Olatunji (2009b) explored the need for counselors to be culturally

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28 competent in order to provide disaster mental health services to communities in need. Utilizing culturally competence allows for the implementation of interventions that are informed by the cultural values of the population in crisis which subsequently enhances the efficacy of this approach (Goodman & West Olatunji, 2009b). So aside from pointing out that counselors need to be culturally competent to be effective, this research shows that there are practical ways to improve pre deployment education, showed one practical application tha t enhanced counselor efficacy, so it would seem that other training programs integrated into the education of counselors in training could at least have the potential to improve efficacy and perhaps even increase the sustainability of counselors and other DMHWs. In order to more fully understand how education for counselors working with disaster survivors can be improved, it is necessary to examine the CR education and training currently implemented to train counselors working in disaster mental health sce narios. The need for fast and effective interventions for trauma survivors is a top priority for disaster response training, but the focus of training appears to be on intervention training with survivors. Interventions such as Psychological First Aid ar e extremely useful in getting services to individuals in need (Ruzek, Brymer, Jacobs, Layne, Verberg, & Watson, 2007). However it is unclear what training is in place to effectively prepare counselors for the possibility of CF before it is a real danger. Organizational Compassion Fatigue Training is made of Compassion Fatigue in their training of Disaster Mental Health Workers (Red Cross, 2010). The Green Cross, a non profit o rganization founded by Dr. Charles

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29 Figley, provides crisis assistance and counseling as requested. Through this organization, an individual may obtain a certification as a Compassion Fatigue Educator or, with significantly more training, advance on to bei ng a CF Therapist (Green Cross, Green Cross, but these individuals do not necessarily have to have a specific level of education to receive this training. Uhernik (2008 ) highlighted the need for counselors to gain familiarity with the National Incident Management System and the Incident Command System. This recommendation comes as a response to the rising importance of the counselor in interdisciplinary disaster respons e teams (Uhernik, field of disaster response, and that the education for counselors to be better prepared for these situations is a vital and continuing process. Academ ic Compassion Fatigue Training There is no specific requirement for CF education in terms of the academic requirements of Counselor Education programs for crisis training. The Council for the Accreditation of Counseling and Related Educational Programs (C ACREP) sets the standards for Counselor Education Programs (CACREP, 2009). The 2009 CACREP Standards highlight the eight core areas that Counselor Education students need to be familiar with and among these is Professional Orientation and Ethical Practice This section states that: Studies that provide an understanding of all of the following aspects of professional functioning: (c) counselors roles and responsibilities as members of an interdisciplinary emergency management response team during a local, regional, or national crisis, disaster, or other trauma causing event, and (d) self care strategies appropriate to the counselor role. (CACREP, 2009, p. 9)

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30 This section refers to the need for training and education for crisis intervention and for self ca re, but there is no apparent connection between the two issues as would be the case in the instance of CF Education. Though there are various ways that CACREP institutions are working to implement disaster and crisis response training into their curricul a, it is clear that there are some gaps in the education that they offer. However, there are still numerous programs and practices already in place in these institutions that offer ideal frameworks for potential application with CF education. Research by Goodman and West Olatunji (2009a) explored how outreach, advocacy, service learning can be used to help counselor education students achieve praxis. As a means of implementing practical education while expanding upon issues of social justice, this resear ch provides a method for CF education at the graduate level that could be utilized to both train counselors for future work with traumatized populations, while also improving their competence as a professional in the field of counseling (Goodman & West Ola tunji, 2009a).

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31 CHAPTER 3 METHODOLOGY Research into the field of post trauma counseling has yielded various issues pertaining to the stress that is experienced by counselors working with trauma survivors such as Secondary Traumatic Stress, Vicarious Trauma, Burnout, and Compassion Fatigue. Compassion Fatigue is possibly the least researched and understood of these terms, but has been shown to be an important issue impeding the efficacy, empathy, and functionality of counselors working with trauma sur vivors (Boscarino, 2004; Sabin Farrel, 2003). Research based on the compassion fatigue experienced by Mental Health Counselors and other Mental Health Workers has suggested that further education and specialized training in disaster work can serve as prote ctive factors against Compassion Fatigue (Craig & Sprang, 2010; Leonard, 2008). The framework for this study was quantitative and descriptive. The study consisted of correlational research focusing on ly variables that already exist ed within the sample pop ulation. This led the author to the following hypotheses and research questions: Research Question 1: What is the relationship between Compassion Fatigue education prior to disaster response deployment and the levels of Compassion Fatigue? Hypothesis 1: There is a relationship between Compassion Fatigue education, prior to disaster response deployment, and the levels of Compassion Fatigue for disaster mental health workers after the deployment period has ended. Research Question 2: What is the relationsh ip between Compassion Fatigue education in the degree level and levels of Compassion Satisfaction after the deployment period has ended.

