Individual and Relational Predictors of Compassion Fatigue Among Counselors-in-Training

Nesime Can, Joshua C. Watson


Scholars have described compassion fatigue as the result of chronic exposure to clients’ suffering and traumatic stories. Counselors can struggle when they experience compassion fatigue because of various reasons. As such, an exploration of factors predictive of compassion fatigue may help counselors and supervisors buffer adverse effects. Utilizing a hierarchical linear regression analysis, we examined the association between wellness, resilience, supervisory working alliance, empathy, and compassion fatigue among 86 counselors-in-training (CITs). The research findings revealed that resilience and wellness were significant predictors of compassion fatigue among CITs, whereas empathy and supervisory working alliance were not. Based on our findings, counselor educators might consider enhancing their current training programs by including discussion topics about wellness and resilience, while supervisors consider practicing wellness and resilience strategies in supervision and developing interventions designed to prevent compassion fatigue.


Keywords: compassion fatigue, counselors-in-training, wellness, resilience, supervisory working alliance



Balancing self-care and client care can be a challenge for many counselors. When counselors neglect self-care, they can become vulnerable to several issues, including increased anxiety, distress, burnout, and compassion fatigue (Ray, Wong, White, & Heaslip, 2013). Counselors might be especially prone to experiencing compassion fatigue because they repeatedly hear traumatic stories and clients’ suffering in sessions (Skovholt & Trotter-Mathison, 2016). This phenomenon is likely pronounced among counselors-in-training (CITs), as lack of experience, skillset, knowledge, and support can lead to struggles when working with clients (Skovholt & Trotter-Mathison, 2016). Coupled with the increased anxiety, distress, and disappointment, CITs can experience compassion fatigue early in their career development, which can lead to exhaustion, disengagement, and a decline in therapeutic effectiveness (Rønnestad & Skovholt, 2013). At this developmental stage, negative experiences can lead to feelings of doubt and a lack of confidence among CITs and potentially lead to career dissatisfaction. Therefore, it is essential and necessary to better understand the predictive factors of compassion fatigue among CITs to prevent its early onset.


Compassion Fatigue in Counseling


Counselors listening to their clients’ fear, pain, and suffering can feel similar emotions. Figley (1995) defined this experience as compassion fatigue; it also can be defined as the cost of caring (Figley, 2002). Whether working in mental health agencies, schools, or hospital settings, counselors experience compassion fatigue because of exposure to large caseloads, painful stories, and lack of support and resources (Skovholt & Trotter-Mathison, 2016). Despite this exposure, counselors are expected to place their personal feelings aside and provide the best treatment possible in response to the presenting issues and needs of their clients (Figley, 2002; Ray et al., 2013; Turgoose, Glover, Barker, & Maddox, 2017). Maintaining this sense of detached professionalism has its costs, as a number of counselors find themselves at risk for experiencing physical, mental, and emotional exhaustion, as well as feelings of helplessness, isolation, and confusion—a situation collectively referred to as compassion fatigue (Eastwood & Ecklund, 2008; Thompson, Amatea, & Thompson, 2014).


Merriman (2015b) stated that ongoing compassion fatigue negatively impacts counselors’ health as well as their relationships with others. Additionally, compassion fatigue can lead to a lack of empathy toward clients, decrease in motivation, and performance drop in effectiveness, making even the smallest tasks seem overwhelming (Merriman, 2015b). When this occurs, counselors can project their anger on others, develop trust issues, and experience feelings of loneliness (Harr, 2013). Therefore, the demands of the counseling profession can affect many counselors’ wellness and potentially could hurt the quality of client care provided (Lawson, Venart, Hazler, & Kottler, 2007; Merriman, 2015a). Further, counselors experiencing compassion fatigue might have difficulties making effective clinical decisions and potentially be at risk for harming clients (Eastwood & Ecklund, 2008). Consequently, scholars appear to agree that compassion fatigue is an occupational hazard that mental health care professionals need to address (Figley, 2002; Merriman, 2015a).


Factors Associated With Compassion Fatigue


Many researchers have studied the relationships between compassion fatigue and various constructs, such as empathy, gender, mindfulness, support, and wellness (e.g., Beaumont, Durkin, Martin, & Carson, 2016; Caringi et al., 2016; Ray et al., 2013; Sprang, Clark, & Whitt-Woosley, 2007; Turgoose et al., 2017). Researchers conducted most of these studies among novice and veteran mental health professionals. Scant research among CITs exists. Our research attempts to fill this gap by exploring factors affecting CITs given their unique position as both students and emerging professionals. The following review of the literature supports the inclusion of predictor variables used in this study.


Empathy and Compassion Fatigue

One of the most widely studied concepts across various cultures is empathy, as it has been determined to be one of the major precipitants of compassion fatigue (Figley, 1995). However, findings in the literature regarding the association between compassion fatigue and empathy remain mixed (e.g., MacRitchie & Leibowitz, 2010; O’Brien & Haaga, 2015; Wagaman, Geiger, Shockley, & Segal, 2015). For instance, O’Brien and Haaga (2015) compared trait empathy and empathic accuracy with compassion fatigue after showing a videotaped trauma self-disclosure among therapist trainees (a combined group of advanced and novice graduate students) and non-therapists. The results indicated that there was no significant association between participants’ levels of compassion fatigue and empathy scores. However, MacRitchie and Leibowitz (2010) found a significant relationship between compassion fatigue and empathy after exploring the relation of these variables on trauma workers whose clients were survivors of violent crimes. The mixed results of these previous studies suggest further research is needed to understand better the relationship between empathy and compassion fatigue and how this relationship impacts counseling practice.


Supervisory Working Alliance and Compassion Fatigue

Although reviewed literature addressed studies suggesting supervision and support are related factors to compassion fatigue, research on this relationship is still insufficient. Kapoulitsas and Corcoran (2015) conducted a study and found that a positive supervisory relationship has a significant role in developing resilience and reducing compassion fatigue among counselors. Knight (2010) also found that students uncomfortable talking with their supervisor reported a higher risk for developing compassion fatigue. Additionally, organizational support appears to reduce compassion fatigue, whereas an absence of support increases practitioners’ and interns’ risk of developing compassion fatigue symptoms (Bride, Jones, & MacMaster, 2007). Given the intense need for support and guidance CITs need during their initial work with clients, it is expected that those students who do not actively work with their supervisors can struggle and be more vulnerable for compassion fatigue.


Wellness, Resilience, and Compassion Fatigue

Although counselors are encouraged to practice self-care activities to continue to enhance personal well-being (American Counseling Association [ACA], 2014; Coaston, 2017; H. L. Smith, Robinson, & Young, 2008), not all CITs can balance caring for self and others. When CITs do not receive training in the protective factors for compassion fatigue, they risk becoming more vulnerable to violating the ACA code of ethics (Merriman, 2015a; Merriman, 2015b). Kapoulitsas and Corcoran (2015) and Skovholt and Trotter-Mathison (2016) highlighted the importance of resilience and self-care activities as protective factors for compassion fatigue. Wood et al. (2017) evaluated the effectiveness of a mobile application called Provider Resilience to reduce compassion fatigue scores of mental health professionals. After a month of utilization, the results indicated that the application was effective in reducing compassion fatigue. Additionally, Lawson and Myers (2011) conducted a study with professional counselors to examine counselor wellness about compassion fatigue and found a negative correlation between total wellness scores and compassion fatigue scores. As CITs balance academic, family, and work demands, the probability of decreased wellness and a corresponding increase in compassion fatigue exists.


