Catholic University of America Vicarious Trauma Discussion

Vicarious Trauma
Overall, most people who work with trauma survivors experience difficult feelings about the
work we do. And yet most organizations do not provide workers with an appropriate way to
cope. As professionals we must be aware of the signs and symptoms of burnout, and develop self
care techniques for ourselves and supervisees. As a community, we must develop a safe and
open forum for self-care.
In this video, we will explore the concepts related to the impact of trauma work on the worker.
Vicarious trauma is a process of transformation. One’s inner experience changes over time due to
empathic engagement with the individual’s or group’s history of trauma and depression. It is the
cumulative effect of our work.
We soak up the experience of others like a sponge. Charles Figley used the term “secondary
traumatic stress” to refer to the natural, consequent behaviors and emotions resulting from
knowledge about a traumatizing event experienced by a significant other. It is the stress resulting
from helping or wanting to help a traumatized or suffering person.
Vicarious trauma, a term introduced by Laurie Pearlman and Karen Saakvitne in their 1995
book, Trauma and the Therapist, looks more specifically at counselors and therapists providing
clinical interventions with trauma survivors. Compassion fatigue is often the result of vicarious
trauma, which is understood to be the inability to sustain connection with an empathy for clients
with trauma histories. We clearly want to avoid this outcome, as trauma-informed care requires
us to be engaged, empathic, and connected.
No matter what you call it, research has shown that providing services to people who have
experienced trauma can have cumulative effects on workers. This means we may not have these
experiences with the first person or the fifth, but over a period of time with many people. It is not
a matter of if you experience vicarious trauma, but when and how. In his study on prevalence
among social workers in 2007, Brian Bride revealed that 70% of social workers experience
symptoms. Similar studies have been done with nurses, teachers, and lawyers.
It is an expected experience and does not mean that you are not doing the work correctly or
somehow not cut out for the work. We do know that novice workers are more likely to
experience vicarious trauma than veteran workers. However, this does not mean that those who
have been doing this work for a while have developed positive strategies for coping with it.
Good supervision, organizational support, and self-monitoring are ongoing strategies that must
be followed regularly.
Now that we have defined the concepts related to vicarious trauma, you will see that this is a part
of working with trauma survivors. Given that we engage with empathy in our work, it should not
come as a surprise that leaves us with complicated feelings about what we encounter.
The good news is that we can identify signs of vicarious trauma and engage self-care activities to
ameliorate them. Self-care is a daily activity that is an ethical obligation in our work. Since we
are the instrument used in our work, we must care for ourselves accordingly.
Signs and Symptoms of Vicarious Trauma
Vicarious trauma can have both personal and professional consequences if left unaddressed. The
signs and symptoms can be identified so that you can take note and intervene early on.
Personally, we experience vicarious trauma on cognitive, emotional, behavioral, spiritual,
interpersonal, and physical levels. Professionally, it can impact job performance, morale,
relationships with colleagues, and professional behavior. In this video, we will explore these
signs and symptoms. Pay close attention here and make note of any that sound familiar in your
own work.
On the cognitive level, what we take in from trauma work can cause us to be preoccupied with
what we learn. This can cause diminished concentration, confusion, a sense of spacey-ness,
decreases in self-esteem, preoccupation with trauma imagery, and a sense of apathy about the
suffering of others. In other words, over time, vicarious trauma can change how we think about
the experiences and how we are able to attend to our work.
The emotional impact of trauma work can be seen in feeling powerless, overwhelmed, anxious,
and even guilty about our own well-being or ability to overcome our own past traumas. We can
feel shut down, numb, or depleted, sad, hopeless, and even depressed. These feelings can come
from the awareness of how deep the impact of trauma can be, and how long it can take for
someone to heal from these experiences. It can also come from engaging with systems that do
not help as they should, and our inability to make them respond in the right way.
How we think and feel influences our behavior. Behavioral impacts of vicarious trauma can be
seen in developing our own maladaptive coping or harmful behaviors similar to those we see in
trauma survivors. This can include turning to drugs or alcohol to numb out and socially isolate.
We can become impatient with ourselves and others, irritable, withdrawn, and moody. Sleep
disturbances and nightmares due to preoccupation with work are common, as our appetite
changes and changes in eating habits. Hypervigilance and an elevated startle response are also
reported by many professionals.
