Compassion Fatigue

by Daniel J. Benor, MD

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Overview

The recent tsunami in Asia and major earthquake in Pakistan have highlighted problems long recognized in the helping professions. Caregivers have known well the potentially draining experiences of compassion fatigue - from experiences of policemen, firefighters, paramedics and other emergency and rescue personnel, through doctors, nurses, psychotherapists and counselors, and not to overlook the family members and volunteers who come forward to help in individual challenges and collective disasters (Figley 1989a; 1989b; 1997; Figley and McCubbin 1983; Rosenheck and Thomson 1986).

When we hear the stories of victims of illness, misfortune and disasters it is natural to feel compassion for their hurt, loss and distress. We help by being there in times of need and grief; our presence is a reassurance that aid is available; our caring through attention, emotional support, advice and material assistance are at the very least injections of hope that repair and order will be restored, and often are much, much more.

It is a help and a healing to those who are suffering to know that their stories of pain, loss and grief are heard and acknowledged; to have the steadying presence of caring people who can help to prioritize and address the immediate needs, to identify and locate the necessary remedies, and to provide support in whatever ways are beyond the victims' capabilities.

Compassion fatigue is a risk in these situations - from the emotional impact upon caregivers who feel overwhelmed by the enormity of individual and collective pain and suffering following disasters (Huggard 2003). Technically, this problem is designated Secondary Traumatic Stress Disorder, which is essentially identical with Post Traumatic Stress Disorder except for the cause of the stress.

Signs of this overload include: weariness that goes beyond appropriate physical fatigue; difficulty concentrating; forgetfulness; depression; labile emotions and emotional outbursts - such as unreasonable irritability, crying or anger; feeling distant from others; difficulty falling asleep; disturbed sleep, waking during the night - with or without nightmares; physical symptoms of stress - such as headaches, backaches, stomach and bowel upsets; feeling it is difficult to get out of bed or to go to work; having a strong startle reaction with minor stimuli; obsessing over traumas or having flashbacks to these.

While the recent focus of the media has been on professional caregivers who experience compassion fatigue in crises, this may also be found in relatives who are dealing with acute and chronic problems of family members, in doctors (Hilfiker 1985; Pfifferling and Gilley 2000) and nurses (Joinson 1992; Radziewicz 2001), in hospice workers (Keidel 2002; Penson et al 2000) and in clergy (Joinson 1992) ministering to people who are ill and dying.

Compassion fatigue may be compounded by caregivers' feelings: guilt that they are not strong enough to continue under stress; guilt that they have not suffered the losses of the people they are helping (Nader); self-doubts and inadequacies in the face of overwhelming problems of the people they are helping; shame at admitting they cannot cope with the stresses of their jobs; frustration at circumstances beyond their control that impede provision of help; and anger at bureaucratic or governmental authorities who are less than cooperative or supportive.

Compassion fatigue may also be a symptom of buried and forgotten psychological trauma that the caregiver experienced in the past. When we repress painful emotions under acute stress (which may be a very helpful and adaptive reaction at the time, allowing us to cope with a situation without feeling overwhelmed) we end up carrying the buried feelings inside us. Compassion for the victim of a similar situation, or for their responses to the situation, may reawaken memories of these buried feelings.

Essentially, compassion fatigue is a form of post traumatic stress disorder (PTSD). Caregivers can be traumatized through hearing the distressing stories of clients or may have their own PTSD activated from the past. If you are wondering whether you might be suffering from compassion fatigue, an on-line test is available to help you clarify this (Florida State University).

Historical notes

Carl Jung (1907) was the first to identify countertransference as a potential problem for psychoanalysts. This is the emotional response of the therapist to the person being treated. Jung noted that in treating severe emotional problems it was possible for the therapist to become emotionally disturbed, particularly when the therapist was inexperienced or had unresolved emotional conflicts that resonated with those of the patient.

Burnout in the helping professions has been recognized for several decades (Maslach 1976; Maslach and Jackson 1981; Maslach and Leiter 1997). This is a broader problem than compassion fatigue, including also overwork, loss of interest out of boredom with routines and job dissatisfaction.

Secondary post traumatic stress was discussed in relatives of Viet Nam veterans (McCubbin, et al. 1977; Rosenheck and Thomson 1986; Verbosky and Ryan 1988), of rape victims (Feinauer 1982; White and Rollins 1981) and of incest victims (Pearlman and Saakvitne 1995).