Compassion Fatigue Among CITs


Most CITs are often unable to master all counselor competencies (Rønnestad & Skovholt, 2013), and therefore they might not know how to deal with possible stressors and the emotional burden of their work (Star, 2013). Although they are learning counseling skills to provide the best care possible to clients, CITs may find themselves working with seriously troubled or traumatized clients without obtaining quality supervision and support (Skovholt & Trotter-Mathison, 2016). Lack of skills and resources increases the likelihood of CITs developing compassion fatigue (Merriman, 2015b). However, there is a lack of focus in compassion fatigue education on preparing CITs to manage compassion fatigue symptoms (Merriman, 2015a). Although scholars have examined compassion fatigue among counselors, there is still a dearth of studies investigating the level of compassion fatigue among CITs and addressing its protective factors within this population (Beaumont et al., 2016; Blount, Bjornsen, & Moore, 2018; Thompson et al., 2014). Subsequently, further research is needed to understand better potential protective factors that can be enhanced to offset the negative impact of compassion fatigue on CITs and the counseling process. Thus, with this study, we aimed at assessing the relationship between resilience, wellness, supervisory working alliance, empathy, and compassion fatigue among CITs in the United States. To accomplish this goal, we sought to answer the following research questions: (1) What is the prevalence of compassion fatigue among CITs? and (2) Do empathy, supervisory working alliance, resilience, and wellness significantly predict levels of compassion fatigue among CITs?





Participants recruited for this study consisted of master’s-level counseling students who are at least 18 years of age and enrolled in an internship course in the United States through mostly professional listservs (e.g., Counselor Education and Supervision Network Listserv [CESNET-L], Texas Association for Counselor Education and Supervision Network Listserv [TACESNET-L], Counseling Graduate Student Network [COUNSGRADS]). Because of the impossibility of knowing how many individuals received the email invitation, we were unable to calculate and determine a response rate. Accordingly, a total of 114 CITs initially agreed to participate in this study. Before data analysis, we inspected the data set for possible entry errors and missing data. After the inspection, we excluded 28 participants from all subsequent data analyses resulting in the reduced sample of 86 CITs used to address our research questions. Overall, the sample consisted of 78 female (90.7%) and eight male (9.3%) participants, and the mean age of the participants was 32.89 years (SD = 9.72) with participants’ ages ranging between 21 and 62 years. Participants were from diverse ethnic and racial backgrounds, with the sample consisting of White (n = 48, 55.8%), Hispanic/Latino (n = 18, 20.9%), Black/African American (n = 12, 14.0%), and Asian (n = 5, 5.8%) CITs. Three participants (3.5%) listed their ethnicities as “other” when providing demographic information. Participants reported their program enrollment as follows: clinical mental health counseling program (n = 47, 54.7%); school counseling program (n = 23, 26.7%); marriage, couple, and family counseling program (n = 4, 4.7%); college counseling and student affairs program (n = 3, 3.5%); addiction counseling program (n = 2, 2.3%); and other programs (n = 7, 8.1%). Additionally, most of the participants (n = 73, 84.9%) reported enrollment in a CACREP-accredited program with the remaining participants (n = 13, 15.1%) enrolled in a non–CACREP-accredited program.



Upon receiving institutional review board approval, we recruited participants from different institutions with the primary researcher contacting professional colleagues at various departments to disseminate the online survey link to potential participants during the 2017 summer and fall semesters. We also recruited participants through professional listservs (e.g., CESNET-L, TACESNET-L, COUNSGRAD), with listserv participants being provided the same informed consent and survey link through a secure website. The survey completion process took approximately 15–20 minutes.



We used the following self-administered survey questionnaires and a separate demographic data sheet in our data collection.


     Professional Quality of Life Scale (ProQOL). This scale is designed to measure the mental and emotional consequences of working with individuals who experienced trauma or painful events (Stamm, 2010). The ProQOL includes two main traits, Compassion Satisfaction (positive) and Compassion Fatigue (negative). Compassion Satisfaction is related to the joy individuals develop when they do their work well (Stamm, 2010). Compassion Fatigue consists of two subscales: Secondary Traumatic Stress (STS) and Burnout. Scholars have defined STS as an emotional state that occurs when an individual becomes upset or traumatized as a result of their exposure to victim experiences (Figley, 2002). The second part of Compassion Fatigue is Burnout, which is a multidimensional syndrome related to the social work environment. Burnout could be related to work overload, lack of control, insufficient rewards, unfairness, and value conflict at a workplace (Skovholt & Trotter-Mathison, 2016).


The ProQOL is a 30-item Likert-type self-report assessment with responses of never, rarely, sometimes, often, and very often for each item. A sample item is “I feel depressed because of the traumatic experiences of the people I [help].” This assessment has 10 questions per each of three main scales measuring separate constructs. However, the Compassion Fatigue scale includes two of these constructs, which are the Burnout and the STS scales. According to Stamm (2010), the ProQOL has good construct validity, as researchers have noted its efficacy in over 200 published articles. Finally, alpha coefficient values for the Burnout and STS scales were .75 and .81, respectively (Stamm, 2010), and are similar (.72 and .79) to the Cronbach’s alpha values from the current study presented in Table 1.


Table 1

Descriptive Statistics of the Study Variables (N = 86)

Variable M SD Min Max Skew α
Compassion Fatigue 41.48 8.03 22 60    .19
BO 21.34 4.38 12 32 .72
STS 20.14 4.96 10 38 .79
Empathy 21.86 4.12   9 28   -.51 .80
Supervisory Working Alliance   5.82   .97   2.16   7  1.26
CF   6.65 1.30   2.17   8.17 .90
R   5.80   .96   2.33   7 .93
Resilience   3.43   .79   1   4.67   -.74 .89
Wellness 47.58 6.23 27 56 -1.39 .86

Note. BO = Burnout; STS = Secondary Traumatic Stress; CF = Client Focus; R = Rapport



     Interpersonal Reactivity Index (IRI). Davis (1983) developed the IRI to measure the reactions of a person to other individuals’ observed experiences. The 28-item instrument has four subscales: Empathic Concern, Perspective Taking, Fantasy, and Personal Distress (Davis, 1983). Researchers report separate subscale scores, as a total score for the instrument has not been recommended (Davis, 1983). In this study, we only used the Empathic Concern subscale to collect data regarding empathy scores of CITs.


Davis (1983) described empathic concern as an emotional response, such as compassion and sympathy, to someone else in need. The 7-item subscale is a self-report assessment with a 5-point Likert-type scale, ranging from Does not describe me well to Describes me very well. A sample item is “I am often quite touched by things that I see happen.” An alpha coefficient of .77 has been reported for the Empathic Concern subscale (Péloquin & Lafontaine, 2010), while the Cronbach’s alpha value of the IRI in the current study was .80.


