Charles R. Figley, PhD

A most pronounced characteristic of the cases seen early in their illness is the profusion with which new symptoms appear and disappear. As time goes on, without treatment, a more stabilized syndrome crystallizes.

Those who have worked with combat veterans know that they are a group of patients who require a special degree of honesty and compassion. According to the US Census Bureau, there are 18.0 million veterans living in the United States, 17% of whom are women.2 In addition, at any given day, 1.4 million men and women serve on active duty, along with 718,000 civilian personnel. Another 1.1 million Americans serve in the 

. It is estimated that 7% of the US population has military experience, which is 

. Among post-9/11 veterans, 43% have a service-connected disability,

 perhaps related to the fact so few in modern society (less than 1%) serve in the all-volunteer military, requiring citizen-soldiers and their families to carry the burden.

Unfortunately, institutions charged with caring for veterans are often unhelpful. The Veteran’s Administration’s (VA) lack of transparency is a significant handicap for veterans and family members seeking treatment and explanations for their mental illnesses. Researchers, clinicians, and journalists are unable to find answers to important questions about the impact of war on veterans and their families. How many post-9/11 veterans have been diagnosed and/or treated for posttraumatic stress disorder (PTSD)? How many veterans have been diagnosed with any other mental health-related condition?

Statistics From the Veterans Administration

It is hard to say. The VA’s annual reports on Analysis of VA Health Care Utilization Among Operation Enduring Freedom (OEF), Operational Iraqi Freedom (OIF), and Operation New Dan (OND) Veterans, stopped being publicly available in 2016. Nevertheless, based on 2015 data, we can say that over a million post-9/11 veterans are using VA healthcare, and mental disorders are prevalent in this population (

 Aside from the fact the data are outdated, the data also captures only those veterans going to the VA. The VA does not keep track of those seeking counseling from the 360 veteran centers across the country

; nor those who seek help through the private sector; nor the largest subset of veterans and military personnel who suffer silently. Of course, there are multiple millions of family members and caregivers within the military population, those critical for the military veteran, are not covered for any services.

Differences in the Treatment of Military Versus Non-Military Populations

Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War

 we were asked to opine on what clinicians should know about treating military populations (

read an introduction to Dr Russell and Dr Figley’s book 

.). First and foremost, while it is true that war changes everyone, it is also a great disservice to assume that most or all citizen-soldiers who served in the military and/or deployed to war zones, are fatally damaged goods. Going to war often signifies both the best and worst of times for veterans. Military populations offer fertile ground for studies on resilience and posttraumatic growth (PTG) among specialties within the service branches.

On the flip side, it is important not to view evidence of resilience or PTG as indicating an absence of mental or physical health-related problems. Another potential mistake is to assume that current or former military personnel must have suffered war trauma, and that is the primary or sole issue that leads them to seek mental health services. In reality, the all-voluntary military faces a wide-range of potential traumatic stressors that are inherent occupational hazards including combat, training accidents, transportation accidents, terrorist attacks, military sexual trauma, victims of crime, natural disasters, humanitarian relief missions, peace-keeping missions, along with other common stressors in the civilian sector (ie, domestic violence, childhood abuse, motor vehicle accidents, betrayal trauma, racial trauma, etc). The wise clinician is alert to the fact that even if a service member is a combat veteran, their distress will likely be a combination of factors, not just a product of combat experiences.

Next, clinicians should be sensitive to a host of risk factors and trauma-related conditions that are not entirely unique to military populations. Like police, federal and state law enforcement, and related professions, combat veterans, may deal with 1) the psychological impact of killing or seeing others killed; 2) having been wounded-in-the line of duty; 3) exposure to the presence of traumatic grief and complicated bereavement of fellow officers or from the death of a loved one, including one’s combat buddies; 4) moral injury from participating or witnessing killings, legal or otherwise; 5) intense survivor guilt, 6) co-occurring traumatic brain injury or phantom limb pain in amputees; 7) posttraumatic anger and sense of betrayal trauma; 8) handling of human remains; 9) being a prisoner-of-war by war enemy, drug cartel, or a political party; 10) chronic pain conditions; 11) opioid misuse; and 12) secondary trauma and compassion fatigue.