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32 Hypothesi s 2: There is relationship between Compassion Fatigue education and levels of Compassion Satisfaction for disa ster mental health workers after the deployment period has ended. Research Question 3: What is the relationship between Compassion Fatigue education and levels of Compassion Satisfaction after the deployment period has ended. Hypothesis 3: Compassion Fatigue education predicts higher levels of Compassion Satisfaction among disaster response mental health workers after the deployment period has ended. Participants The participants in this study consist ed of a sample of 101 crisis responders who have worked previously in a mental health capacity as part of a larger disaster response eff ort. These participants were solicited from the membership of the Florida Crisis Response Team, a group comprised of individuals who have undergone training w ith the National Organization for Victim Assistance in order to ( 1) h elp local decision makers identify all the groups at risk of experiencing trauma ( 2) t rain the local caregivers who are to reach out to those groups after the FCRT has departed, and ( 3) l ead one or more group crisis intervention, also known as psychological first aid, sessions to show how those private sessions can help victims start to cope with their distress (National Organization for Victim Assistance, 2010) This group was chosen sp ecifically because they are required to receive some amount of Compassion Fatigue training as part of their NOVA training. These individuals had either direct experience in responding to disaster situations and working with trauma survivors or had not be en deployed with the FCRT yet This population provide d a sample of individuals who

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33 have both gone through various types of disaster response training and, given their trauma work experience, may have a higher likelihood of developing Compas sion Fatigue t han mental health workers not working in disaster response. This population will consist ed of individuals from various mental health professions and backgrounds as well as various education le vels. The participants were asked to participate in this resea rch through a contact with the Florida Crisis Response Team and w ere e mailed a link to an online Instrument with demographic questions. Instrument s Demographic Questionnaire The demographic portion of the questionnaire was comprised of questions regarding gender, ethnicity, profession, education level, number and length of deployments with the FCRT, and level of training on Compassion Fatigue. For a complete list of the demographic questions ( Appendix D ) Stressful Life Experiences Screening Short Form The Stressful Life Experiences Screening Short Form was utilized to establish the trauma history of the study participants. This information provides a base of knowledge for how much, if any, personal trauma the participants may have been affected by in their lives. This instrument uses Likert scale type questions to establish how well a statement reflects the experiences of that participant. Please see Appendix B for the entire form. The Professional Quality of Life Scale The Professional Quality of Life Scale: Compassion Satisfaction and Fatigue (ProQOL) Version 5 (Stamm, 2009) is a non diagnostic tool developed initially by Dr. Charles Figley and later updated and refined by Dr. Beth Hudnall Stamm. The intent of

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34 the scale is to measure levels of Co mpassion Satisfaction, Burnout, and Secondary Traumatic Stress. The authors of the scale clearly state that their definition of Compassion Fatigue is that it is comprised of two parts, one being Secondary Traumatic Stress and the other being Burnout. The scale is a useful tool for determining the likelihood that an individual may develop Compassion Fatigue. It is again important to note the CF is not a diagnosable condition and therefore this is not a diagnostic test, merely a screening and research tool for finding individuals who may potentially be struggling with Compassion Fatigue related issues. The scale is comprised of a total of 30 questions with 10 questions on each of the CS, BO, and STS subscales as mentioned earlier. The reliabilities for e ach of the ProQOL subscales are as follows: the CS scale errors for these measures are 0.22 for CS, 0.21 for BO, and 0.20 for STS. The ProQOL manual cites good construct validity of the instrument based on the use of the instrument in over 200 published papers and the presence of over 100,000 articles about it on the internet (Stamm, 2009). The Burnout, Secondary Traumatic Stress, and Compassion Satisfaction scales measure separate constructs. The CF scale, comprised of Burnout and Secondary Traumatic Stress, is distinct. The inter scale correlation with Secondary Traumatic Stress is 2% shared va riance (r= .23; co inter scale correlation with Bu rnout is 5% shared variance (r= .14; co Though there is shared variance, the Burnout and Secondary Traumatic Stress scales measure different constructs. The shared v ariance can be attributed to the common

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35 areas assessed by the two scales. The ProQOL manual reports the shared variance between the Burnout and Secondary Traumatic Stress scales at 34% (r=. 58 ; co 34%; n=1187). Each scale is similar, but there are var iations such as the subject of fear in the Secondary Traumatic Stress Scale (Stamm, 2009). Protocols Informed consent was approved by the Institutional Review Board (IRB) of the University of Florida ( Appendix A) Solicitation to participate in the study was made to the available members of the Florida Crisis Response Team through a designated contact with the FCRT by e mail. Participation was voluntary and there was no compensation offered. Participants had access to an online survey that included the P roQOL 5 instrument, the Stressful Life Experiences Screening Short Form and demographic questions. All participants were given notice at the end of the informed consent form that proceeding implied their consent Their responses were collected in the on line survey system. Data Analysis Based on previous studies ( Leonard, 2008 ) the correlation could be found to be between .2 and .1. For power to be .7 to detect the effect we would need an approximate sample of 614. If the correlation is 15 for power to be .7 to detect the effect we would need a sample of 271. If the correlation is .2 for power to be .7 to detect the effect we would n eed a sample of 151. Since we did not know what the correlation was going to be, we took the most conservative estimate w hich is a correlation of .1, and therefore attempted to gain a sample of 614. For hypothesis and question 1, a MANCOVA was conducted with the data. For hypothesis and question 2, an ANCOVA was conducted using two independent variables: Deployment status and Compassion

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36 Fatigue Training. For hypothesis and question 3, an ANCOVA was conducted using three independent variables: Deployment status, Compassion Fatigue training, and Profession Group. Limitations Limitations of this study include the non random nature of the sampling process, the bias of the study toward individuals who favor the use of e mail over standard mail, and the multidisciplinary nature of the study. Further limitations include the lack of a specific instrument for measuring Compassion Fatigue alone rather than as a combination of Secondary Traumatic Stress and Burnout. Other limitations in the study included the indirect distribution of the survey to FCRT members. The survey, by necessity was sent through the director of the FCRT who maintains the membership lists. Thus, the researchers did not have direct access and had no control over the frequency of the distribution. This also meant that there was an unknown percentage of members of the FCRT who were not Internet accessible. Any undeliverable messages would not have been sent to the researchers, but rather to the FCRT director. There was no real way to know how many members of the team were actively receiving the invitation to participate in the survey.