     Supervisory Working Alliance Inventory: Trainee Form (SWAI-T). Efstation, Patton, and Kardash (1990) developed this inventory to measure supervisees’ perceptions about the effectiveness of the working relationship with their supervisors, and we used the SWAI-T to measure the construct of the supervisory working alliance. With a total of 19 items, the self-report assessment includes a 7-point Likert-type scale with responses ranging from almost never to almost always. A sample item is “When correcting my errors with the client, my supervisor offers alternative ways of intervening with the client.” The SWAI-T has two subscales—Client Focus and Rapport—and the Cronbach alpha coefficients of these scales were .77 and .90, respectively (Efstation et al., 1990). For the current study, we calculated Cronbach alpha values of .90 for the Client Focus subscale and .93 for the Rapport subscale. Because some researchers have found high correlations between these two subscales, they decided to combine them in their studies (e.g., Ganske, 2007; White & Queener, 2003). Therefore, in this study, after conducting a correlation analysis with the subscale scores, we also chose to combine subscales as the results of subscale scores were highly correlated.


     Brief Resilience Scale (BRS). The BRS was developed to measure a person’s ability to recover from stress and cope with challenging situations (B. W. Smith et al., 2008). The BRS is used to measure the construct of resilience. As a 6-item self-report assessment, the BRS includes a 5-point Likert-type scale with responses ranging from strongly disagree to strongly agree. A sample item is “I usually come through difficult times with little trouble.” B. W. Smith and colleagues (2008) reported that the Cronbach’s alpha values of the BRS range from .80 to .91, and we calculated a Cronbach alpha of .89 for the current study.


     Flourishing Scale (FS). The FS was designed to measure individuals’ self-perceived success in areas like optimism and relationships (Diener et al., 2010) and used to measure the construct of wellness in this study. The FS is an 8-item self-report assessment with a 7-point Likert-type scale with responses ranging from strongly disagree to strongly agree (Diener et al., 2010). A sample item is “I lead a purposeful and meaningful life.” Diener and colleagues (2010) reported moderately high reliability with a .87 Cronbach’s alpha coefficient, and in the current study, the FS had a Cronbach alpha of .86.


Data Analysis

     Statistical power analysis. We used an a priori type of the G*Power to set the minimum number of participants needed to detect statistical power for this research design. Based on an alpha of .05, a power level of .90, and four predictors (Faul, Erdfelder, Buchner, & Lang, 2009), the computation results suggested that a minimum of 73 participants was required to detect statistical significance with at least a moderate size effect (.15). We had 86 participants, suggesting adequate power.


     Preliminary analyses. We analyzed all data using the Statistical Package for the Social Sciences, Version 20 (SPSS; IBM Corporation, 2011). Before addressing our stated research questions, we cleaned the dataset and addressed missing data. We did not observe any pattern between missing data points. Therefore, the type of missing data was completely random, which was addressed using the series of mean function within the SPSS. Next, we calculated descriptive statistics and alpha coefficients for each scale used in the study (see Table 1). Before performing hierarchical regression analyses, we tested all associated model assumptions. First, we examined study variables based on their types and concluded each utilized a continuous scale. We then assessed normality with the Shapiro-Wilk test of normality (W > .05), indicating data was normally distributed for the dependent variable. To identify outliers, we examined boxplots. Although there were a few mild outliers, no extreme scores were detected. We assessed linearity and homoscedasticity through inspection of standardized residual plots. To assess for the assumption of multicollinearity, we examined the correlation matrix of study variables to determine if any correlated highly. According to Field (2013), correlations above .80 are considered high and may indicate the presence of multicollinearity. In the present study, none of the correlation coefficients were above .50 (see Table 2). Collectively, these findings indicated no evidence suggesting any of the model assumptions had been violated. As a result, the dataset was deemed appropriate for analysis using a hierarchical regression design.


     Primary analysis. Descriptive statistics were calculated to organize the data by producing means, mode, median, standard deviations, and minimum and maximum scores for the study variables (Field, 2013). Individually, we reviewed descriptive statistics for the compassion fatigue variable, and results were reported to address the first research question. Next, we performed a three-step hierarchical linear regression to address the second research question.


Table 2


Intercorrelations for Scores on the Study Variables

Variable 1 2 3 4 5
1. ProQOL-CF
2. SWAIT-T   .04
3. IRI-EC  -.06  .04
4. BRS    -.47** -.09 -.11
5. FS    -.45**  .12    .25* .35**

Note. N = 86; ProQOL = Professional Quality of Life (Compassion Fatigue [CF] subscale score is presented); IRI = Interpersonal Reactivity Index (Empathic Concern [EC] subscale score is presented); SWAI-T = Supervisory Working Alliance Inventory: Trainee Form; BRS = Brief Resilience Scale; FS = Flourishing Scale.

*p < .05.  **p < .01.






Compassion fatigue scores of CITs represent the sum of scores of all items on the STS and Burnout subscales. According to the ProQOL administration manual (Stamm, 2010), individuals scoring below 22 may indicate little or no issues with Burnout and STS, while scores between 23 and 41 indicate moderate levels of Burnout and STS, and scores above 42 indicate higher levels of Burnout and STS. For this sample, participants’ Burnout scores ranged from 12 to 32 with a mean of 21.34 (SD = 4.38), and STS scores ranged from 10 to 38 with a mean of 20.14 (SD = 4.96). These results indicated a low risk of both Burnout and STS among CITs.


To address the second research question, we performed a three-step hierarchical linear regression analysis. With this analysis, we aimed to assess the association between resilience, wellness, supervisory working alliance, empathy, and compassion fatigue. We chose to implement a hierarchical multiple regression analysis because scholars previously have highlighted the essential relationship between empathy, supervision, and compassion fatigue (Figley, 2002; MacRitchie & Leibowitz, 2010). In the first step, empathy scores entered the model as a predictor variable, as Figley (1995) stated that empathy is one of the main factors contributing to compassion fatigue. However, among this sample, we found that empathy was not a significant predictor of compassion fatigue: F(1, 84) = .2, p = .66 , R2 = .002 (adjusted R2 = -.01). Then, we added supervisory working alliance scores to the model in the second step, as both Knight (2010) and Miller and Sprang (2017) emphasized the importance of supervisory support for mental health practitioners. Results revealed that the supervisory working alliance variable also was not a significant predictor of compassion fatigue: F(2, 83) = .16, p = .85, R2 = .004 (adjusted R2 = -.02). In the third step, resilience and wellness scores were entered into the model to determine whether these variables significantly improved the amount of explained variance in compassion fatigue. Results showed that this combination of variables significantly predicted 26% of the variance in compassion fatigue: F(4, 81) = 8.57, p < .001, R2 = .30. Therefore, it was concluded that CITs with greater wellness and resilience reported developing less compassion fatigue (see Table 3).


Table 3

Hierarchical Regression Analysis Results for Variables Predicting Compassion Fatigue

Variables B SEB β R2 ΔR2
Step 1 .002 -.01
Empathy   -.09 .21 -.05
Step 2 .004 -.02
Empathy   -.10 .21 -.05
SWA    .33 .91  .04
Step 3 .30*  .26
Empathy   -.03 .19 -.02
SWA    .36 .78  .04
Wellness   -.39 .14  -.30*
Resilience  -3.66     1.05  -.36*

Note. SWA = Supervisory Working Alliance

*p < .05.