Similarly, war has taught us time and again that human beings have manifest traumatic stress injuries. These injuries cross a spectrum of possible conditions, and that diagnosis like PTSD represents only a sliver of possible afflictions.

 Historically, war or other traumatic stress injuries are often divided into 2 broad classifications: 1) neuropsychiatric conditions that consists of the culturally accepted diagnostic labels of the day such as PTSD, mood disorders, anxiety disorders, psychotic disorders, impulse control disorders, substance use disorders, neurocognitive disorders, eating disorders, sexual disorders, personality disorders, and others, and 2) medically unexplained physical symptoms (MUPS) which include chronic fatigue, headaches, chronic pain, atypical cardiac symptoms, idiopathic seizures, autoimmune conditions, and others.

In the 21st century, the Department of Veterans Affairs 

, “such as chronic pain and fatigue, are common in the general and military veteran populations” and that “Chronic Fatigue Syndrome (CFS), Fibromyalgia (FM) and Irritable Bowel Syndrome (IBS) are among the most commonly diagnosed medically unexplained conditions.” However, there are far more potential MUPS diagnoses. These include noncardiac chest pain, pseudo seizures, multiple chemical sensitivity. Other studies on MUPS in the current war cohort indicate a high frequency of somatic complaints (

 Additionally, OEF/OIF veterans with and without a diagnosed mental health condition were treated in the VA for 222 types of MUPS.

As many clinicians are aware, somatic complaints are often considered a cultural idiom of distress.

 This is particularly true with military populations whereby stigma and fear of career reprisal can be so oppressive. The career-related stress makes it more likely to complain of headaches, back pain, and sleep problems as opposed to emotional symptoms.

Common Obstacles Military Populations Face to Receive Proper Mental Health Care

By far, the biggest obstacle that current and future military populations face regarding mental health care is the pattern of a sustained, self-inflicted mental health crises plaguing generations of Americans and society since World War I.

 These largely preventable catastrophes are caused primarily by chronic neglect and lack of accountability by the military and its government. Our most 

 noted 10 foundational lessons of war trauma identified by every military cohort since WWI. These lessons are essential to meeting the wartime mental health needs:

1) Recognizing that war inevitably causes large numbers of legitimate spectrum of war stress injury;

2) Adequate research, planning, and preparation are indispensable during both war and peace;

3) A large cadre of well-trained behavioral health specialists is compulsory during times of war and peace;

4) A holistic, public health approach to war stress injuries necessitates close collaboration with the private sector along with full mental health parity; 

5) Effective mental health services demand the empowered leadership of an independent, unified, organizational structure, a behavioral Health Corps, providing integrated, well-coordinated continuity of care equal to medical services;

6) Elimination of mental health stigma, barriers to care, and disparity should be a priority for leadership, as it directly affects individuals, families, and military readiness;

7) Ensure ready access to high-quality mental health services, including definitive care prior to military separation or discharge;

8) Families must receive adequate mental health and social support during and after military service;

9) Accurate, regular monitoring and reporting are crucial for timely, effective, management of mental health needs; and,

10) Robust dedicated mental health “lessons learned” policy and programs are integral to meeting present and future needs and prevent crises.

Despite being learned again at the end of every war, these lessons have not substantially improved veterans’ care. Perhaps the best evidence that little progress has been made comes from a Department of Defense (DOD) Task Force on Mental Health. In 2007 it identified

A single finding underpinning all others: The Military Health System lacks the fiscal resources and fully trained personal to fulfill its mission to support psychological health in PEACETIME or fulfill the enhanced requirements imposed during times of conflict (p. ES2).

The time for action is now. The human and financial costs of un-addressed problems will rise dramatically over time. Our nation learned this lesson, at a tragic cost, in the years following the Vietnam War. Fully investing in prevention, early intervention, and effective treatment are responsibilities incumbent upon us as we endeavor to fulfill our obligation to our military service members. 

