She lay dead in her room with her panties around her neck. The police are unsure whether it was a suicide or foul play. Years of mental illness had taken a toll.

Cindy, a 42- year old- social worker, contacted me for counseling because her client's death was giving her nightmares and causing her extreme distress. As her caseworker, she had received several non- urgent requests from this client who always acted as if she was in crisis. Cindy also told me that this was the eleventh death she had experienced in her community mental health job in seven years. I was puzzled as to why she never sought counseling till now. However, like many who work in a helping role with traumatized populations, Cindy had to reach a desperate point before seeking help.

It was obvious to me that Cindy's visual flashbacks of her client lying dead on the bed, in her nightmares and waking state, were symptoms of vicarious trauma. Also referred to as vicarious trauma, compassion fatigue is a particular form of burnout that results from exposure to your client's painful stories. In addition to regular burnout symptoms you can get symptoms associated with post-traumatic stress such as hyper arousal, excessive numbing and intrusive images of your client's traumatic stories. You don't have to be a counselor or work with disturbed clients to get  compassion fatigue. Anyone in a helping role is vulnerable.

Prevention is often the best cure. Having clear boundaries. making time for exercise, good nutrition and nurturing activities can help counteract the negative effects of stress. Cindy's self-care habits were not that great. She was unaccustomed to thinking about her day to day personal needs. She got by financially, rarely exercised or thought about her health. She sought emotional support from friends or a therapist only when life became really bad. Although Cindy had been suffering from stress for so many years that she experienced it as normal. This particular incident triggered the stress that had been present for years and building which finally broke through in a dramatic way. For years she felt drained, but things weren't dire enough for her to notice the toll her work was taking on her health, relationships and quality of life. Dealing with the continual strain of working with troubling client situations was familiar. This was due partly to the fact that she had become numb to her feelings through busyness or other compulsive behaviors. This particular incident triggered the stress that had been present and building for a long time, and finally broke through in a dramatic way.

Many helpers just don't believe that exposure to other people's trauma can significantly impact them. Those who are exposed to negativity and suffering often lose touch with their own feelings and personal needs. Their exposure to painful stories and traumas often increases vulnerability to compassion fatigue. People who are drawn to mental health work are often predisposed to set aside their own needs. Judith Herman (1992) has written that repeated exposure to people's suffering and troubling stories diminishes the helper's trust in humanity and often leads to a heightened sense of vulnerability. Pearlman's (1995) long-term study on vicarious trauma and mental health professionals discussed how their schemas about safety and trust eroded over the years of being exposed to their patient's painful stories.

I knew that if I could help Cindy take better care of herself, this could alleviate her immediate PTSD symptoms. De-escalating the immediate crisis and her symptoms was my first priority, along with addressing her need for a greater sense of feeling safe. Cindy's post- traumatic stress symptoms may have been alleviated by helpful techniques like EMDR. She also needed to take time away from work, be with supportive friends, and go for walks on the beach. Focusing on self-care prescriptions is helpful to a point.

Some approaches to preventing and counteracting burnout and vicarious trauma focus on changing workplace policies. Stamm (1995) and Maschlach (1997) have emphasized the need to change workplace attitudes to prevent susceptibility to burnout. They advocate rewarding employees' efforts, using meeting time to speak about the impact of their work, monitoring staff shortages, having flexible hours and a more balanced caseload that is equally distributed among staff. While making changes to workplace policies is very important, it is often difficult. There are also some people who are more resilient than others even though they have the same external pressures and conditions. In my view, none of these strategies goes far enough. What is often overlooked is the crucial task of addressing the emotional dynamics and fixed identities that limit attention to self-care and underlie susceptibility to burnout and compassion fatigue. If underlying issues like difficulty relinquishing control are not addressed, then mindfulness and relaxation techniques may not be effective.

People in helping roles, and particularly mental health professionals, need to understand and address what causes them to give too much and overlook their own needs. For many helpers, attending to others needs often becomes their primary source of worth and identity. This sets the stage for taking on people's problems and failing to keep an adequate distance from clients. The helpers become more susceptible to vicarious trauma and burnout.

Cindy's identity was based on the good she does for others. Growing up being valued primarily for her helpfulness as the "good one" formed her identity. Cindy grew up being valued primarily for her helpfulness. She had narcissistic parents who expected her to attend to their needs. Her mother would become very cold whenever Cindy make a mistake or didn't go along with her terms. Cindy learned that disappointing them meant she was bad, which caused her to experience guilt and feel shame. She also developed an exaggerated sense of responsibility. It became difficult for her to recognize her worth independent of how others perceived her.

As an adult, Cindy continues to feel it is wrong for her to let someone down who depends on her. This plays out in her relationship to friends and boyfriends. She needs to be needed and thus she attends to others' needs while putting her own needs last. Cindy's reactions to her client's death were also due partly to intense guilt. Although she knew logically that the incident was not her fault, Cindy couldn't stop thinking about what she should have or could have done to prevent her client's death. At work she felt "it is all up to me" and if anything goes wrong "it is my fault". When her client died, she blamed herself. Her feelings of failure triggered the old story from her family. She was "bad" for letting people down, for not being able to fix a problem and for not being perfect.

Being focused on others increases susceptibility to compassion fatigue and burnout. It causes you to overlook your limits and needs. For Cindy, it manifested as a need for validation and acceptance in order to feel her worth. She also defined herself by how much she gave to others. Her need for external validation fed into her tendency to put others' needs before her own needs.