In this study, CITs reported having a low risk of compassion fatigue. When we examined the Burnout and STS scores separately, the main contributors of compassion fatigue (Stamm, 2010), both subscale scores indicated participants having a low risk for STS and Burnout. This finding is similar to results found by Beaumont and colleagues (2016) in their study of compassion fatigue, burnout, self-compassion, and well-being relationships among student counselors and student cognitive behavioral psychotherapists. According to their research findings, a total of 54 student participants reported high scores on self-compassion and well-being and reported less compassion fatigue and burnout (Beaumont et al., 2016).


One of the goals of this study was to seek understanding of whether wellness and resilience explain a statistically significant amount of variance in compassion fatigue among CITs after accounting for empathy and supervisory working alliance. The results indicated that empathy and supervisory working alliance were not significant predictors of compassion fatigue. Regarding empathy and compassion fatigue relation results, the findings of this study did not support Figley’s (1995) assumption of empathy as one of the main contributors to compassion fatigue. This result also is inconsistent with Wagaman and colleagues’ (2015) results indicating a significant association between empathy and compassion fatigue among social workers. However, current results aligned with those studies that found no correlation between empathy and compassion fatigue (e.g., O’Brien & Haaga, 2015; Thomas & Otis, 2010). An explanation of the variability between this inquiry and previous studies might lie with the difference between participants’ field of study and measurement differences. Also, none of the previous studies used CITs solely as their sample, nor used a similar way to measure the construct of empathy. Additionally, CITs would have less experience working with clients compared to experienced counselors, and thus less time for feelings of compassion fatigue to build.


Although scholars addressed the importance of supervision and supervisory working alliance to help prevent compassion fatigue (Kapoulitsas & Corcoran, 2015; Merriman, 2015a), this study’s results indicated supervisory working alliance was not a significant predictor of compassion fatigue among CITs. Like current results, Ivicic and Motta (2017) and Williams, Helm, and Clemens (2012) found no statistically significant association between supervisory working alliance and compassion fatigue among mental health practitioners. It is noteworthy that these studies highlighting the importance of supervision and the supervisory relationship are qualitative in design, and participants did not consist solely of CITs. Additionally, their results emphasized the importance of supervision as support to counter the negative impact of trauma exposure (Kapoulitsas & Corcoran, 2015; Ling, Hunter, & Maple, 2014). According to the current study results, CITs did not report experiencing a high level of compassion fatigue. This finding could be interpreted as CITs not yet feeling the need for supervisory support to help with compassion fatigue.


Results also indicated that resilience and wellness were significant predictors of compassion fatigue among CITs. In other words, when reflecting on both the regression and correlation results, CITs with greater resilience and wellness reported lower scores of compassion fatigue and these results were consistent with Tosone, Minami, Bettmann, and Jasperson’s (2010) research findings. Regarding a wellness and compassion fatigue relationship, Beaumont and colleagues (2016) conducted a study with student counselors and student cognitive behavioral psychotherapists. The results of Beaumont et al.’s study revealed that individuals with high scores of self-compassion and well-being reported having less compassion fatigue and burnout. Thomas and Morris (2017) also highlighted the significance of self-care and well-being not only for preventing and helping to manage the potentially damaging impact of practice, but also for facilitating the counselor’s personal and professional growth.


Implications for Counselor Educators and Supervisors


The research findings provide data-driven results regarding compassion fatigue among CITs that have meaningful implications for counselor educators and supervisors. Present study results revealed that CITs indicated experiencing a low risk of compassion fatigue. However, raising awareness on this issue may still help CITs as a preventative measure to cope with possible compassion fatigue experience in the future. To address this issue, counselor educators may consider raising awareness on this topic by reviewing current counseling program curricula to add discussion questions related to compassion fatigue and its empirically predictive factors—wellness and resilience. Roach and Young (2007) stated that students in counseling programs reported group counseling, counseling techniques, legal and ethical issues, practicum, and wellness courses as contributing most to their knowledge and skills regarding wellness. Therefore, counselor educators might use different assignments, including group discussions, projects, and role-playing exercises, to open a discussion about the compassion fatigue phenomenon and the relation with its predictive factors and these courses. Counselor educators may also use the ProQOL scale as an assignment in an assessment and testing course to inform CITs about how to use this instrument as a self-monitoring aid. For example, professional counselors may feel overwhelmed because of working with trauma survivors after graduation and start noticing compassion fatigue symptoms in themselves. These individuals may self-administer the ProQOL scale to determine whether they have developed compassion fatigue. Additionally, in a practicum or an internship course, CITs may fill out the ProQOL as part of their continuing personal wellness plan by comparing personal results over time and sharing their thoughts and reflections about the results.


Supervisors need to find ways to raise awareness of compassion fatigue and its protective factors with CITs. For instance, during internship experience, supervisors may develop a site training including compassion fatigue awareness for CITs, as CITs should be prepared for the possible emotional and psychological consequences in working with trauma survivors. Student counselors also should be encouraged to advocate for themselves when they notice symptoms of compassion fatigue. Supervisors might consider the administration of the ProQOL scale regularly to assess both organizational and individual risks (Newell & MacNeil, 2010). Additionally, supervisors can use the ProQOL scale with their supervisees to start a conversation about compassion fatigue. Although the ProQOL is not a diagnostic test, the 30-item self-report scale can be utilized readily as a conversation starter in supervision sessions.


The results suggested that empathy and supervisory working alliance did not predict CITs’ compassion fatigue level. However, wellness and resilience are significantly related to contributing to it. Therefore, both counselor educators and supervisors might consider enhancing CITs’ resilience and wellness a worthwhile endeavor. For example, Miller and Sprang (2017) developed a component-based practice and supervision model to reduce compassion fatigue for use in training, supervision, and clinical practice. A tool like this one can be added to existing training curricula and supervision practice to improve CITs’ resilience and wellness.



The results of this study aim to provide greater clarity regarding the predictive factors of compassion fatigue among CITs. However, interpretation of results should take into consideration the limitations that emerged because of uncontrollable influences and choices we made. The study was limited in its ability to represent all CITs throughout the United States, as we utilized a convenience sampling approach. Additionally, we gathered data through self-report questionnaires, which introduce the possibility of response bias in the findings. Although we assumed participants answered each question honestly, they might not have been honest in their responses because of the fear of being perceived as weak or less competent. It is important to note that being in an internship class might also increase participants’ interest in the profession as they currently are engaged in the practice of counseling. Therefore, participants might have had a higher level of enthusiasm and reported less compassion fatigue. Also, individuals who suffer from compassion fatigue might have preferred not to respond to these items. Finally, although participants were enrolled in an internship class, each participant may have different numbers of hours of client experience.


Future Directions for Research

Additional research should be conducted to expand and clarify the current research findings of compassion fatigue among CITs. A phenomenological study using a qualitative research method is recommended to expand the findings of this current study. Future researchers may use the ProQOL scale to assess CITs’ level of compassion fatigue and then conduct interviews with the volunteer participants reporting a higher level of compassion fatigue to better understand CITs’ experience with compassion fatigue and its contributing factors. The data collected through a qualitative study may provide greater insight into the phenomenon of compassion fatigue among CITs. Additionally, researchers can replicate the present study with early-career counselors who have recently graduated, because of the noted intensity of those first years after graduation (Skovholt & Trotter-Mathison, 2016). Therefore, future researchers exploring novice counselors’ experiences with compassion fatigue will help counselor educators and supervisors better understand when counselors may start developing compassion fatigue symptoms, as well as how they cope with the symptoms.