This is a stirring plea for action, but the DOD offers no concrete proposal on where to start, or a sense of when we will know when it is enough. Without concrete proposals and ongoing commitment to investing in prevention, early intervention, and effective treatments, pleas like this one will remain empty.

Have we learned our lessons? More than 6 years into a shooting war, 99 urgent recommendations were made by the DOD task force, all reflecting neglect of the military’s well-documented centuries of “lessons learned.” The media, Congress, and Commander-in-Chiefs alike still have not met their responsibilities to investigate the reasons for gross negligence that harm countless members of the military population for this and future generations.

From our vantage point, the military is positioned in a unique leadership role within the broader society. It could inspire other leaders to step up, be accountable, and finally call for ending the stigma surrounding the mental health of its members. The question remains: why has the US government and its military refused to learn its war trauma lessons and what concrete actions are necessary to end the generational cycle of neglect and crises?

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service

is the Paul Henry Kurzweg, MD, Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

Those who served: America’s veterans from World War II to the War on Terror

. US Census Bureau, U.S. Department of Commerce. June 2020. Accessed September 15, 2021. 

Analysis of VA health care utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans, from 1st Qtr FY 2002 through 3rd Qtr FY 2015

 (October 1, 2001—June 30, 2015). June 2015. Accessed September 15, 2021. 

5. Russell MC, Figley CR. Generational wartime behavioral health crises: Part one of a preliminary analysis. 

6. Hoge CW, Terhakopian A, Castro CA, et al. 

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.

Medical care needs of returning veterans with PTSD: their other burden.

Idioms of distress among trauma survivors: subtypes and clinical utility.

9. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: Part two of a preliminary analysis. 

10. Russell MC, Figley CR, Robertson KR. Investigating the psychiatric lessons of war and pattern of preventable wartime behavioral health crises

. Journal of Psychology and Behavioral Science

11. Arthur D, MacDermid S, Kiley K, et al. 

An achievable vision: report of the Department of Defense Task Force on Mental Health

. Department of Defense Task Force on Mental Health. Defense Health Board. June 2007. Accessed September 15, 2021. 

Articles

What psychiatric illnesses are most prevalent among veterans? And how can clinicians help them overcome obstacles to care?  

Treatment of Military Populations

Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare.

The psychiatric casualties of war may be inevitable, but the way the military responds to them is not. Since the 19th century, numerous books have been written on the history of war trauma, and they have included 

 Too often, however, the United States it seems like the military has failed to learn the lessons of the previous war. Veterans’ mental health has suffered in the process, resulting in a generational cycle of largely 

Why has the American military’s health care system refused to learn the fundamental lessons of wartime trauma, and how can the system be improved? Based on decades of research, writing, and our lived experiences as active-duty service members and mental health clinicians, we have taken up these questions in 

 We offer concrete solutions that, if enacted, could propel the military as a lead social change agent in eliminating harmful mental health stigma and disparities.

. I can trace my interest in war trauma back to the second grade, when I was living on the Camp Pendleton Marine Base in Oceanside, California. It was 1968, the height of the Tet Offensive in Vietnam. My father was a career enlisted Marine, a combat veteran of the Korean war and currently serving in the Vietnam war.

I have vivid memories of a steady stream of classmates whose names were called over the loudspeaker and instructed to go to the nurse’s office to be met with what we could only assume was traumatic news. The visibly anguished teachers had us keep our heads down on our desks while the nervous students gathered their personal effects; they were met at the door by an entourage composed of the vice principal, school nurse, and the base chaplain. We never saw those classmates and friends again.

When I embarked on my enlisted Marine career in 1979, I witnessed firsthand the residual effects of trauma associated with military service during war and peacetime. As a young lance corporal, I was hospitalized with a surgically-repaired broken jaw, and I serendipitously read David S. Viscott, MD’s 

 It resonated with my childhood experiences and ignited my dream of becoming a military psychologist.