Just as trauma is carried in the body, vicarious trauma can have physical impacts. Bearing
witness to horrific experiences can cause shock, rapid heartbeat, sweating, difficulty breathing,
aches and pains, dizziness, and other somatic reactions. Working long hours and not getting
enough sleep can leave us vulnerable to getting sick, particularly during cold and flu seasons.
Here in particular, self-care is very important.
The spiritual and religious impact of vicarious trauma is often overlooked. When we are exposed
to traumatic material in our work, it can lead to questioning the meaning of life, loss of a sense of
purpose in our work, and anger at a higher power. This work can cause us to question our
religious beliefs and our faith in the church or other institutions that have not acted to address
trauma.
There is also an interpersonal impact, as vicarious trauma can affect our interest in connecting
with others. Self-isolation, anger at friends or family members who don’t understand our work,
and generalized mistrust of people are some of the social consequences of unaddressed vicarious
trauma. This can carry over to work, as vicarious trauma can have an impact on morale and job
performance, as well as relationships with colleagues.
The effects of trauma work on the worker are well-documented in research. In reviewing the
common effects, the hope is that you will recognize them early and engage in self-care activities
to mitigate them. In the next video, we will address the individual and organizational solutions to
caring for ourselves in trauma work.
Engaging Spirituality in
Addressing Vicarious
Trauma in Clinical Social
Workers: A Self-Care Model
Eileen A. Dombo & Cathleen Gray
Research has shown that vicarious trauma results in great personal and professional costs for social workers (Bride, 2007). The social work profession has an
obligation to their members, and those they serve, to ensure that those providing
mental health interventions are functioning optimally (National Association of
Social Workers, 2008). Burnout and vicarious trauma prevent workers from
functioning at maximum capacity. Clinical social workers are particularly
vulnerable to burnout with spiritual dimensions in the form of questioning the
meaning of work, loss of purpose, hopelessness, and internalizing the suffering
of their clients? trauma. Spiritual practices have often been engaged to lessen
the effect of trauma and facilitate personal and professional growth (Siegel,
2010; Stern 2004). Social workers can re-engage with the meaning of their
work through concrete spiritual practices that improve their ability to sustain
the amount of emotion involved in working with trauma (Collins, 2005; Trippany, Kress & Wilcoxon, 2004). This article addresses ways social workers can
support themselves and their work through spiritual self-care, in the service
of improving client outcomes through sustained connection. Spiritually based
practice will be explored as a way to re-connect to the meaning of the work and
the satisfaction compassion can bring (Griffith & Griffith, 2002; Pargament,
2007). A self-care model will be presented to help individual workers address
the impact of the work, and organizations to address the environmental and
cultural contributors to vicarious trauma. This model will integrate spiritual
practice and present specific spiritual self-care meditation practices.
R
egardless of practice area or population, social workers will
engage with individuals, families, communities, and populations with
histories of trauma. Research shows that 50% of people experience
some form of traumatic stressor in their lifetime (Dass-Brailsford, 2007).
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Social workers work with the most vulnerable of clients who are suffering
from the effects of trauma. Working with clients who are suffering from
trauma can also be painful for the social workers trying to help.
Trauma and Vicarious Trauma
Traumatic stressors consist of direct exposure to major events such as
war, rape, fatal accidents, and situations in which persons fear their lives
are in danger or that physical injury is threatened. Traumatic stressors also
include indirect exposure through witnessing or learning about such events
happening to others (American Psychiatric Association, 2000). Examples
seen in client populations in clinical practice include the sudden death of
a family member, pregnancy loss, divorce, immigration, and other difficult
life experiences. These negative life events are difficult to work through.
They can produce distress so great that the normal capacity for coping may
be psychologically overwhelmed (Herman, 1992). The resulting emotions
and behaviors of this distress, referred to as ?sequelae,? are often what bring
people to social work services.
However, the reality of the experience of trauma is subjective. Whether
or not this experience results in difficulties in social functioning is related
to strengths, resiliency, and event-specific factors (Dass-Brailsford, 2007).
What may cause somatic problems, dissociation, and problems with affect
regulation in one person, may not in another. Much of this depends on
the individual?s unique history. Previous traumatic experiences, systematic discrimination, oppression, and lack of familial and social supports
can leave a person vulnerable to the sequelae of trauma (Brown, 2008;
Courtois, 2004). It is important that the breadth of traumatic experience
be realized to provide the deepest understanding of the vicarious effect of
client trauma on social workers.