CITs may struggle when they continuously hear painful stories of clients because of a lack of experience, skillset, or support (Skovholt & Trotter-Mathison, 2016). Researchers have described this experience as compassion fatigue. With this study, we aimed to provide a better understanding of the predictive factors of compassion fatigue among CITs. Using data-driven research results to determine ways to work with CITs on compassion fatigue and its predictive factors can be beneficial in preventing compassion fatigue symptoms from an early onset. CITs may take precautionary measures to ensure they remain enthusiastic and energized by the work they do. Further, implications of the current study may help CITs start their professional careers better prepared to provide their clients with the optimal care needed throughout the counseling relationship by minimizing compassion fatigue.



Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.






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Nesime Can is an instructor at Ankara University in Turkey. Joshua C. Watson, NCC, is a professor and department chair at Texas A&M University–Corpus Christi. Correspondence can be addressed to Nesime Can, Ankara University Faculty of Educational Sciences, Department of Educational Sciences, Program of Counseling and Guidance, Office 3111, Çankaya, Ankara, Turkey 06590,

Counseling Children With Cystic Fibrosis: Recommendations for Practice and Counselor Self-Care

Cassandra A. Storlie, Eric R. Baltrinic

Cystic fibrosis is a progressive, chronic disease that affects approximately 30,000 adults and children in the United States. Counseling children with the special needs specific to cystic fibrosis can be overwhelming for mental health professionals due to the progressive and deteriorating nature of the illness, long-term contact with clients, and discouraging prognosis. Being exposed to long-term therapeutic relationships with chronically ill children and witnessing treatment failure can contribute to burnout, compassion fatigue and vicarious trauma in counselors, highlighting the need for targeted literature addressing holistic self-care strategies. The purpose of this manuscript is to provide a review of the current literature illuminating the challenges facing children with cystic fibrosis and to provide targeted self-care suggestions for professional counselors working with this population.


Keywords: children, chronic disease, compassion fatigue, cystic fibrosis, self-care



Cystic fibrosis (CF) is a chronic, terminal disease targeting most organ systems (Withers, 2012) and affects approximately 30,000 children and adults nationwide (Cystic Fibrosis Foundation [CFF], 2014a). CF primarily affects the gastrointestinal and respiratory systems (Withers, 2012), and although the life expectancy has greatly improved, CF is fatal and there is no known cure (CFF, 2014a). Counseling children with chronic illnesses, such as CF, presents special challenges for mental health professionals (Sidell, 1997), including professional counselors. As the nature and severity of clients’ problems impact levels of counselor burnout or compassion fatigue (Figley, 2002), it is essential that professional counselors working with children with CF maintain healthy self-care practices.


There is an abundance of information examining the physiological aspects of CF that clients experience throughout the disease progression (CFF, 2014a; Pearson, Pumariega, & Seilheimer, 1991; Sawicki, Sellers, & Robinson, 2009; Sawicki & Tiddens, 2012). However, there is limited literature on the special considerations that need to be taken when counseling children with CF. Furthermore, there is a paucity of counseling literature targeting how professional counselors can foster personal self-care while working with young clients with special needs and chronic conditions. The purpose of this manuscript is to provide a review of literature that illuminates the challenges facing children with CF and provides a primer for self-care suggestions for professional counselors who work with these children.


Special Needs of Children with Cystic Fibrosis


Physiological Challenges Facing Children with Cystic Fibrosis

Professional counselors need to be knowledgeable of chronic diseases affecting their clients in order to be sensitive to the traumas experienced by children and families coping with illness (Thompson & Henderson, 2007). CF is most commonly diagnosed during newborn screening and severely affects the exocrine system (CFF, 2014b). Within the exocrine system, there is a lack of appropriate enzymes available during digestion, so children with CF are unable to properly digest their food and absorb essential nutrients for healthy growth and development. They experience recurrent gastrointestinal distress such as issues of diarrhea and constipation with foul-smelling stools due to poor absorption (CF Living, 2014). As such, children with CF often suffer from malnutrition and an inability to maintain a healthy weight. However, the most notable signs and symptoms affecting children with CF result from chronic lung and respiratory infections that lead to frequent coughing spells to clear the lungs of thick mucus. This inability to clear the lungs requires multiple episodes of daily chest physiotherapy (Berge & Patterson, 2004). Over time, the respiratory infections produce lung damage that appears cyst-like, giving name to the disease cystic fibrosis (CFF, 2014a).


Children with CF can spend hours per day on medical treatments such as nebulizer treatments to improve breathing, medications prior to meals to improve digestion, and oral, inhaled or intravenous antibiotics to treat respiratory infections (CF Living, 2014). However, disabilities from CF are not often visibly apparent until later stages of the disease. Decreased mobility and debilitating side effects from long-term medications, along with decreased lung capacity, all contribute to clients with CF requiring oxygen therapy for survival (Withers, 2012). The later stages of CF are inundated with frequent hospitalizations. Treatment during end-stage CF is palliative rather than curative (Lowton & Gabe, 2003), and without lung transplantation, CF remains a fatal disease due to respiratory failure (Hayes, Anstead, Warner, Kuhn, & Ballard, 2010). Nevertheless, medical breakthroughs have increased the survival rate of children with CF (Blum, 1992) and now many children are living into adulthood. Advanced clinical drug trials, aggressive antibiotic medications and innovative gene therapy research have been successful with CF clients of all ages. In 1955, children with CF were not expected to live to attend grade school. Children born with CF in this decade are projected to live into their 40s (CFF, 2014a). With this increase in life expectancy, health care teams are faced with unique challenges specific to the turbulence of adolescence and treatment compliance (Withers, 2012). Although there has been a predominant focus on treating CF based on medical science (Chesson, Chisholm, & Zaw, 2004), there is a strong interconnection of the psychosocial and physical challenges facing children and adolescents with CF. As such, professional counselors are called to increase their knowledge, skill and awareness of not just the physical challenges affecting children with CF, but also the emotional obstacles facing this population.


Psychosocial Challenges Facing Children with Cystic Fibrosis

Emotional and behavioral health disorders affect approximately 20% of all children and adolescents nationwide (Canning, Haner, Shade, & Boyce, 1992), and children with chronic illness may exhibit even higher incidences of mental health and psychosocial issues (Barnes, Eisenberg, & Resnick, 2010). For example, children with CF may experience extreme psychological challenges (e.g., depression, hopelessness, suicidal ideation) and physical complications (e.g., poor lung functioning, malnutrition) throughout the progression of their chronic condition. Taken together, these comorbidities contribute to the complexity of supporting an intense treatment modality (Anderson, Flume, & Hardy, 2001; Withers, 2012) that also promotes healthy psychosocial development and family system functioning (O’Haver et al., 2010).