In 1989, I ended my enlisted career in pursuit of a doctorate degree in clinical psychology at the Pacific Graduate School of Psychology (now Palo Alto University). For my dissertation I interviewed hundreds of combat veterans from World War II, the Korean War, and the Vietnam War.

 In 1992, I fulfilled my dream by restarting a career as a Navy clinical psychologist in the aftermath of the Persian Gulf War.

In 2003, I was deployed as head of neuropsychiatry for Fleet Hospital Eight in Bremerton, Washington, in support of the Iraq War invasion. It was then that I was awakened to the military’s failed mental health policies. My naval officer career was cut short due to my assuming the role of 

 Much of this story is documented in Tom Donahue’s film, 

Perhaps the most pivotal experience occurred after President Bush prematurely proclaimed “mission accomplished.” Near the same time the military’s highest ranking psychiatrist visited our field hospital and presented the outcomes of an innovative combat stress screening and reconditioning program.

 The admiral fatefully pronounced, “This is very exceptional work; however, unfortunately, it will all be forgotten and will need to be rediscovered by the next generation.”

After my military retirement in 2009, I embarked on a new career at Antioch University Seattle’s Doctor of Psychology (PsyD) program and established the Institute of WarStress Injury, Recovery, and Social Justice. Its mission is to end the pattern of mental health neglect and stigma associated with crises within and outside of military circles. The opportunity to collaborate with someone as esteemed as Charles Figley, PhD, the institute’s board chair, has been instrumental in paving the way to fulfill these high-vaulted goals. 

 represents our collective efforts to share a written history in the hopes of ending the harmful consequences of neglecting war trauma lessons. In doing so, we hope the military will take a lead role in transforming mental health care in this country.

Writing this book with Mark was an education. I do not recall the first time I corresponded with Mark, but I had heard of him for some time. He was already a hero among those most connected to veterans’ rights. Coming from a military family, he believed in and loved America and its military so deeply yet he was willing to risk everything to help veterans get better health care.

We wrote this book to identify what has gone wrong and to share a blueprint for correcting the harms we uncovered.

Mark’s journey from enlisted Marine to naval officer had enabled him to become the strongest voice for systemic improvement in behavioral health within the military. The bedrock values that emerged from our study are vital to all fighting forces: trust, confidence, and collective effort—despite the fear and fog of war.

We knew there would need to be at least one significant book to address the relevant research. There was so much to report—so many stories of hope and then disappointment. The deeper we dove into the files, the more consistent the larger story became. Soldiers are taught to fight, and even kill, but their system of care does too little to prepare them for combat, and too little to help them reflect on their experiences afterward. Too often, they have no answer to reasonable questions, such as “how will I be treated if I am injured and need help?”

Our primary goal is first to convince our colleagues and fellow researchers that the number of psychological and psychiatric casualties are staggering, despite the fact that they rarely register on a measuring device beyond paper-and-pencil tests.

Every war cohort since World War I has described 10 fundamental lessons of war trauma; these lessons seem to be routinely ignored and then need to be rediscovered.

 These lessons include 1) the need to provide comprehensive mental health services including definitive treatment for traumatic stress injuries prior to discharge from the military; and 2) the need to eliminate mental health stigma and barriers to care.

Neglecting war trauma lessons perpetuates a preventable generational cycle of mental health crises.

To manage the military’s dilemma of fulfilling the 2 often competing missions of fighting and winning wars with providing health protection to its forces, the military has relied upon 10 strategies that prevent it from advancing war trauma lessons.

 For instance, the military’s 100-year-old frontline psychiatry doctrine is primarily aimed at reducing both personnel attrition and the cost of mental-health-related disability pensions. However, we argue that this doctrine is ultimately quite harmful to the well-being of veterans and their families.

War is not a pleasant thing, but we can learn from it. For instance, lessons from combat medicine have helped advance emergency medical and mental health care. By synthesizing the lessons learned from the mental health impacts of war trauma, we may find a working model to transform mental health care in general and eliminate related stigma.

