Objectives: The aim of this research was to evaluate psychophonetics methodology for self-care and empathy skills as an intervention for compassion fatigue. Objectives were to measure levels of compassion fatigue pre-intervention, then to apply the intervention and retest levels one month and six months post-intervention.

Method: The research applied a pilot test of a developed intervention as a quasi-experiment. The study sample comprised home-based carers working with HIV-positive patients at a hospice in Grabouw, a settlement in the Western Cape facing socioeconomic challenge.

Results: The result of the pilot study showed a statistically-significant improvement in secondary traumatic stress, a component of compassion fatigue, measured with the ProQOL v5 instrument post-intervention.

Conclusion: The results gave adequate indication for the implementation of a larger study in order to apply and test the intervention. The study highlights a dire need for further research in this field.

Contexte: La prise en charge à domicile est reconnue comme étant une occupation stressante. Les praticiens travaillant avec des patients connaissant des niveaux élevés de traumatisme peuvent être susceptibles de souffrir de fatigue de compassion, la nécessité continue de faire preuve d’empathie étant un facteur y contribuant.

Objectifs: L’objectif de cette étude consistait à évaluer la méthodologie psychophonétique pour les compétences d’auto-prise en charge et d’empathie, comme intervention contre la fatigue de compassion. Les objectifs consistaient à mesurer les niveaux de fatigue de compassion avant l’intervention, puis à appliquer l’intervention et à tester à nouveau les niveaux un mois et six mois après l’intervention.

Méthode: L’étude a appliqué un test pilote d’une intervention développée comme une quasi-expérimentation. L’échantillon étudié comprenait des soignants à domicile travaillant avec des patients séropositifs dans un hospice à Grabouw, un village du Cap occidental confrontés à des défis socioéconomiques.

Résultats: Le résultat de l’étude pilote a indiqué une amélioration statistiquement significative du stress traumatique secondaire, une composante de la fatigue de compassion, mesurée avec l’instrument ProQOL v5 après l’intervention.

Conclusion: Les résultats ont fourni une indication adéquate pour la mise en œuvre d’une étude de plus grande envergure afin d’appliquer et de tester l’intervention. L’étude met en avant l’absolue nécessité de mener d’autres études dans ce domaine.

It is well recognised that caregivers working with people who are experiencing, or have experienced, trauma may be susceptible to compassion fatigue.^4,5,6,7 The sustained need to remain empathic to one’s patients has been cited as being a significant factor contributing thereto.⁶ Compassion fatigue may be defined as being a state of tension and arousal experienced by people helping others, by re-experiencing of the traumatic events, numbing and avoidance, or persistent arousal.⁸ It is measured in terms of burnout and secondary traumatic stress.⁹ Offering empathic care to those who have been traumatised may result in an overwhelming, vicarious sharing of the trauma and consequent secondary traumatic stress,^4,10 or, as in the case of burnout, a more gradual onset of exhaustion with a resultant need to cut oneself off from those one is caring for, a disengagement from the caring work and a loss of sense of satisfaction and accomplishment with one’s work.^7,10,11,12 It is recognised that caregivers who are able to care for the self are likely to be more resilient to these stressors.^4,8,13,14

A person may be traumatised both by being in harm’s way and by bearing the distress of others who are. Trauma requires that a severe threatening event has occurred, involving death, injury, or their threat to the person, or to those around them, and includes chronic illness.¹⁵ Thus, chronic illness such as HIV may be experienced as trauma.

Empathy has been described as being an emotional state or condition that is congruent with another’s emotional state or situation.^16,17 Empathy may result in an expression of empathic concern or personal distress in the observer.^5,6,7 An unconscious sharing of emotions occurs as emotional resonance,¹⁸ whilst empathy in a prosocial context requires a moderating cognitive process and an awareness of self in relation to the person being cared for.¹⁸ The unconscious proclivity to share experiences (including traumatic experiences) between people, if not mediated by self-awareness and cognitive processing, may therefore impact upon the caregiver.