In order to provide evidenced-based practices to clients with CF, as well as their families and loved ones, professional counselors need to be current on mental health research related to this special population. Studies have identified that children with CF may be predisposed to psychological issues and attachment and behavioral problems (Berge & Patterson, 2004) that may require additional training for professional counselors to effectively and efficiently counsel this population. When compared to healthy peers, children with chronic health conditions also have been found to have a slightly higher risk of attempting suicide (Barnes et al., 2010). Grief and loss, internal and external stress, negative body image, and difficulty managing emotions are common challenges experienced by children with CF (Berge & Patterson, 2004; Withers, 2012). In managing these difficulties, internalizing behaviors and anxiety also have been found prominent among this population (Berge & Patterson, 2004). Younger male children with CF have been found to exhibit higher levels of anxiety (Bregnballe, Thastum, & Schiøtz, 2007) and female children with CF have demonstrated internalizing behaviors by expressing less anger than female children without CF (Bregnballe et al., 2007).


Although research supports the idea that individuals with chronic illnesses are at increased risk for depression (Quittner et al., 2008), studies conducted on individuals with CF have provided mixed results (Pearson et al., 1991; Thompson, Hodges, & Hamlet, 1990). Berge and Patterson (2004) identified higher incidences of depression among youth with CF, whereas Tluczek et al. (2014) found that patients with CF report similar psychosocial functioning as their healthy peers. One possible factor affecting the mixed reports of depression among children with CF may include the level of disease acceptance. Previous investigations have identified that the level of disease acceptance among youth with CF can significantly lessen levels of anxiety, depression and disability in adolescents with CF (Casier et al., 2008). Nonetheless, depression and depressive symptoms have been shown to impact the progression of chronic diseases, such as CF, by increasing the likelihood that clients will be less compliant with treatment regimens and partake in risky behaviors (Quittner et al., 2008; Withers, 2012). Hence, we recommend assessing and screening for depressive symptoms frequently and examining the level of disease acceptance in clients with CF. Professional counselors working with children with CF will need to further tailor interventions based on the client’s symptom patterns (Chesson et al., 2004), while accounting for changes typical of childhood development.


Recently, scholars have researched the experiences of adolescents with CF in their transition to adulthood. This turbulent time (Withers, 2012) may need special consideration by professional counselors. Qualitative research on the experiences of adolescents with CF who were transitioning to adulthood generated the following three emerging themes: treatment compliance, health-related problems and future outlook concerning their disease (Berge, Patterson, Goetz, & Milla, 2007). Male participants described being more independent with treatment compliance, whereas females desired an accountability partner for their treatment regimen. Female participants expressed issues with depression, negative body image and fear of diabetes as a complication from CF, whereas males only disclosed their fear of acquiring diabetes as the disease progressed. Interestingly, both male and female participants expressed a positive outlook concerning CF regarding identity and acceptance of the disease (Berge et al., 2007). Identifying and maintaining a positive outlook while dealing with a chronic and debilitating illness can be a challenge for children with CF and their parents and families. Professional counselors working with youth with CF need to consider these findings. Special attention may be given to issues of treatment compliance, further physical complications from CF and maintaining a positive outlook.


Regarding risky behaviors (Quittner et al., 2008), teenagers with CF have admitted to using alcohol and drugs to seek relief from the challenges of CF (Vaeth & Martins, 2015). As such, professional counselors working with children with CF need to tailor interventions to the individuals’ symptom-specific patterns (Chesson et al., 2004) and be mindful of behaviors that may hasten the disease process. The use of alcohol and drugs may hasten the disease’s progression because of the ways in which these substances can interact with the client’s current prescription medication regimen. Alcohol use may result in pancreatitis and a hypoglycemic reaction (Withers, 2012). Likewise, clients who smoke legal and illegal substances contribute to the deterioration of lung functioning. We recommend frequently assessing and screening for substance abuse and depressive symptoms and exploring the level of disease acceptance among youth with CF in creative, developmentally appropriate ways. Importantly, professional counselors preparing counseling interventions for children with CF need to account for the added psychosocial and developmental challenges that are typical in childhood development.


Special Considerations When Counseling Children with Cystic Fibrosis


     Many children share similar psychological and developmental needs as they grow (Thompson & Henderson, 2007). However, children with chronic illness may struggle to be emotionally mature, while simultaneously managing the physical symptoms of their conditions (Dahlbeck & Lightsey, 2008). Furthermore, the psychosocial complexities and the chronic nature of CF may create unique challenges for professional counselors providing services to children and their families, such as the deteriorating nature of CF, frequent hospitalizations and the life-threatening prognosis (Frels, Leggett, & Larocca, 2009; Morison, Bromfield, & Cameron, 2003). Counseling professionals’ increased sensitivity to the progression and impact of this disease can help guide their intervening efforts (Chesson et al., 2004) by leading them to consider the physiological and psychological trauma caused by CF. Professional counselors must ensure that they have developed rapport with the child as an individual, instead of a child with a disability (Thompson & Henderson, 2007).


Counseling interventions for children with CF begin with recognizing that children with CF are not adults with CF. Therefore, treatment and counseling efforts need to allow for special consideration of childhood development and understanding (Chesson et al., 2004; Geldard & Geldard, 2008). Chesson et al. (2004) offered suggestions for meeting the needs of children with chronic illnesses through counseling. First, counselors need to obtain the child’s understanding of counseling (e.g., what it is, how it will help, roles, communication). Although parental support and involvement is important when counseling children (Geldard & Geldard, 2008; Morison et al., 2003), relying solely on parental reports is not a replacement for exploring the child’s perspective of counseling (Geldard & Geldard, 2008). Chronic illnesses such as CF impact the whole family system (Kirk et al., 2013). However, within the therapeutic counseling relationship, children with CF must feel as if they are the experts on their lives and their mental health, regardless of age.


Second, counselors working with children should limit the amount of talking they do in session (Chesson et al., 2004) in favor of engaging children through natural modes of expression such as play, drawing and games. We recommend structuring counseling sessions to include discussions alongside an activity, versus a sole reliance on face-to-face conversation, in order to improve rapport building within the therapeutic relationship. Children engaging in healthy interdependent relationships with counselors can begin to develop a sense of independence and trust (Juntunen & Atkinson, 2002) within the counseling process, despite the tumultuous times during the disease progression. The adverse impact of chronic illness on social functioning (Last, Stam, Onland-van Nieuwenhuizen, & Grootenhuis, 2007) can lead to social withdrawal (Dahlbeck & Lightsey, 2008), which can be intensified when there is a concentrated focus on the child via adult approaches to counseling (e.g., making the child the center of attention to discuss his or her illness). As such, we recommend that professional counselors make age-appropriate and developmental adjustments to the counseling session and consider instituting group counseling modalities to counter the regularity of social isolation among these children.


Third, professional counselors developing a therapeutic relationship with a child experiencing CF must incorporate interactions that address the traumatic impact of living with the illness. Children with CF undergo physically stressful and painful experiences during medical treatment. Geldard and Geldard (2008) suggested that professional counselors clarify the nature of counseling and differentiate it from medical treatments. They also suggested maintaining an environment that provides acceptance and invites free disclosure. Professional counselors are urged to explain the distinction between counseling and medical procedures (e.g., there are no needles or painful medical procedures in counseling). Professional counselors also are encouraged to engage children in activities and play to reduce their level of anxiety and guardedness (Chesson et al., 2004). These targeted counseling strategies can promote resiliency factors such as self-efficacy and empowerment so that children may cope with adversity throughout the illness (Dahlbeck & Lightsey, 2008; Luszczynska, Gutiérrez-Doña, & Schwarzer, 2005). Chesson et al. (2004) further suggested that counselors gradually establish the therapeutic relationship over a number of shorter sessions in order to establish trust with the child. We caution against rushing the counseling relationship-building process and encourage professional counselors to listen openly in order to understand the child’s world.