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37 CHAPTER 4 RESULTS This chapter presents the results from this posttest only quasi experimental study looking at the hypothesized effects of Compassion Fatigue education on the levels of Compassion Fatigue and Compassion Satisfaction that participants self reported i n the online survey, while also looking at their history of traumatic experiences. For hypothesis and question 1, a MANCOVA was conducted with the data. For hypothesis and question 2, an ANCOVA was conducted using two independent variables: Deployment stat us and Compassion Fatigue Training. For hypothesis and question 3, an ANCOVA was conducted using three independent variables: Deployment status, Compassion Fatigue training, and Profession Group. Demographics The participants in this study were sample d fr om 800 potential total members of the Florida Crisis Response Team (FCRT). These members were contacted by a mass email from the director of the FCRT, inviting members to participate in the study This invitation includ ed a summary purpose of the study a nd a link to the online survey At the end of a month 101 participants had attempted to complete the survey, providing a 12.6% response rate. The sample included 73 female s, 9 male s, and 28 non answers with a mean age of 51 years old (M = 50.575, SD = 10. 509). The sample ethnicities consisted of 66.33% White, 6.93%, Black 5.94 % Latino, 2.97 % Multicultural, and 17.8% non answers. The professional groups to which the p articipants belonged were simplified into three, this included Advocates 35.6 % (N = 36) followed by Other professions

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38 29.7 % (N = 30 ), and Mental Health professional s 28.7 % (N = 29 ) Demographic frequencies can be found in Tables 4 1 through 4 9. Results of the Data Analysis Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS ) Version 19 and the R statistical software version 2.13 The data was examined for accuracy of data entry, missing values, outliers, multicollinearity and the model assumptions were tested and were found to not violate any of the assumptions. Preliminary independent samples t tests were conducted to determine if there were any group differences between the independent variables (demographics) and the dependent variables (CS, BO, and STS). I ndependent t tests showed no s ignificant differences. Hypothesis 1 Hypothesis 1 stated that there would be relationship between Compassion Fatigue Training (present or not present) and Deployment status (either pre or post deployed) on the level of Compassion Fatigue A multivariate analysis of covariance (MANCOVA) was used to examine these effects, using Trauma History as the covariate. The dependent variables in this analysis were the two subscales on the ProQOL: Burnout(BO) and Secondary Traumatic Stress(STS), that make up Compass ion Fatigue as described by Stamm ( 20 10). Assumptions of homogeneity of variance and equality of Covariance were held as The results of data with missing values indicate d that the model does not significantly predic t an effect for Deployment status F( 2 61 ) = 0.607 p > 0.05 ), Compassion

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39 61) = 2.202, p > 0.05) (see Table 11). This model had a sample of 66 out of 101, which is 65.3% of the total collected data. None of the interactions were significant and so were not included in the model. Hypothesis 2 Hypothesis 2 stated that t here would be a relationsh i p between Compassion Fatigue Training (present or not present) and Deployment status (either pre or post deployed) on the level of Compassion Satisfaction An analysis of covariance ( ANCOVA) was used to examine these effects in order to al low for greater power, sensitivity, and accuracy for the small sample size as well as accounting for and reducing the error variance (Fie ld, 2009). With the inclusion of Trauma History as a covariate, t he results of data with missing values indicate d that the model does not significantly predict any effects for Deployment status (either pre or post deployed) ( F( 1 62 ) = 3.519 p = 0.0 654) or Compassion Fatigue Training (present or not present) ( F( 1 62 ) = 3.433 p = 0.0 687) (see Table 15). This model included 66 participants, providing 65.3% of the total collected sample. Hypothesis 3 Hypothesis 3 stated that t here would be a relationsh i p between Compassion Fatigue Training (present or not present), Profession Group membership, and Deployment status (either pr e or post deployed) on the level of Compassion Satisfaction With the inclusion of Trauma History as a covariate, t he results of the ANCOVA indicate d that Compassion Satisfaction significantly differed on the nature of Deployment status (pre or post) ( F( 1 59 ) = 4.546 p < 0.05 2 = 0.0018). Deployment status accounted for 0.18% of variance in Compassion Satisfaction. Compassion