Various studies conducted in Africa have identified empathy as being an associative factor^19,20 as well as being the consistent moderating factor²¹ in secondary traumatic stress. These studies were conducted with caregivers responding to patients who had experienced violent crime-related trauma. No distinction was made between empathy as emotional resonance or as a prosocial empathic response in the studies. No studies were available in relation to compassion fatigue in home-based carers.

The psychophonetics parallel counselling process describes a methodology for enabling a prosocial empathic response in two phases: (1) becoming aware of and processing the observer’s experience and (2) creating an empathic response as an inner picture in the caregiver of the client’s experience.²²

Psychophonetics is a coaching methodology based on the work of Rudolf Steiner and developed by Yehuda Tagar. In the methodology of psychophonetics, Tagar²³ identifies three factors, namely awareness of bodily response, internal gesture and visualisation, as being non-verbal aspects of experience that, when brought to consciousness, facilitate an awareness of self. These non-verbal modes of experience are factors that enable an observer to become more aware of the unconscious affective component of emotional resonance and to provide information about this to the observer for further cognitive processing.²³ The methodology regards the human body as being an instrument of meaning through the mediation of gesture.²³ When a person observing another mimics the ‘gesture’ or facial, vocal and postural expression of the person being observed, through the process of emotion sharing, the information of this experience becomes available to the observer by the internal sensation of the soma.²⁴ Through the mediation of gesture²³ and the proprioceptive sensory system,²⁴ the human body can serve as a map for experience and, through empathy, the experience of the other individual.

For the caregiver to be able to provide a prosocial empathic response and protect themselves from the potentially-deleterious effects of emotion sharing, it is essential that they engage in a parallel internal process of integrating and transforming their experiences.¹⁰

The objectives of the research were to measure compassion satisfaction and compassion fatigue in terms of secondary traumatic stress and burnout, using the ProQOL v5 software programme, in the study sample of home-based carers, then to deliver the pilot intervention. Thereafter, the levels were again assessed one month and six months post-intervention, by means of the same instrument.

The ProQOL v5 questionnaires were scored according to the tables in The ProQOL Concise Manual.⁹

The participants were a pre-existing group, already working as a team. Rabiee²⁵ advocates using pre-existing groups, as acquaintances relate to each other’s comments and may be more able to challenge each other because of a preformed level of trust, further advancing the advantages of these groups when exploring sensitive issues.

For each of the parameters measured, the average score in validation results of other studies was 50, with about 25% of people reporting > 57 and about 25% of people reporting < 43. The results were recorded as total scores for each parameter of compassion satisfaction and compassion fatigue rather than as specific results for each of the items of the questionnaire.

Burnout: The mean t-score measured for burnout was 56.18. No participants fell within the low-risk cut range and 54.55% of the participants were within the high-risk range. This reflects a high level of risk for burnout amongst the participants in comparison with the test group reported by Stamm.⁹

Secondary traumatic stress: The mean t-score measured for secondary traumatic stress was 73.72. Five of the analysis group scored the maximum reflected score on the raw to t-score conversion table, representing 45% of the group. All participants scored in the high-risk cut range. These results reflect a significantly high risk for secondary traumatic stress amongst the participants tested.

Burnout: The mean t-score measured for burnout was 56.18 before the intervention. One month and six months post-intervention, the mean t-scores had decreased by 1.88 points to 54.30 and by 2.28 points to 53.90, respectively. The median score decreased from 58 to 56 and the lowest score from 45 to 38. The highest score decreased from 65 to 59 but increased again to 70.

All of the post-intervention six month scores fell within the range of 38–60, except for one participant. This participant had experienced the death of three close family members during the six-month period of the research. At the time of completion of the final questionnaire, she was experiencing extreme personal trauma and was feeling emotionally overwhelmed.