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service.

1. Appel JW, Beebe GW. Preventive psychiatry; an epidemiologic approach.

2. Russell MC, Figley CR. Generational wartime behavioral health crises: part one of a preliminary analysis.

3. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: part two of a preliminary analysis.

6. Russell MC. Attentional focus and states-of-mind in post-traumatic stress disorder among

7. Zoroya G. Psychologist: Navy faces crisis. 

. January 17, 2007. Accessed July 14, 2021. 

8. Russell M. Mental health crisis in the Department of Defense: DoD Inspector General Hotline Investigation #98829 submitted by Commander Mark Russell, USN on 05JAN2006. Available upon request via Freedom of Information Act (FOIA) at Department of Defense; Office of Freedom of Information, 1155 Defense Pentagon; Washington, DC 20301-1155.

9. Russell M. The future of mental health care in the Department of Defense. Invited testimony before the Congressionally-mandated Department of Defense Task Force on Mental Health, on 19-20 October 2006, San Diego, CA.

Strangers at home: The Untold Story of American Military Mental Health

12. Russell M, Shoquist D, Chambers C. Effectively managing the psychological wounds of war. 

13. Glass AJ. Lessons learned. In: Glass AJ, Bernucci RJ, eds. 

Medical Department United States Army. Neuropsychiatry in World War II Volume I: Zone of Interior.

 Office of the Surgeon General, Department of the Army; 1966:735-759.

Between Flesh and Steel: A History of Military Medicine From the Middle Ages to the War in Afghanistan

A working model for eliminating stigma and transforming mental healthcare within the military.

Treating Psychiatric Combat Casualties

Traumatic experiences can be as unique as the individuals who have them. But it is also possible for large groups to undergo collective traumas, whether these are caused by viral pandemics or military service in a warzone.

In this Mental Health Minute, Charles F. Figley, PhD, shares his expertise on collective traumas. He discusses his latest research on the effects of the COVID-19 pandemic and his forthcoming book, co-authored with Mark C. Russell, PsyD, 

is the Paul Henry Kurzweg, MD Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

How should psychiatrists address collective traumas? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

Videos

Memorial Day is a time to remember not only those who have lost their lives, but also those whose psychic wounds have not yet healed. 

Suffering a Common Fate

, about his work in the area of PTSD, trauma, and disaster. In this podcast he discusses:

2. What the military is (and is not) doing to help veterans with PTSD

3. His own experiences as a marine in Vietnam

Dr Figley is the Paul Henry Kurzweg, MD Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

Podcasts

How can psychiatrists meet the challenge of treating PTSD in veterans?

When the War Comes Home

Psychiatrists face growing challenges both as health practitioners and as sources of reassurance and empathy for their patients. But what if the effort to understand and help patients itself becomes a burden? The purpose of this article is to provide a brief overview of what we know about secondary trauma-frequently called compassion fatigue or vicarious trauma.

Studies related to the effects of exposure to psychosocial stressors on individuals have primarily focused on the effects on nonprofessionals who provide social support.

 Until recently, there has been far less concern about the impact of social support provisions on professionals working with traumatized patients.

 Secondary traumatization also affects other health care professionals, including those who work with patients with AIDS or cancer or who are involved in critical care or hospice care.

Generally, those who work in psychotherapeutic professions attempt to alter the cognitive status, emotional state, or the behavior of patients by providing cognitive-therapeutic interventions as well as empathy and strategies for coping with stress.

 Within this context, it has been suggested that providing therapy to patients who have experienced a traumatic event can be especially emotionally difficult.

 Specifically, therapists who work with traumatized patients often show signs of psychological distress, including symptoms of posttraumatic stress disorder (PTSD), which appears to result from “vicarious” traumatization.

 Thus, it appears that providing psychotherapy to traumatized patients puts therapists at risk for mental health problems.

Despite findings that suggest that many therapists experience symptoms of vicarious traumatization, research has been limited.