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40 Satisfaction significantly differs on Compassion Fatigue Training ( F( 1 59 ) = 6.3697 p < 0.05 2 = 0.0025). Compassion Fatigue Training accounted for 0.25% of variance in Compassion Satisfaction. Compassion Satisfaction significantly differs on the profession of the participants ( F( 2 59 ) = 3.473 p < 0.05 2 = 0.0028). Profession of participants accounted for 0.28% of variance in Compassion Satisfaction (see Table 17). The post hoc test identified that individuals who were post deployment had higher compassion satisfaction scores than those that had never been deployed at all (M post M pre = 1.955, SE = 0.917, p < 0.05). Participan ts that had Compassion Fatigue Training had higher Compassion Satisfaction scores than those without training (M CFtrain M NoCFtrain = 2.221, SE = 0.880, p < 0.05). Children and Victim Advocates had significantly higher compassion satisfaction scores than th ose in the Other Professions group (M 2 M 3 = 2.745, SE = 1.045, p < 0.05), but were not significantly different than Mental Health professionals (M 2 M 1 = 1.361, SE = 1.062, p > 0.05). The Mental Health professionals were not significantly different from the Other Professions category either (M 1 M 3 = 1.384, SE = 1.138, p > 0.05). This is possibly due to small effect size and small sample sizes within the cells. Trauma History accounted for 0.17% of variance in Compassion Satisfaction and showed a negative re lationship with the dependent variable. None of the interactions were significant and so were not included in the regression slopes was also held as shown by interaction graphs. Thi s m odel included 65 participants, providing 64.4% of the total collected data. The MANCOVA for Question and Hypothesis 1 did not yield any significance, nor did the ANCOVA for Question and Hypothesis 2. The overall results of the study only

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41 showed signifi cance in Question and Hypothesis 3. The post hoc for this question yielded the finding that individuals who were post deployment had higher compassion satisfaction scores than those that had never been deployed at all. The significance of these results an d further recommendations will be discussed in the section to follow.

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42 Table 4 2. Gender Gender Frequencies Percentage Missing Female 73 72.28 Male 9 8.91 Total 82 19 Table 4 3. Race and e thnicity Ethnicity Frequencies Percentage Missing White 67 66.34 Black 7 6.93 Hispanic/Latino 6 5.94 Multicultural 3 2.97 Total 83 18 Table 4 4. Profession Profession N Frequencies Percentage Missing Mental Health Professionals Counselor 19 5 3 2 29 28.7 Psychologist Nurse Social Worker Advocates Victim Advocate 34 2 36 35.6 Child Advocate Other Professions Law Enforcement 10 20 30 29.7 Other Total 95 6 Table 4 5. C ompassion Fatigue e ducation Compassion Fatigue Education N Frequencies Percentage Missing No Training N one 31 30.69 Any Training College 8 50 49.5 Master's 15 Doctoral 6 Other Relief Organization 32 Independent Training 13 Total 81 20 Table 4 1. Age N Non Answers Min Max Mean Age 73 28 29 69 50.575

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43 Table 4 6. Education l evel Education Level Frequencies Percentage Missing High School 5 4.95 Associate's Degree 7 6.931 College Degree 27 26.73 Master's Degree 29 28.71 Doctorate or Prof. Degree 13 12.87 Other 1 0.99 Total 82 19 Table 4 7. Descriptive f requencies for d eployment l ength Deployment Length N Non Answers Min Max Mean SD S hortest D eployment 65 36 0 10 1.231 1.529 L ongest D eployment 64 37 0 180 8.813 24.629 Table 4 8. Descriptive f requencies for c ategorical i ndividual v ariables Deployment Region Frequencies Percentage Missing Local 37 36.63 Florida 32 31.68 National 4 3.96 Total 73 28 Table 4 9. Deployment s tatus Frequencies Percentages Missing Deployment Status Pre (never been deployed) 23 22.77 Post (has been deployed) 51 50.50 Total 74 27 Table 4 10. Analysis of c ovariance t ests with CS (Dataset with missing data) Independent Variable Sum Sq Df F value Pr(>F) (Intercept) 27783.3 1 2433.66 < 2e 16** Deployment Status(pre/post) 51.89 1 4.546 0.037** 0.0018 Compassion Fatigue Training 72.72 1 6.370 0.014** 0.0025 Reduced Professional Groups 79.29 2 3.473 0.038** 0.0028 Trauma History 49.63 1 4.347 0.041** 0.0017 Residuals 673.56 59 Corrected Total 28710.39 64 ** p < .05

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44 CHAPTER 5 DISCUSSION Significance Of Findings Results of this study showed that Compassion Fatigue education was a significant predictor of having higher levels of Compassion Satisfaction and that a lack of Compassion Fatigue education could predict higher levels of Compassion Fatigue. These results Compassion Satisfaction are on a spectrum in which the higher the CS, the lower CF will be (Stamm, 2002). These results suggest a reduction of Compassion Fatigue risk and that, with CF e ducation, people are finding their disaster response work to be more fulfilling, satisfying, and sustaining. A primary purpose of this study was to seek out ways to improve the sustainability of disaster response counselors. The results of this study su ggest that Compassion Fatigue education, by improving Compassion Satisfaction, reduces Compassion Fatigue. In knowing that CF education protects disaster response counselors, it is important for the further implementation of CF education in both formal an d informal training to enhance the sustainability and well being of responders. By implementing this training for graduate students in CACREP programs as well as informally through workshops for responders prior to deployment, responders will be more like ly to be sustained, happy, and useful. act a protective and sustaining factor for responders, while simultaneously increasing the levels of Compassion Satisfaction for respon ders and reducing their Compassion Fatigue levels following their deployment. The significance of this relationship suggests