Vicarious trauma refers to the taking in of the experiences, emotions,
and reactions of trauma survivors by professionals working with them in
the healing process (Pearlman, Saakvitne, & Buchele, 1995). It is not just
the effect of one individual or family with whom the social worker comes
in contact, but rather it is the cumulative effect of the work over time. The
resulting distress reflects the transformation of the social worker?s inner
experience due to empathic engagement. In reality, it is a natural by-product
of the work; it should be expected, normalized, and anticipated. Unfortunately, this has not always been the case in the social work profession.
In our experience, social workers were not encouraged to address their
feelings about the vicarious trauma in their work, and supervisors were
not trained to deal with workers? reactions and feelings in supervision. It
was not until Charles Figley (1995) began writing about vicarious trauma
as a form of compassion fatigue among professionals that there was any
scholarly writing on the topic.
Addressing Vicarious Trauma in Clinical Social Workers
Pearlman, Saakvitne, & Buchele (1995) addressed vicarious trauma
as it related to psychotherapists working with incest survivors. Although
vicarious trauma is not specifically connected to the type of trauma the
client has experienced, current writing on vicarious trauma focuses on
the ways client experiences of child abuse, rape, and war impact the social
worker (Clemans, 2004; Cunningham, 2003; Tyson, 2007; Van Hook &
Rothenberg, 2009).
Vicarious trauma often leads to physical and psychological difficulties. Common vicarious trauma reactions were identified on professional,
interpersonal, and intrapersonal levels (Pearlman, Saakvitne, & Buchele,
1995; Richardson, 2001). Professional changes were seen in decline in
work product, poor morale, and lack of connection with colleagues. Interpersonal changes were seen with social isolation, difficulty in intimate
relationships, and changes in parenting. Intrapersonal transformations
included changes in emotions (feeling depressed or powerless), behavior
(being hyper-vigilant), cognitions (distortions about competence), and
spirituality (anger at God, challenging prior religious beliefs).
More recent literature reflects more compassionate conceptualizations
of vicarious trauma that do not indicate pathology or weakness on the part of
the professional (Lipsky & Burk, 2009; Richardson, 2001). Some literature
calls for changes in social work education to help new social workers be
aware of vicarious trauma and able to address it as it arises (Hesse, 2002;
Radey & Figley, 2007). Specific approaches for clinical teams to address
ways clinical issues surface personal experiences have been presented
(Geller, Madsen, & Ohrenstein, 2004).
Finally, more and more social workers are viewing spirituality as an
important element in self-care, and seeing self-care as both a spiritual activity and an ethical obligation (Collins, 2005). One area that is lacking in
the literature on vicarious trauma is a clear understanding of how spiritual
practices can alleviate vicarious trauma. Little attention has been paid to
the use of spiritual practices for burn out prevention in social workers.
Our purpose is to present a model that defines and attends to the use of
spirituality to prevent vicarious trauma from becoming burnout.
Burnout, Vicarious Trauma, and Moral Injury
Burnout is a long recognized phenomenon among professionals and
has been defined as a combination of emotional exhaustion, an increasing
depersonalization of clients, and a decreased feeling of personal accomplishment (Maslach & Jackson, 1981). Burnout is attributed to the psychological
stressors of work with vulnerable populations. However, vicarious trauma
can be a spiritual violation as well as a psychological violation. Many stressors in professional work, or life, can be perceived as spiritual violations, such
as serious verbal aggression or hearing of a parent having slapped a child.
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Some affect the social worker deeply at the level of vicarious trauma. At the
point of vicarious trauma a clinician may be experiencing a moral injury,
which is the doing, or witnessing of, something that is against our moral
belief system. Moral injury has only recently been explored through the
lens of war trauma; in the extreme, soldiers must kill (Foy, Kelly, Leshner,
Schultz & Litz, 2011, Litz, et al, 2009). However, in many other instances,
moral injury is experienced through every day interactions with trauma
survivors that raise moral and ethical implications for social workers. We
are exploring the understanding of moral injury beyond war, as clinical
social workers often listen to descriptions of behaviors that are against
their personal moral beliefs. This can be a vicarious form of moral injury
for the clinician working with trauma.