 One problem has been a lack of conceptual clarity.

 For example, the adverse consequences of working with traumatized patients have been variously described as vicarious trauma, secondary traumatic stress, and compassion fatigue, and also in other terms.

 Moreover, different scales used in the past have used different conceptualizations.

 We briefly review a study that attempted to address these problems and, on the basis of this research, we offer brief assessment tools to screen for both vicarious trauma and job burnout in clinical practice.

-It can be emotionally difficult to provide therapy to patients who have experienced a traumatic event; therapists who work with traumatized patients often show signs of psychological distress, including symptoms of posttraumatic stress disorder, which may be a result of “vicarious” traumatization.

-Professionals exposed to similar stressors are not equally vulnerable to the negative consequences of occupation-related stress: individuals from historically disadvantaged groups and those who have a history of psychological trauma are more vulnerable to stress exposures.

- Recently developed burnout and vicarious trauma scales seem to be appropriate assessment tools for identifying professionals at risk for compassion fatigue and other psychological difficulties.

Our work suggests that vicarious trauma and job burnout are separate phenomena and that both syndromes are related to working with traumatized patients.

 Our recent conceptualization of vicarious trauma was developed from analytical models that incorporate the broader conceptualization of compassion fatigue in the clinical literature.

 For this project, we assessed a random sample of senior-level social workers in New York City following the 9/11 attacks.

With the inclusion of PTSD in DSM-III, stress response symptoms related to psychological trauma have been defined as a psychiatric disorder. The concept of compassion fatigue emerged when clinicians noted the occupational effects among mental health workers who work with traumatized patients. In essence, some professionals appeared to experience the effects of their client’s trauma vicariously.

 It seemed that vicarious trauma was a risk factor for mental health professionals who were exposed to significant numbers of traumatized individuals and who had an empathic orientation to their patients.

Thus, the therapist who reports symptoms related to reexperiencing the client’s traumatic event, who wishes to avoid both the client and reminders of the client’s trauma, and who experiences persistent arousal from knowledge of the client’s traumatic experiences may be suffering from vicarious trauma-a component of compassion fatigue.

 Compassion fatigue has been clinically defined as the formal caregiver’s reduced capacity or interest in being empathic or “bearing the suffering of clients” and is the behavioral and emotional state that results from knowing about a traumatizing event experienced by another person.

 Our work suggests that compassion fatigue is a hazard associated with many clinical settings and has at least 2 components-vicarious trauma and job burnout.

From a behavioral point of view, the general psychological mechanisms for the patient-to-therapist transmission of this condition can be understood in terms of cognitive-behavioral conditioning.

 More complex mechanisms have also been suggested to explain this phenomenon, such as “countertransference,” but we prefer a cognitive-behavioral framework because of its parsimony and direct therapeutic implications.

The current evidence also suggests that vicarious trauma and job burnout tend to overlap.

 However, vicarious, or secondary, trauma is not the same as job burnout, and each seems to have a unique effect on well-being.

 Job burnout is often defined as a response to prolonged exposure to demanding interpersonal situations and is characterized by “emotional exhaustion, depersonalization, and reduced sense of personal accomplishment.”

 High emotional involvement without adequate social support or feelings of personal work accomplishments (ie, job satisfaction) may leave the health care professional vulnerable to job burnout.

We conceptualized vicarious trauma and job burnout within a stress-process framework.

 This framework contends that challenging environmental stressors typically require individuals to respond both physiologically, through alterations in neuroendocrine and hormonal systems, and psychologically, usually through changes in cognitive functioning.

Studies suggest that other aspects of the caregiver’s environment can influence the development of compassion fatigue, vicarious trauma, and job burnout.

 This means that professionals exposed to similar stressors are not equally vulnerable to the negative consequences of occupation-related stress.

 Stress research indicates that individuals from historically disadvantaged groups are more vulnerable to stress exposures.

 A history of psychological trauma also increases the likelihood of developing compassion fatigue.

 Furthermore, positive coping and social support can reduce or moderate the influence of stressful events on well-being.