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45 the need for further education on Compassion Fatigue at various levels prior to responder deployment. There are many professionals who work in disaster response beyond just mental health disaster responders. For these individuals, whether nurses, victim, advocates, or law enforcement members, these results are important as well. Compassion Fatigue training can act as a sustaining a nd protective factor for these individuals too and should be a part of their training and preparation just the same as for mental health counselors. Any profession working in disaster response could benefit from including CF training as part of the disast er response preparation and training. Increased exposure to trauma was related to a decrease in Compassion Satisfaction, but this study was unable to ascertain whether the trauma exposure was witnessed or experienced. The Stressful Life Experiences Short Form did not delineate between whether the participant directly experienced the trauma or if they were a witness to it. Recommendations for Counselors The results of this study suggest that Compassion Fatigue education needs to be implemented much more sys tematically to provide for more prepared professionals with decreased risk of Compassion Fatigue. Current disaster response training can be broken down into formal and informal training, with formal preparation taking place at the academic or institutiona l level and informal preparation taking place at the organizational level prior to deployment for responders. Compassion Fatigue education needs to be more thoroughly integrated into these systems to better prepare and protect responders. CACREP institut ions that already have disaster response training requirements for their curricula can improve their Compassion Fatigue education in

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46 several ways. Rather than just briefly mentioning Compassion Fatigue during a disaster response lecture, CF education coul d be given an entire lesson. If this were done throughout the entire curriculum, with one lesson per course, the students prepared by CACREP programs would graduate with an incredible level of preparation for disaster response work. Additionally, trainin g on Compassion Fatigue could be modeled after the Culture Center model (Goodman & West Olatunji, 2009 a ). By giving students the opportunity to put their CF education and disaster response training into practice prior to graduation and deployment, CACREP programs could produce more graduates prepared to be disaster responders with reduced Compassion Fatigue risk. The goal of having CACREP institutions implement all of this training is to provide training for counselors that would exceed that of informal r esponder preparation. Programs not affiliated with CACREP could adopt a similar approach to their curricula as the CACREP programs, by implementing required Compassion Fatigue training and education that would prepare future responders to be able to respo nd effectively across the world. Another recommendation would be for additional certifications on Compassion Fatigue that are more advanced and rigorous than the trainings already available. An online or in person training program for disaster mental heal th responders would provide more advanced training on Compassion Fatigue for any individual looking to be a better prepared responder. The goal of this training would be to provide a more thorough and advanced level of preparation than what is already off ered by preparation organizations. Having multiple courses that culminate in the awarded certification could provide a greater depth and understanding of Compassion Fatigue than what one might receive from some of the training organizations.

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47 Informal tra ining for groups or organizations about to deploy should always include some form of Compassion Fatigue training. Even if it is limited to a one hour workshop on Compassion Fatigue education and prevention, it would still provide a measure of protection f or the responders prior to deployment. The results of this study suggest that Compassion Fatigue education has a significant relationship with higher levels of Compassion Satisfaction. It then would follow that informal trainings should include CF educat ion in order to better prepare responders. If a simple workshop on Compassion Fatigue can increase the likelihood of high Compassion Satisfaction and subsequently lowered risk of Compassion Fatigue, it absolutely should be considered an integral part of t he training process. Future Research One of the greatest difficulties of this study was finding an instrument that could effectively evaluate Compassion Fatigue levels. The Professional Quality of Life Scale is a useful instrument, but it is also the only instrument. Future research should focus on developing new instruments to measure Compassion Fatigue and Compassion Satisfaction. Further development of the Compassion Fatigue and Satisfaction constructs could allow for assessment instruments that could give a clearly defined score for Compassion Fatigue or Satisfaction. The current framework of measuring Compassion Fatigue requires it to be broken down into Secondary Traumatic Stress and Burnout sub scores. New constructs for Compassion Fatigue and Sa tisfaction could eliminate this breakdown, thus allowing for greater focus on Compassion Fatigue rather than vague components that may overlap to contribute to Compassion Fatigue. A clear construct for Compassion Fatigue would give more credibility and de finition to the concept of CF, rather than having to rely on related concepts for which there is no

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48 clear delineation how or if they overlap to contribute to Compassion Fatigue. Further research into a Compassion Fatigue instrument could allow for better assessment of CF levels. This advantage is essential for two reasons. First it would allow for better evaluation of those individuals who are at risk of developing Compassion Fatigue. Second, it would allow for more specific research to be developed in a dvancing knowledge about Compassion Fatigue. An instrument that evaluates Compassion Fatigue in its own right would give more credibility to the existence of Compassion Fatigue and would be invaluable in advancing research about Compassion Fatigue. Furth er research into a new instrument for measuring Compassion Fatigue and Compassion Satisfaction is essential and could further advance what is already known about Compassion Fatigue. Further research should also investigate the relationship between length o f deployment, type of deployment, exposure to trauma (personal), and exposure to trauma (vicarious). This additional research could advance understanding about how these specific variables may impact levels of Compassion Fatigue and Compassion Satisfactio n in disaster response mental health workers. It is also recommended that there be repeated measures to determine factors that make disaster responders at risk for compassion fatigue. Knowing these primary risk factors could help responders, supervisors, and response organizations to identify, remove, or control for the risk factors.