This kind of spiritual violation or moral injury can result in burnout
characterized by the clinician?s questioning the meaning of life, loss of a
sense of purpose in her or his work, an inability to see holiness in others,
feelings of hopelessness, feelings of anger at higher authorities?God, the
government, the boss?and carrying the suffering of clients into one?s
personal life.
Clinical Theory
The inappropriate carrying of the suffering of the client that reflects
burnout may be understood through a variety of theoretical perspectives. The
theory we find is most helpful is object relations theory. While the theory is
broad, we focus on the basic concepts of holding and containing (Berzoff,
Melano, Flannagan, & Hertz, 2008,Winnicott, 1956). The holding of a client
is the process of attuned listening, support, and provision of an environment
in which the client feels safe. The containment involves the ability to contain
one?s own affect while helping the client to contain their experience.
In this therapeutic environment clinicians are invested in the client
while being attuned to their own separateness from the client. This is what
Winnicott (1956) refers to as the ?good enough? stance. The experience
of listening to trauma challenges the clinician?s ability to provide a ?good
enough? environment which is necessary to build the client?s own resiliency. Holding and containing help a clinician understand how to ?be?
with clients rather than ?do? for clients. ?Being? with a client is truly being
present with the client.
In a spiritual clinical practice while working with trauma, there is a
clear distinction between ? taking in? what the client is experiencing and
?taking on? the client?s experience. The practice of taking in involves the
holding and containing aspect of practice. It is being present with the client
when in the presence of the client. With burnout, there is more likelihood
of the taking on of the client?s experience. This involves the absorption of
the client?s experience into the clinician?s life, talking a great deal about the
Addressing Vicarious Trauma in Clinical Social Workers
trauma of the clients, and/or bringing the energy left over from work into
one?s personal life. When taking on the experience of the client, the clinician puts herself onto center stage, bringing the attention of others to the
self (Salzberg, 2011a). When burnout affects one?s feelings and perceptions
of the client and enables the taking on of the client?s burden, it is difficult,
if not impossible, to be fully present for the client. For social workers to
manage burnout and enhance the possibility of a fuller presence for the
client, we propose a comprehensive self-care model.
A Self-Care Model
A model of self-care that engages spiritual practices to address vicarious trauma and prevent burnout can help social workers develop adaptive
coping responses to reactions. The focus in this article is on how individual
social workers can mitigate the effects of vicarious trauma through professional training, adopting self-care skills, and striving to balance work and
personal life. However, a model of self-care must be comprehensive and
be aimed at multiple levels to be effective (Brady, Guy, Poelstra, & Brokaw,
1999; Trippany, Kress, & Wilcoxon, 2004).
Almost twenty years since Figley described the phenomenon of vicarious trauma (1995), Bell, Kulkarni, & Dalton (2003) found that organizations are generally unable to effectively respond to professionals? reactions
to their work and make system-level changes to support them. The profession?s person-in-environment perspective (Germain, 1973) calls social
workers to attend to the role of the environment in which they practice.
This allows an expansion beyond only a micro focus on the professional
and his or her reactions to the work, to include a more macro focus on the
ways the organizational practices, availability of resources, and the impact
of the physical setting on the professional.
A comprehensive self-care model for organizations requires interventions at the macro-organizational level, mezzo-team level, and the
micro-individual social worker level. At the macro level, organizations can
undertake assessments of their policies, procedures, and programs and their
impact on the worker. They can ensure that leaders and supervisors receive
training on vicarious trauma and are prepared to intervene effectively with
staff. Finally, they can proactively engage in changing problematic structural
and environmental factors. To further foster spiritual self-care, organizations
can create sacred spaces for social workers to meditate, pray, and reflect on
their work. They can allow workers to schedule breaks to use this space,
or engage in other spiritual practices.
On the mezzo level, clinical and interdisciplinary teams can provide a
safe environment to process reactions to the work, including the spiritual.
Mentoring relationships can be established where veteran social workers
help novice workers, and share their own spiritual practices. Supervision
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can include a focus on vicarious trauma reactions and developing self-care
skills that include spiritual practices. Case presentations can include time
to discuss professionals? reactions to the case, address spiritual dimensions
of the case and its impact on the worker, and share self-care ideas.