Secondary traumatic stress: The mean t-score measured for secondary traumatic stress before the intervention was 73.72. This decreased by 9.42 points (to 64.30) after one month, but only by 7.09 points (to 66.63) after six months. The median score decreased from 76 to 62 and the lowest score decreased from 64 to 50 after one month and to 52 after 6 months. The highest score remained constant at 77.

Two participants who had maintained high scores for secondary traumatic stress throughout the six-month research and intervention period had experienced significant stressful and traumatic experiences in their personal lives during the period.

For compassion satisfaction and for burnout there were no significant differences amongst the periods of pre-intervention, one month post-intervention and six months post-intervention. The p-value for the repeated measures analysis of variance was 0.67 for compassion satisfaction and 0.52 for burnout. With regard to secondary traumatic stress, the p-value was 0.0066, indicating a significant difference. Pairwise comparisons show that the mean at baseline was different from one month (p = 0.0023) and six months (p = 0.0193) but the means were not significantly different (p = 0.3553).

Most of the literature on the topic of compassion fatigue links empathy with compassion fatigue, but with conflicting results as to whether it plays an undermining or protective role. Various studies conducted in developed countries, specifically within the context of traumatic episodes such as acts of violence or terrorism,^7,13 identify the sustained empathy of a caregiver as contributing to compassion fatigue. Studies conducted in Africa identify empathy as having a protective effect against secondary traumatic stress,^20,26 with one study specifically identifying empathy as being the only constant moderator of secondary traumatic stress.²¹ However, these studies do not distinguish between various empathy-related responses such as emotion resonance and prosocial empathy as identified in a recent theoretical paper on the components of empathy.¹⁸

Psychophonetics methodology for empathy skills was identified by the researcher as applying the components of prosocial empathy in a practical and experiential methodology. The intervention of psychophonetics methodology for self-care and empathy skills focused on encouraging increased levels of self-awareness and body awareness, enabling caregivers to become aware of stressors as they occur, so as to identify the various determining factors, and to become aware of other lifestyle and behavioural options available to them. Making use of a systematic parallel internal process, the methodology trained the participants to identify in themselves the various components of the empathy process.

An increased self-awareness provides the platform for alternative choices to be made. An additional objective of the self-awareness process is to enable participants to have a greater awareness of self and other, as well as the interrelationship between the two. This is to enable the participants to take care of their own needs, allowing them to maintain a state of engagement rather than having to distance themselves from the interaction, in an attempt to protect themselves from further impact, thus enabling a prosocial empathic response, whilst at the same time maintaining protection of themselves.

This study is the first to apply psychophonetics methodology for self-care and empathy skills in relation to compassion fatigue and to measure the results, as no other studies have been recorded in the literature up to now.

The results of the ProQOL v5 questionnaire prior to intervention delivery indicated that the participants were at moderate risk for burnout and high risk for secondary traumatic stress. The groups measured slightly higher scores for job satisfaction than the average of 50 recorded in the research population of more than 1000 used in the development and assessment of the instrument. They measured moderately-higher scores for risk of burnout and significantly-high scores for risk of secondary traumatic stress. The results confirmed quantitatively that the participants were at risk of burnout and secondary traumatic stress.

The range of scores within the group increased in the post-intervention one- and six-month tests for burnout and secondary traumatic stress, compared with the pre-intervention test. The increased range can be attributed to two outliers at the high end of the range. Two participants, experiencing personal distress, maintained high scores for burnout and secondary traumatic stress. Whilst this result may be seen as being a limitation of the instrument and approach, in that it does not record outcomes specific to occupational issues, it alerts one to the possibility of personal factors, specifically personal trauma, contributing toward burnout and secondary traumatic stress in the work context. It further alerts one to the fact that additional mechanisms should be put in place, in an occupational setting, where employees are dealing with extreme client and patient adversity, in order to provide support for them with their own challenges.

A further limitation of this research is the use of the time-series design with only one time-series and one group. The results of the research would have been enhanced if there had been a non-equivalent control group or a multiple time-series design.

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