 Finally, psychological qualities such as self-esteem and a “sense of mastery” can reduce the adverse impact of psychosocial stressors.

Social support is usually provided by significant others in the form of emotional, informational, or instrumental support. Individuals who have few social support resources are more vulnerable to stressors and tend to suffer greater physical and psychological health problems.

 Among mental health professionals, social support can come from friends, family members, or significant others outside the work environment or from coworkers and supervisors within the work environment. Generally, the evidence suggests that coworker support is very important to the mental health professional.

To address limitations in previous research related to vicarious trauma and job burnout (ie, compassion fatigue), we undertook a study among a random sample of senior social workers with a Masters in Social Work (or higher) in clinical practice affected by the September 11 terrorist attacks. We chose to study social workers, because their professional work environment-high case loads, direct contact with patients, poor social support, and limited resources-potentially offers little protection from compassion fatigue and vicarious trauma.

We assessed a number of factors among these social workers that could have increased vicarious trauma and job burnout, and we examined their association with psychological distress. From this research, we developed 2 reliable, validated scales.

 Using the scales, we tested the hypothesis that vicarious trauma was different from burnout. Our data analyses supported our hypothesis.

 We found the two scales tended to measure different aspects of the more general phenomenon of compassion fatigue.

Selected results from this study are shown in 

 As can be seen, vicarious trauma tends to be associated with other negative life events, greater disaster recovery involvement, a lower sense of mastery, and worse mental health; it is also associated with job burnout. Job burnout tends to be associated with being single, negative life events, greater lifetime trauma exposure, a lower sense of mastery, and worse mental health status; it is also associated with vicarious trauma. Additional multivariate analyses suggested that exposure to traumatized patients increased vicarious trauma, but not job burnout. In turn, both vicarious trauma and job burnout were related to experiencing psychological problems. These associations held even after we took into account (ie, adjusted for) demographic and other factors (eg, personal history of trauma) that could place the therapist at greater risk for reasons outside of his or her work life.

The results of our analyses support our contention that the scales used were valid.

 Therefore, the burnout and vicarious trauma scales seem to be appropriate assessment tools for identifying professionals at risk for compassion fatigue and other psychological difficulties. In summary, using these scales, we showed that working with traumatized patients is related to vicarious trauma, but not job burnout, and that both vicarious trauma and job burnout (compassion fatigue) are associated with psychological problems. More important, these outcomes will likely result in problems with service delivery and higher job turnover and will produce serious issues for continuity as well as quality of care provided by mental health professionals.

The following several strategies can reduce professionals’ chances of developing compassion fatigue

• Improved social support from others, including coworkers

From a stress-process perspective, resiliency skills and self-care strategies are essentially coping skills. The main theme of these strategies includes both social and organizational functions for reducing compassion fatigue and vicarious trauma. Organizationally, social service agencies need to recognize the workplace hazard of compassion fatigue and offer training in self-care and other strategies to reduce this problem. Increased social support from coworkers and supervisors can also reduce this work hazard.

Our work may help clarify the conceptual differences between vicarious trauma, job burnout, and compassion fatigue.

 Among therapists, compassion fatigue contains at least 2 components: vicarious trauma and job burnout. Developing a valid and reliable instrument to detect compassion fatigue is a prelude to devising intervention strategies to mitigate its negative effects on practitioners. In

 we show the scales developed from our study. Although additional research is required, findings from the study suggest that professionals who score a 15 or higher on the vicarious trauma scale and/or 30 or higher on the job burnout scale may require clinical attention or further clinical evaluation for these syndromes.

Clearly, compassion fatigue demands concern and resonates among mental health professionals. Psychiatrists are drawn to work with those who are mentally ill, because they value providing care to others and often overlook their own needs. The characteristics that bring people into the caring professions are, ironically, the very factors that make them vulnerable to vicarious trauma and job burnout. It is our responsibility to ensure that these adverse outcomes are minimized among those who have chosen such a career.

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