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49 APPENDIX A INSTITUTIONAL REVIEW BOARD DOCUMENTS

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52 APPENDIX B STRESSFUL LIFE EXPER IENCES SCREENING SHORT FORM We are interested in learning about your experiences. Below is a list of experiences that some people have found stressful. Please fill in the number that best represents how much of the following statements describe your experiences. If you are not sure of your answer, just give us your best guess. Describes your Experiences (use in Describes Experiences Column) 1 2 3 4 5 6 7 8 9 10 I did not A little somewhat like exactly like exp. like my exp. my experiences my experiences Describes Experience Life Experience I have witnessed or experienced a natural disaster; like a hurricane or earthquake. I have witnessed or experienced a human made disaster like a plane crash or industrial disaster. I have witnessed or experienced a serious accident or injury. I have witnessed or experienced chemical or radiation exposure happening to me, a close friend or a family member. I have witnessed or experienced a life threatening illness happening to me, a close friend or a family member. I have witnessed or experienced the death of my spouse or child. I have witnessed or experienced the death of a close friend or family member (other than my spouse or child). I or a close friend or family member has been kidnapped or taken hostage. I or a c lose friend or family member has been the victim of a terrorist attack or torture. I have been involve din combat or a war or lived in a war affected area. I have seen or handled dead bodies other than at a funeral. I have felt responsible for the serious injury or death of another person. I have witnessed or been attacked with a weapon other than in combat or family setting. As a child/teen I was hit, spanked, choked or pushed hard enough to cause injury. As an adult, I was hit, choked or pus hed hard enough to cause injury. As an adult or child, I have witnessed someone else being choked, hit, spanked, or pushed hard enough to cause injury. As a child/teen I was forced to have unwanted sexual contact. As an adult I was forced to have unwanted sexual contact. As a child or adult I have witnessed someone else being forced to have unwanted sexual contact. I have witnessed or experienced an extremely stressful event not already mentioned. Please explain: B. Hudnall Stamm Traumatic S t ress Research Group, 1996, 1997 http://www.isu.edu/~bhstamm/ index.htm This form may be freely copied as long as (a) authors are credited, (b) no changes are made, & (c) it is not sold.

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53 APPENDIX C PROFESSIONAL QUALITY OF LIFE SCALE, VERSI ON 5 B. Hudnall Stamm, 2009. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). /www.isu.edu/~bhstamm or www.proqol.org. This test may be freely copied as long as (a) author is credited, (b) no changes are made, and (c) it is n ot sold. 1 PROFESSIONAL QUALITY OF LIFE SCALE (PROQOL) COMPASSION SATISFACTION AND COMPASSION FATIGUE (PROQOL) VERSION 5 (2009) When you [help] people you have direct contact with their lives. As you may have found, your compassion for those you [help] can affect you in positive and negative ways. Below are some questions about your experiences, both positive and negative, as a [helper] Consider each of the following questions about you and your current work situation. Select the number that ho nestly reflects how frequently you experienced these things in the last 30 days 1=Never 2=Rarely 3=Sometimes 4=Often 5=Very Often 1. I am happy. 2. I am preoccupied with more than one person I [help] 3. I get satisfaction from being able to [help] people. 4. I feel connected to others. 5. I jump or am startled by unexpected sounds. 6. I feel invigorated after working with those I [help] 7. I find it difficult to separate my personal life from my life as a [helper] 8. I am not as productive at work because I am losing sleep over traumatic experiences of a person I [help] 9. I think that I might have been affected by the traumatic stress of those I [help] 10. I feel trapped by my job as a [helper] 11. Because of my [helping] I have felt "on edge" about various things. 12. I like my work as a [helper] 13. I feel depressed because of the traumatic experiences of the people I [help]. 14. I feel as though I am experiencing the trauma of someone I have [helped] 15. I have beliefs that sustain me. 16. I am pleased with how I am able to keep up with [helping] techniques and protocols. 17. I am the person I always wanted to be. 18. My work makes me feel satisfied. 19. I feel worn out because of my work as a [helper]. 20. I have happy thoughts and feelings about those I [help] and how I could help them. 21. I feel overwhelmed because my case [work] load seems endless. 22. I believe I can make a difference through my work. 23. I avoid certain activities or situations because they remind me of frightening experiences of the people I [help] 24. I am proud of what I can do to [help] 25. As a result of my [helping] I have intrusive, frightening thoughts. 26. I feel "bogged down" by the system. 27. I have thoughts that I am a "success" as a [helper] 28. I can't recall important parts of my work with trauma victims. 29. I am a very caring person. 30. I am happy that I chose to do this work.

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54 APPENDIX D DEMOGRAPHIC QUESTION S 1. What is your current profession? Counselor Psychologist Nurse Nurse Practitioner Medical doctor Psychiatrist Other (Please Specify in 30 characters or less) 2. What is the highest level of education you have obtained? High School Diploma College Degree Doctorate or other Professional Degree Other (Please Specify) 3. What is your date of birth? (MM/DD/YYY Y) 4. What is your gender? Female Male Other (Please Specify) 5. By what ethnicity do you identify yourself? Asian Pacific Islander Black Hispanic Native American White Other (Please Specify) 6. As an FCRT member, where have the majority of your deployments been? Local (near where you live) Within Florida National

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55 7. Have you had additional training on Compassion Fatigue outside of FCRT training and if so at what level? (Check all that apply) No College Doctoral or other Professi onal Program Other relief or assistance organization Independent Research 8. How many times have you been deployed for the FCRT? (Approximate Number of Times) 9. How long was your longest deployment? (# Months, # Weeks, # Days) 10. How long was your short est deployment? (# Months, # Weeks, # Days)