On the micro level, a comprehensive model of self-care involves individual practitioners strengthening themselves through their own efforts on
spiritual levels. This micro-level self-care effort will facilitate the capacity
of social workers to sense God or sacredness in all clients, listen without
judgment, and regard the space in which they work as sacred. The spiritual
dimension can add to what individual social workers can learn about vicarious trauma in their professional training, adopt their own self-care skills, and
strive to balance work and personal life. We have chosen to focus this article
on the micro level intervention we developed using meditation techniques.
Table 1: Self-Care Model
Intervention
Level
Intervention focus
Spiritual Dimension
Macro
Environmental factors;
policies, procedures, and
programs that contribute
to vicarious trauma.
Sacred space for spiritual
practices; time allotted for
use of space.
Mezzo
Team meetings; mentoring
relationships; supervision
time to address self-care.
Sharing spiritual practices
in supervision, mentoring
relationships, and case presentations.
Micro
Education on vicarious
trauma and self-care techniques.
Meditation practice for
trauma work
Spiritual Practices for the Social Worker
Examples of Helpful Spiritual Practices
When social workers are attending to their own well-being, maintaining a spiritual practice is easier. Burnout can interfere with the ability to
sense inner goodness in clients, especially difficult clients. It is hard to
listen without judgment when there has been trauma. When the worker
is experiencing vicarious trauma, it is difficult if not impossible to be fully
present for the client. One?s own spiritual practices can offer the support
needed to be present in clinical practice.
Some of these practices have been adapted from the work of Kenneth
Pargament, who has done extensive research on integrating spirituality
Addressing Vicarious Trauma in Clinical Social Workers
into psychotherapy (Pargament, 2007, Pargament, Koenig, & Perez, 2000,
Pargament, Koenig, Tarakeshwar & Hahn, 2004). From understanding the
work of others, we have applied and modified the practices both in teaching
and in our clinical practices.
Spiritual practice can be spiritual reading, attending religious services,
meditation, prayer, or anything that helps the social worker to find meaning
beyond self, meaning in relationships, and meaning in clinical practice. A
few basic steps to a spiritual practice include: clear your own mind, pay
attention to the present moment and surroundings, breathe consciously,
be still (only then can you listen), in the stillness listen to the affect, and,
most importantly, ?be? with the client.
Rest-taking: An often-neglected practice is rest-taking, which can
restore the mind, body and spirit. It can have a positive and renewing effect on emotional exhaustion, depersonalization, and a sense of personal
accomplishment (Chandler 2008). Rest helps the ability to contain the
stressful work with trauma. Rest-taking obviously means getting vacation
time and sleep. It can also mean incorporating rest during the work day.
Rest can be just sitting or stretching between clients rather than checking
email or returning business calls. After a particularly draining meeting, one
can go to a quiet place, sit or lie down, close their eyes and breathe deeply
for a few minutes. This can also mean planning restful time after work,
not bringing a briefcase full of work home.
Spiritual Collaboration: Spiritual collaboration can be very helpful,
as it involves spiritual practice done with others. This could be attendance
at religious services, singing in a choir, or attending a prayer or meditation
group. A prayer or meditation group would not be a place to speak about
specifics of work with clients, but rather a place where the clinician can
release some of the energy of the work. Meditation or prayer groups can
help regain meaning of work in an indirect manner. They may provide a
sacred place where the clinician may feel ?held? in the presence of others.
Helping soothe oneself helps to hold the trauma of clients.
Professional Spiritual Support: Spiritual support can be gained
through peer group and individual supervision. In these settings, there is
confidentiality and boundaries. Time constraints often seem to interfere
with social workers making use of peer support systems, but the lack of
spiritual support may deny the clinician the affirmation needed for this
work. Often personal spiritual thoughts or insights are not discussed with
peers or supervisors, as these discussions can feel taboo in the workplace.
However, it is important for both the social worker and client to feel free
to discuss spiritual beliefs, as these often become part of transference,
countertransference, and projection.
Spiritual Cleansing: Another important practice is a spiritual cleansing ritual (Pargament, 2007). This offers ways to cleanse oneself in making
the transition from work to personal life. Each person is encouraged to
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develop rituals that work for them. The following are ones we have practiced ourselves. Some rituals for spiritual cleansing might include burning
some sage before leaving the workspace. Sage may be purchased at health
food stores or online and is believed to cleanse space. Another ritual may
be to take five minutes for a brief meditation of transition, engage in active
meditation such as consciously washing out coffee cups, or use walking
meditation, such as walking slowly and with meditative intention around
the block before getting into a car or on the bus. A personal cleansing ritual
can be soothing, as if the act of having a ritual is more than just what the
ritual may be. Part of the restoration can be simply in the taking time to
think about and engage in it.