As children struggle with chronic illnesses such as CF, acute emotional reactions are invariably triggered, which may increase the propensity for children to act out in self-injurious ways (Vaeth & Martins, 2015). The counseling process requires consistency and transparency when discussing how a child’s treatment progress will be shared among adults. Accordingly, a fourth special consideration needs to be illuminated—the limits of confidentiality. Professional counselors must illustrate the circumstances when parents will be notified of instances of self-harm or suicidal and homicidal ideation. Given the susceptibility of children with chronic illnesses to depression (Quittner et al., 2008) and suicidal ideation (Barnes et al., 2010), coping with the challenges and effects of CF are constantly in the minds of these children. Rebecca Mueller (2001) illustrated this point as a young person struggling with the illness as follows:


All the information I have about my disease has been dispersed in small pieces over time. The idea that [when] a child with CF reaches a certain age, truth and honest answers should suddenly be given is awful. With the many different sides and aspects of CF or other diseases, the information needs to come out over time, giving the person time to react and contemplate. (p. 43)


Professional counselors working with children with CF understand the need for a collaborative approach in supporting individuals and families experiencing the trauma of chronic illness. Children with chronic diseases are involved with multiple treatment professionals (e.g., dieticians, respiratory therapists, physicians, nurses, case managers, mental health and school counselors). Chesson et al. (2004) recommended that counselors assist children with understanding the decisions made by their parents, doctors and other professionals about their treatment. This task can be done by assessing the child’s knowledge of the disease process and treatment and initiating family sessions or sessions with other health care professionals when warranted. Ultimately, children who protest treatment interventions can be overridden by a caregiver’s decision. When children have a history of adult-driven decisions related to life-preserving medical treatments, this experience can make behavioral counseling interventions difficult. We suggest that counselors make every effort to respect the feelings and wishes of children with CF, including helping to “coordinate services, rearranging physical environments, removing barriers and inconveniences, and securing special equipment and materials” (Thompson & Henderson, 2007, p. 713). Professional counselors can further facilitate this supportive process by empowering children to identify and articulate their perspectives on medical treatments, given their limited choices (Chesson et al., 2004; Morison et al., 2003).


Family Involvement

Family involvement is critical to all aspects of treatment of children with CF, starting with diagnosis. Parents and families are significantly affected when their child is diagnosed with a chronic illness (Anderson et al., 2001; O’Haver et al., 2010). Thompson and Henderson (2007) explained, “The demands for energy, time, and financial resources may add a heavy burden of stress to families” (p. 602). It is essential to note that families and children face myriad stressors related to the “uncertainty and uncontrollability” of chronic illness, along with “restrictions on their freedom” (Last et al., 2007, p. 102). However, family members (particularly parents) are often responsible for providing an environment in which children can develop resiliency and independence. Family members provide a supportive environment and help to promote children’s sense of self-worth and ability to cope with challenging life situations (Juntunen & Atkinson, 2002). These tasks may be especially difficult for parents of children with CF in that they too are more vulnerable to higher incidences of depression (Quittner et al., 2008; Tluczek et al., 2014). Hence, we recommend that professional counselors working with the family system ensure that parents of children with CF have access to the emotional supports necessary to sustain family functioning and equilibrium, including participation in their own counseling as needed (Tluczek et al., 2014). Similarly, professional counselors may find it necessary to provide parent education about the CF disease process in order to help parents identify strategies to enhance resiliency in their child (Juntunen & Atkinson, 2002).


Counseling children with CF involves implementing prolonged and gradual approaches to relationship building, increasing one’s knowledge of the illness, adapting treatment approaches to account for the impact of invasive medical procedures, and involving parents, guardians and other professionals in the counseling process. Above all, honoring the perspective of the child is central to success in counseling this population, which can be easier said than done. The chronic and complex nature of CF and its treatment requires a great deal of effort and presents additional clinical challenges for professional counselors. Over time, the challenges of working with children with special needs can affect the wellness of professional counselors providing services. Therefore, it is important for counselors to recognize the factors contributing to impairment and burnout, particularly among counselors who work with children experiencing chronic illnesses like CF.


A Self-Care Primer for Professional Counselors


Professional counselors and other health professionals engaged in prolonged therapeutic contact with clients with CF are vulnerable to burnout, compassion fatigue and vicarious trauma (Coady, Kent, & Davis, 1990; Lewiston, Conley, & Blessing-Moore, 1981; Savicki & Cooley, 1987), potentially leading to impairment. Counselors have an ethical obligation to recognize their state of wellness and potential impairment (American Counseling Association [ACA], 2011), which may be impacted by burnout, compassion fatigue or vicarious trauma while working with children experiencing chronic conditions (Angerer, 2003; Kalliath, O’Driscoll, Gillespie, & Bluedorn, 2000; Najjar, Davis, Beck-Coon, & Doebbeling, 2009; Sexton, 1999) such as CF. Such occupational risks may be heightened when professionals work with clients with a poor prognosis associated with chronic illness, including CF (Coady et al., 1990).


Counselors and other mental health professionals experience occupational stressors such as long working hours, work with challenging clients, poor interdisciplinary support and poor supervision (Coady et al., 1990). Lewiston et al. (1981) examined burnout among health care providers working with clients experiencing CF. They found high levels of emotional exhaustion and client depersonalization (i.e., a sense of inability to impact clients’ improvement while watching clients’ illness progress), and a lower sense of accomplishment among health care providers working with this population. The implications of these results are intensified because “psychotherapists who work with chronic illnesses tend to disregard their own self-care needs when focusing on the needs of clients” (Figley, 2002, p. 1433).


Children with CF and their families are survivors of both medical and psychosocial traumas. Frequent trips to the emergency room, an inability to breathe, surgeries, and understanding the unpredictable and fatal progression of CF are among the traumas endured by this special population. Professional counselors who hear these traumatic stories within the therapeutic milieu must understand that vicarious trauma can occur for even the most experienced counselor. Sommer (2008) clarified that vicarious traumatization is not inadequacy on behalf of the counselor or emotional damage of the client but can be considered an “occupational hazard” (p. 52). Vicarious trauma, defined as “a traumatic reaction to specific client-presented information” (Trippany, Kress, & Wilcoxon, 2004, p. 32), also may occur among professional counselors working with children who have CF due to the erratic and terminal progression of the illness.


Professional counselors serving the CF community must recognize their vulnerabilities to burnout, compassion fatigue and vicarious trauma. Given the realities of clinical practice and responsibilities of everyday living (e.g., busy schedules, high caseloads, supervision barriers, family responsibilities, maintaining relationships), poor self-care and wellness may be easy to identify but difficult to change. In order to prevent issues of burnout, compassion fatigue and vicarious trauma, the following self-care strategies are suggested for professional counselors who work with this special population.