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56 LIST OF REFERENCES Adams, R. E., Boscarino, J. A., & Figley, C. R. (2006). Compassion fatigue and psychological distress among social workers: A validation study. American Journal of Orthopsychiatry, 76 (1), 103 108. doi:10.1037/0002 9432.76.1.103 Adams, R. E., Figley, C. R., & Boscarino, J. A. (2008). The compassion fatigue scale: Its use with social workers following urban disaster. Research on Social Work Practice, 18 (3), 238 250. doi:10.1177/104973150 7310190 American Red Cross. (n.d.). Emergency services Retrieved from http://www.redcrossncfc.org/prep.htm Arthur, N. M. (1990). The assessment of burnout: A review of three inventories useful for researc h and counseling. Journal of Counseling & Development, 69 (2), 186. Boscarino, J. A., Figley, C. R., & Adams, R. E. (2004). Compassion fatigue following the september 11 terrorist attacks: A study of secondary trauma among new york city social workers. International Journal of Emergency Mental Health, 6 (2), 57 66. Bride, B., Radey, M., & Figley, C. (2007). Measuring compassion fatigue. Clinical Social Work Journal, 35 (3), 155 163. doi:10.1007/s10615 007 0091 7 Campbell, L. (2007). Utilizing compassion f atigue education in hurricanes ivan and katrina. Clinical Social Work Journal, 35 (3), 165 171. doi:10.1007/s10615 007 0088 2 quality of life: The protective role of sense of community, efficacy beliefs and coping strategies. Social Indicators Research, 94 (3), 449 463. doi:10.1007/s11205 009 9441 x Clukey, L. (2010). Transformative experiences for hurricanes katrina and rita disaster volunteers. Disasters, 34 (3), 644 656. d oi:10.1111/j.1467 7717.2010.01162.x Corey Souza, P. (2007). Compassion fatigue in members of the florida crisis response team: A consequence of caring. ProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engi neering, 68 (4 ). (2007 99200 084) Council for Accreditation of Counseling and Related Educational Programs (CACREP). (2009). CACREP 2009 Standards Retrieved from http://www.cacrep .org/doc/2009%20Standards%20with%20cover.pdf Craig, C. D., & Sprang, G. (2010). Compassion satisfaction, compassion fatigue, and burnout in a national sample of trauma treatment therapists. Anxiety, Stress & Coping, 23 (3), 319 339. doi:10.1080/106158009030 85818

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57 Creamer, T. L., & Liddle, B. J. (2005). Secondary traumatic stress among disaster mental health workers responding to the september 11 attacks. Journal of Traumatic Stress, 18 (1), 89 96. Devilly, G. J., Wright, R., & Varker, T. (2009). Vicarious tr auma, secondary traumatic stress or simply burnout? effect of trauma therapy on mental health professionals. Australian & New Zealand Journal of Psychiatry, 43 (4), 373 385. doi:10.1080/00048670902721079 Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: and overview New York, NY: Bruner/ Mazel, Inc.. Figley, C. R. (2002). Compassion fatigue: Psychotherapists' chronic lack of self care[SUP 1]. Journal of Clinical Psychology, 58 (11), 1433 1441. Figley, C. R., & Kleber, R. J.. B Kleber, R., Figley, C., & Gersons, P., eds. Beyond Trauma: cultural and societal dynamics. New York: Plemum Press, 1995: 75 98. Gentry, J. E., Baranowsky, A. B., & Dunning, K. (2002). The accelerated r ecovery program (ARP) for compassion fatigue. In C. R. Figley (Ed.), Treating compassion fatigue. (pp. 123 137). New York, NY US: Brunner Routledge. Goodman, R. D., & West Olatunji, C. A. (2009 a ). Engaging students in outreach as an extension of advocacy t o achieve praxis. Journal for Civic Commitment 12. Retrieved from http://www.mc.maricopa.edu/other/engagement/Journal/Issue12/Goodman.shtml Goodman, R. D., & West Olat unji, C. (2009 b ). Applying critical consciousness: Culturally competent disaster response outcomes. Journal of Counseling & Development, 87 (4), 458 465. Green Cross Academy of Traumatology. (n.d.). Green cross academy of traumatology Retrieved from http://www.greencross.org/ Jacobson, J. M. (2006). Compassion fatigue, compassion satisfaction, and burnout: Reactions among employee assistance professionals providing workplace crisis intervention and disaster managemen t services. Journal of Workplace Behavioral Health, 21 (3), 133 152. doi:10.1300/J490v21n03_08 Kennedy, A. (2006, July). When disaster strikes. Counseling Today, 49:1 6. Lambie, G. W. (2006). Burnout prevention: A humanistic perspective and structured group supervision activity. Journal of Humanistic Counseling, Education & Development, 45 (1), 32 44.