Maintenance of One?s Own Spiritual Practice: A final and most important practice for spiritual coping is the maintenance of one?s own spiritual
practice. To maintain working with clients who are traumatized, social
workers always need a ?cushion? of support. In the same way that physical
exercise can reduce stress, regular spiritual practice of prayer, chanting,
meditation, drumming, or any practice that supports the meaning of life
can reduce stress (Koenig, McCullough, & Larson, 2001). While the effects
may not be immediately noticed, contemplative practices such as prayer and
meditation can boost serotonin levels and arousing spiritual practices such
as singing and high engagement worship practices boost norepinephrine
and dopamine which increase energy (Koenig et.al., 2001, Siegel, 2007,
Young, 2011). If the clinician is experiencing vicarious trauma, burnout,
or moral injury, there is such a depletion of self that there is little energy
to hold and contain the client?s experience (Chandler, 2008; Fahy, 2007).
Meditation as Spiritual Practice
The regular practice of meditation can clearly help the clinician maintain the ability to contain the clinical work and avoid burnout (Kristeller
& Johnson, 2005). While most religions offer some form of contemplative
practice, meditation practice transcends any particular religion and does
not involve giving up one?s religion or religious practices.
Meditation can be loosely defined as a personal practice of training
our attention inward in a focused manner. It involves awareness of internal
processes as well as what is happening externally in the present moment
(Salzberg, 2011b). This awareness of the internal as well as external experience allows the practitioner to choose whether to respond to specific
thoughts, sensations, and feelings. Meditation can bring the practitioner
fully into the present moment. The practice of meditation offers, much as
prayer can, the ability to be still and to quiet the mind. Meditation requires
no equipment or special clothing.
There are a variety of meditative traditions, all of which have the common elements of focused attention and a nonjudgmental thought process.
Addressing Vicarious Trauma in Clinical Social Workers
A simple meditation would be to focus attention on the breath. In this
style of meditation, attention is open noticing of whatever thoughts come
into awareness. What is important is the purposefulness of not analyzing
the thought, but rather noticing its presence (Kristeller & Johnson, 2005).
Meditation is simple to describe and challenging to practice. The
practice suggests you sit comfortably and straight in a chair or on the floor
with hands in your lap and eyes closed. Slowly focus on a chosen thing
such as breathing in and breathing out, paying attention to the sensation
of breath as it flows through your body. Mindfulness meditation helps
one monitor all the experiences and thoughts that enter the mind as an
aware observer. The practice is to become an observer who is aware of all
thoughts, but detached from any one of them. As the mind wanders away,
invite it back to the breath (Salzberg, 2011b). By focusing on the breath,
the practitioner is holding and containing many thoughts, but observing
them without attachment or judgment.
Meditation takes mostly patience?the patience with self during
distractions, as well as the patience in seeing the overall positive effects
of the practice (Salzberg, 2011b). The value of meditation is not in how
long one sits in meditation, but in the regularity with which one practices
it (Salzberg, 2011b, Kornfield, 2008).
Along with patience, meditation requires concentration. Clients who
are experiencing trauma report having very scattered, fearful thought patterns (Courtois, 2004). With vicarious trauma reactions, the clinician can
experience a similar thought pattern. A mind that is jumping from the
past to the future can rarely stay in the present. Regular meditation can be
helpful in focusing on the present. Tich Nhat Hanh (1998) suggests using
everyday activities as meditation to bring us into the present. A small example he offers is to concentrate on food, such as an apple for a few minutes
before eating it, or, while driving, to use a red light to notice one?s breath,
which will bring you into the present. The practiced awareness of breath
and awareness of self and helps the clinician to be present with clients.
Concentration of meditation provides the ability to gather fleeting thoughts
while not giving in to them and giving them energy (Salzberg, 2011b).
The third aspect of mediation is compassion. Compassion differs from
empathy, which is feeling for another. Empathy may extend to the taking
on of the pain of others. Compassion is more of the taking in. In teaching
social work