Self-Care Strategies for Professional Counselors

Although counselors are taught to utilize a developmental and wellness approach when working with clients (Myers & Sweeney, 2005), they often neglect their own health and well-being. Self-care strategies embedded in a wellness philosophy may help to prevent incidences of burnout among those working with the unique emotional and psychosocial stressors affecting children with CF and their families. Myers and Sweeney (2005) identified wellness as both a process and an outcome in that it is an “overarching goal for living and a day-by-day, minute-by-minute way of being” (p. 9). Self-care strategies involve managing stress in ways that limit the impact on the individual (Young, 2005). Within the counseling literature, wellness is depicted as incorporating social, emotional, physical, intellectual and spiritual dimensions (Roscoe, 2009). Counseling wellness models have been empirically supported in the counseling literature (Myers & Sweeney, 2005; Myers, Sweeney, & Witmer, 2000; Sweeney & Witmer, 1991; Witmer & Sweeney, 1992) and inform individuals about methods to limit their stress and maintain a healthy sense of well-being. Hence, we recommend that professional counselors use multidimensional, holistic self-care strategies to maintain a sense of wellness when working with youth experiencing special needs. The following section provides physiological, cognitive and spiritual wellness strategies for professional counselors to use while working with children with CF and other chronic conditions.


Physiological self-care strategies. Professional counselors are accustomed to working with clients regarding wellness and self-care but may not always practice their own healthy suggestions. Self-care strategies that are body-focused may help alleviate the impact of stress (Young, 2005), particularly among those working with children with special needs such as CF. Young (2005) recommended approaches such as progressive relaxation, balanced exercise and nutrition, and adequate rest to assist with integrating a wellness focus and enhancing self-care. A healthy diet and physical activity are readily known to prevent physical and mental health conditions, while also increasing energy levels. Furthermore, “minding the body” and having adequate sleep and bodily rest are additional suggestions for restoring self-care as a priority for professional counselors (Norcross & Guy, 2007, pp. 64–65). Professional counselors interested in implementing physiological self-care strategies to address potential issues of vicarious trauma while working with children diagnosed with CF may consider simple tasks such as taking a brisk walk during their lunch break, joining a gym, or being more intentional with their diet and bedtime routines. In addition to focusing on physical health and wellness, self-care in the cognitive domain is equally important for fostering a sense of well-being.


Cognitive self-care strategies. Stress from occupational risks accumulated through working with youth with special needs may be further prevented if counselors utilize cognitive approaches to support their own self-care. Professional counselors interested in improving their self-care in cognitive ways may consider cognitive restructuring to formulate new thinking patterns and assertiveness training to bring about direct changes in behaviors that may have been impacted by stress (Young, 2005), which often accumulates during the long-term therapeutic relationship with children and families affected by CF. Moreover, the use of guided imagery may provide both cognitive and physical benefits in helping to create a cognitive break from daily stress inside and outside the workplace. Notably, cognitive self-care strategies begin with self-monitoring, insight and self-awareness (Norcross & Guy, 2007). Despite counselors’ close therapeutic connection to clients with CF and their families, healthy boundaries are imperative to prevent issues of burnout and compassion fatigue. Norcross and Guy (2007) noted that “setting boundaries consistently emerges in the research as one of the most frequently used and one of the most highly effective self-care principles” (p. 94). Due to counselors’ innate desire to help others, they often take on too many clients or are mandated to do so by agency policies. Counselors may provide extra time to ancillary responsibilities and have unrealistic expectations of themselves. As such, we recommend that professional counselors obtain good supervision to help manage and maintain work–life balance, particularly when working with children with special needs. In addition to the benefits of physical and cognitive self-care strategies, spirituality also has been shown to enhance levels of wellness and thus decrease the potential for burnout and compassion fatigue.


Spiritual self-care strategies. Spirituality comes in many forms and there is no finite definition of how one engages in his or her spiritual self. Many counselors and psychotherapists identify their own career path as a calling to care for others and commitment to growth and self- knowledge (Norcross & Guy, 2007). Research supports that spirituality, prayer and meditation are positive manners in which to promote wellness and augment self-care (Cashwell, 2005). Spiritual beliefs, practices and experiences are intricately connected and may continue to foster support from communities and individuals, along with reinforcing healthy emotions. While working with children experiencing the later stages of CF, professional counselors’ spirituality may help them connect with clients on a more meaningful level. Taking a spiritual perspective can further shape counselors’ perspective on life events (Young, 2005), particularly when they are grieving the death of a child with CF. In seeking a spiritual connection to a higher power, the negative responses to stressful events may be limited (Young, Cashwell, & Shcherbakova, 2000), strengthening one’s wellness and ability to care for oneself. These actions, along with discussing spirituality with the child and family affected by CF, may further model healthy practices during difficult times in the disease process.


Spiritual self-care can include the use of mindfulness, which can be viewed as the nonjudgmental awareness of one’s own inner suffering (Birnie, Speca, & Carlson, 2010) and reflections on self-compassion (Neff, 2003). Birnie et al. (2010) described self-compassion as the awareness of “feelings of caring and kindness towards oneself in the face of personal suffering” and the “recognition that one’s suffering, failures, and inadequacies are part of the human condition” (p. 2). When counseling children with CF, professional counselors may consider routinely expressing self-compassion as part of their inner dialogue. The following mantra used by the second author may be of assistance to professional counselors implementing spiritual self-care:


Suffering is part of life. My clients suffer, but did not choose this illness. They are walking in its wake and I will walk alongside them. I will extend loving kindness in all the work I do, despite the pain and suffering I experience and witness.


We highlight the following three essential components of self-compassion: (a) extending kindness and understanding toward oneself rather than harsh judgments or criticism, (b) recognizing that suffering (even chronic illness) is a part of the larger human condition, and (c) not overidentifying with the awareness of one’s painful thoughts (Birnie et al., 2010; Neff, 2003). By engaging in self-compassion and mindfulness, professional counselors may help to prevent incidences of compassion fatigue while working with children and families affected by CF by recognizing that this illness has a role in their humanity.




     Professional counselors working with children and families affected by CF should consider the physical and psychosocial challenges facing this special-needs population. With the discouraging nature of the disease progression, professional counselors must have a basic understanding of the client’s chronic condition (Thompson & Henderson, 2007) and how the progression of the illness affects the child’s emotional state. Professional counselors must further explore how to limit the impact of occupational stress that may lead to burnout, compassion fatigue and vicarious trauma. This article provides a primer on the physiological, psychosocial and special needs specific to youth with CF and offers targeted self-care strategies for professional counselors. Children with CF are a special population and professional counselors are called to implement these special considerations in their thoughtful practice. There is an abundance of literature examining the physiological aspects of CF (CFF, 2014a; Pearson et al., 1991; Sawicki et al., 2009; Sawicki & Tiddens, 2012). However, more research is warranted to examine the salient factors that affect the therapeutic relationship between professional counselors and children with CF. Meanwhile, professional counselors can develop and implement individualized, multidimensional self-care strategies to counter the effects of this difficult yet rewarding work.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.



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Cassandra A. Storlie, NCC, is an Assistant Professor at Kent State University. Eric R. Baltrinic is an Assistant Professor at the University of Toledo. Correspondence may be addressed to Cassandra Storlie, 310 White Hall, PO Box 5190, Kent, OH 44242,