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58 Leonard, L. G. (2008). Trauma therapists' quality of life [electronic resource] : The impact of individual and workplace factors on compassion fatigue and compassion satisfaction Gainesville, Fla.: University of Florida. Maslach, C., & Jackson, S. E. (1980). The measurement of experienced burnout. Journal of Organizational Behavior, 2 (2), 99 113. doi: 10.1002/job.4030020205 Meadors, P., Lamson, A., Swanson M., White, M., & Sira, N. (2009). Secondary traumatization in pediatric healthcare providers: Compassion fatigue, burnout, and secondary traumatic stress. Omega: Journal of Death & Dying, 60 (2), 103 128. doi:10.2190/OM.60.2.a Meir, S. T. (1983). Toward a theory of burnout. Human Relations, 6 899 910. doi: 10.1177/001872678303601003 Moore, A. L. (2004). Compassion fatigue, somatization, and trauma history: A study of disaster mental health professionals after the oklahoma bombing. ProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 65 (5 ). (2004 99022 254) Nelson, T., Johnson, S., & Bebbington, P. (2009). Satisfaction and burnout among staff of crisis resolution, assertive outreach and communit y mental health teams. Social Psychiatry & Psychiatric Epidemiology, 44 (7), 541 549. doi:10.1007/s00127 008 0480 4 National Organization for Victim Assistance. (2010). Retrieved from http://www.trynova.org/crt/ Ofman, P. S., Ma stria, M. A., & Steinberg, J. (1995). Mental health response to terrorism: The world trade center bombing. Journal of Mental Health Counseling, 17 (3), 312 320. Osborn, C. J. (2004). Seven salutary suggestions for counselor stamina. Journal of Counseling & Development, 82 (3), 319 328. Pearlman, L. & Saakvitne, K. Trauma and the therapist. New York: W. W. Norton, 1995 Phelps, A., Lloyd, D., Creamer, M., & Forbes, D. (2009). Caring for careers in the aftermath of trauma. Journal of Aggression, Maltreatment & Trauma, 18 (3), 313 330. doi:10.1080/10926770902835899 Prati, G., Pietrantoni, L., & Cicognani, E. (2010). Self efficacy moderates the relationship between stress appraisal and quality of life among rescue workers. Anxiety, Stress & Coping, 23 (4), 463 470. doi:10.1080/10615800903431699

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59 Rothschild, B. & Rand, M. (2006). Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma. New York, NY: W. W. Norton & Company. Ruzek, J. I., Brymer, M. J., Jacobs, A. K., Layne, C. M., Vernber g, E. M., & Watson, P. J. (2007). Psychological first aid. Journal of Mental Health Counseling, 29 (1), 17 49. Sabin Farrell, R., & Turpin, G. (2003). Vicarious traumatization: Implications for the mental health of health workers? Clinical Psychology Review, 23 (3), 449. doi:10.1016/S0272 7358(03)00030 8 Sang, M. L., Baker, C. R., Cho, S. H., Heckathorn, D. E., Holland, M. W., Newgent, R. A., Ogle, N. T., Powell, M. L., Quinn, J. J., Wallace, S. L., & Yu, K. (2007). Development and initial psychometrics of the counselor burnout inventory. Measurement & Evaluation in Counseling & Development (American Counseling Association), 40 (3), 142 154. Sang, M. L., Cho, S. H., Kissinger, D., & Ogle, N. T. (2010). A typology of burnout in professional counselors. Jo urnal of Counseling & Development, 88 (2), 131 138. Sprang, G., Clark, J. J., & Whitt Woosley, A. (2007). Compassion fatigue, compassion satisfaction, and burnout: Factors impacting a professional's quality of life. Journal of Loss & Trauma, 12 (3), 259 280 doi:10.1080/15325020701238093 Stamm, B.H. (1997). Stressful Life Experiences Screening Short Form Idaho State University: Sidran Press. Stamm, B. H. (2002). Measuring compassion satisfaction as well as fatigue: Developmental history of the compassion satisfaction and fatigue test. In C. R. Figley (Ed.), Treating compassion fatigue. (pp. 107 119). New York, NY US: Brunner Routledge. Stamm, B. H. (2005). The ProQOL Manual: The Professional Quality of Life Scale: Compassion satisfaction, burnout & compas sion fatigue/secondary trauma scales Baltimore, MD: Sidran Press. Stamm, B. H. (2009). The concise ProQOL manual Baltimore, MD: Sidran Press. Stamm, B.H. (2010). The c oncise ProQOL m anual (2nd ed.). Retrieved from ProQOL.org website: http://proqol.org/up loads/ProQOL_Concise_2ndEd_12 2010.pdf Tehrani, N. (2007). The cost of caring the impact of secondary trauma on assumptions, values and beliefs. Counselling Psychology Quarterly, 20 (4), 325 339. doi:10.1080/09515070701690069

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60 Tehrani, N. (2010). Compassion fatigue: Experiences in occupational health, human resources, counselling and police. Occupational Medicine, 60 (2), 133 138. Uhernik, J. A. (2008). The counselor and the disaster response team: An emerging role. In R. K. Yep (Ed.), Compelling counseling interventions: Celebrating VISTAS' fifth anniversary. (pp. 313 321). Alexandria, VA Ann Arbor, MI US: American Counseling Association; Counseling Outfitters. Ulman, K. H. (2008). Helping the helpers: Groups as an antidote to the isolation of mental health disaster response workers. Group, 32 (3), 209 221.

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61 BIOGRAPHICAL SKETCH Steven Vutsinas is a native of Nashville, Tennessee. He obtained his Bachelor of Science degree in Family, Youth, and Community Science with a minor in Organizational Leadershi p for Non Profits, as well as a Bachelor of Arts in Classical Studies from the University of Florida. Steven received his Master of Arts in Education from the University of Florida in the summer of 2011.