Helpers can build resiliency and become more willing to care for themselves when they shift from being directed externally to becoming more self-referential. Being self- referential has nothing to do with selfishness or narcissism. Ironically, it increases your effectiveness in helping others. When you are self-referenced you have a heightened awareness of your feelings and body sensations. You are present with your internal world and this increases your capacity to self-regulate and self-soothe.

Cindy became more self-referenced by measuring her value according to her own criteria rather than by others' views of her. She also identified and challenged the survival strategies that she learned growing up in her family. Cindy recognized the core assumption that was fueling her external focus. She came to recognize the core assumption that was fueling her external focus: "If I am not helpful to others I am worthless".

It is human to develop strategies in response to threats that were real at one time. Had Cindy not been so helpful with her family she would have faced disapproval and withholding of love. In adult life the mind continues to believe these threats are true  because they have been translated, usually unconsciously, into core assumptions. These core assumptions then become implicit in our actions, acted out, rather than being internalized as beliefs.

Life improved for Cindy when she became more connected to her own needs and less focused on attending to the needs of others. She also began to value her own intrinsic qualities that were unrelated to helping others. Cindy recognized that her parents' expectations were unfair and that letting people down didn't make her less worthy. She also stopped feeling guilty about paying more attention to her needs. She became more attuned to her inner signals and began listening to feelings and physical sensations that tell her it is time to slow down or reach out for support.

Understanding the roles and strategies you employed in your family is one of the best ways to discover and change the underlying psychological factors that perpetuate burnout and make you susceptible to compassion fatigue. For example, are you re-creating familiar roles from your upbringing that impact your work style? In addition to early family dynamics, what cultural and gender influences play a role in shaping personality. Girls are taught to be nurturers. A nurse who was dealing with codependency issues traced her helping style to learning in church to give until it hurts. .

To break out of fixed identities and better understand how your upbringing relates to your work style ask yourself the following questions:

1. Did your family look to you to provide emotional stability or be a stabilizing influence? Perhaps you were in the role of peacekeeper and became good at putting out fires? Were you the "responsible one" in your family? Did you feel responsible for the well being of a family member? When you were living with your parents, did either of them look to you for answers or were you in a caretaker role to a family member? How much permission do you give yourself to be irresponsible, impractical or incompetent? How much tolerance do you have for your being undependable, impractical, irresponsible? For example, at times when you have not completed an assignment or you have fallen behind in your work, how did you feel about yourself? Charles Figley (1995) has linked compassion fatigue to an inability to let go. If you have an exaggerated sense of responsibility, letting go and maintaining healthy detachment with clients may be difficult. You may feel compelled to fix and rescue, and you may have difficulty tolerating lack of resolution.

2. What were your parents' spoken and unspoken expectations of you? How do you typically feel about yourself when you do not measure up to your expectations? If parental expectations are too high, you can become self-critical and intolerant of your shortcomings. Developing realistic standards goes a long way in counteracting stress and burnout. When you are faced with your shortcomings do you feel defective or less worthy? What messages did you receive about being self-reliant and strong? How important is it that others view you as self-reliant and appearing as though you "have it all together"? Do you have difficulty relying on others or asking for support? Everyone agrees that a strong support network is crucial for preventing and healing burnout. Defining yourself by your strengths may get in the way of recognizing and asking for support.

3. What behaviors did your parents reward and encourage? As a little boy or girl, what did you do to be included and keep your parents' approval? Did you adopt particular behaviors growing up in order to conform to your parents' expectations, or because you figured out that it would get you attention or prevent unpleasant consequences?

4. How clear were the boundaries in your family? Clear boundaries enable you to set limits and be empathic without "taking on" other people's problems. One way your boundaries can become blurred is by serving as a confidante for a parent. Boundaries can also become blurred when a parent is intrusive, domineering or overly protective.

5. In the workplace, are you re-enacting roles from your early family experience? Arkowitz (1991) writes about therapists who master their disappointment about their early caretakers by becoming idealized caretakers to their clients.

6. Do you have a history of trauma? When working with people who have experienced trauma, Williams and Summers (1997) recommend that clinicians who have a history of trauma be intimately familiar with their own triggers, including early losses and deaths of significant others. They emphasize that being aware of how your history can become activated when working with clients can lessen vulnerability to compassion fatigue. They also stress the need for a strong foundation in all aspects of trauma theory.

It is crucial to identify and refute beliefs and fears that are based on outdated threats from the past. Cindy had been unaware that many of her responses were attempts to avoid outdated painful emotions or consequences. Focusing on the needs of others and feeling an exaggerated responsibility enabled her to ward off her parents' cold withdrawal and abandonment. She learned, however, that she no longer needed to respond this way to the world as an adult. Doing so had increased her stress and undermined her ability for self-care. Think about when you were younger. Picture yourself being less responsible or less helpful around your family. Perhaps you refuse to listen to your mother's problems or do fewer chores than asked of you. How would your parents respond? Would this lead to less attention at home, or more instability, disapproval, or punishment?

In this article I have emphasized the unique stresses and consequences associated with helping people who are in distress. My primary focus has been on psychodynamic issues from the past, especially those habits, beliefs and outdated survival strategies that make helpers more susceptible to burnout, compassion fatigue and self-neglect. My experience has taught me that addressing unresolved issues from family of origin greatly enhances our capacity to employ self-care strategies, both at work and outside of work.