Compassion fatigue was first named as such in 1992 by Joinson, who pointed out that nurses and ministers were subject to exhaustion of their capacities to provide empathetic care, due to being repeatedly traumatized secondarily by having to deal with the stresses of patients they cared for. Various authors have followed up on this subject (Figley 1993; 1995; 1997; 2002; 2003; Kottler 1992; McCann and Pearlman 1990; Stamm 1995).

Remedies

A common sense, Cost vs. Benefit Analysis (CBA) of your situation while under stress will often point to obvious changes you can make in order to change and improve the situation. For instance, working fewer hours is permitted! If you are exhausted, you will be less than fully effective and may unintentionally even become a burden or a liability yourself to the caregiving endeavors. Taking some time off for a break, to recharge your batteries and restore your healing perspective may be advisable. Breaks during the day as well as days off for rest and recuperation allow for release of tensions and rejuvenation.

Stress is a word whose meaning has completely changed. It used to be a medical condition.  Now it's often seen as something positive.  For many people, it's an aspiration. Our role models are busy, busy, busyÉ Many people whose lives are not frantic suffer from 'stress envy.'  They've accepted a new definition of the good life: It's not the quality of life, it's the quantity.  Success is measured by how much you can squeeze in.  Time has become a currencyÉ But we're also going to have to learn to turn things off. Employers are going to have to help people step away occasionally - to demand that people take a holiday or go on sabbatical.  Without punctuation marks, life can become jumbled and incoherent.
 Martin Hayward.

If you have identified limited, specific issues that trigger your fatigue, you might ask not to be assigned to people who have those types of problems - until you can work on and clear the issues within yourself that are asking for attention.

Working with a team and having support from peers (Collins and Long 2003; Young 1994)  is very helpful, preventing the feeling that you are alone in the fray or solely responsible for the problems of those you are helping. On the other hand, having to deal with bereaved relatives, particularly if they are angry, can contribute to the development of compassion fatigue.

De-stressing for the caregiver is essential to being able to be fully present and congruent with teaching de-stressing techniques to careseekers (Figley 2002; Rowe 1999). Reminders and updates for caregiver through periodic refresher courses on preventing compassion fatigue can be helpful (Rowe 1999).

Sharing what you are experiencing with others is often a relief, particularly if they are familiar with the type of work you are doing. Regular planning, debriefing and ongoing assessments with colleagues can go a long way towards preventing and relieving compassion fatigue.

         A problem shared is half a consolation.
                                                            - Israeli observation

Critical Incident Stress Debriefing (CISD) has been recommended for caregivers prior to and after experiencing acute stress (Everly and Mitchell; Kinzel and Nanson 2000). In its full implementation, this involves pre-stress planning and training; a detailed review of the incident with a trained debriefer following the incident, over several sessions if needed; and follow-ups for discussion and (if necessary) treatment of post traumatic stress disorders. While for many people this may provide relief, for others this can be a retraumatizing experience -reviving all the intensity of the emotions of the original stress - particularly when the primary or sole intervention is the debriefing. This may leave stressed people feeling worse than before - particularly when they did not choose to undergo the treatment but were required to do so by their employers. Numbers of experts are questioning the efficacy of this approach (Gist 1996).

Journaling can provide substantial release from the multitude of issues and feelings that trigger compassion fatigue. A journal can also provide self-feedback on how you are dealing with the stresses because in a challenging situation it is easy to lose perspective and overlook how your responses are shifting over a period of time.

Many techniques are available for de-stressing (Benor 2005).

It's not stress that kills us, it is our reaction to it.
                                                            - Hans Selye

Eye Movement Desensitization and Reprocessing (EMDR) can be helpful in releasing traumatic memories and emotions from recent and distant stressful experiences (http://www.emdr.com/). EMDR has been well validated as a treatment for PTSD but is best done in the presence of the therapist because it can bring about intense emotional releases that could panic or retraumatize a person.

Emotional Freedom Technique (EFT) involves tapping at a series of acupressure points while reciting an affirmation focused on the trauma. This provides immediate, rapid release of the emotional residues of a PTSD without a clinical abreaction (strong expression of emotions). It then allows the installation of positive feelings, beliefs and attitudes (http://www.emofree.com/).

WHEE - the Wholistic Hybrid derived from EMDR and EFT - is a method of self-healing that releases stress and psychological distress. It is very rapidly effective, rather like a vacuum cleaner that allows you to clear away old junk that you carry around with you from hurtful experiences. WHEE not only relieves stresses but can also transform your attitude towards stress - from one of annoyance to one of gratitude that you are being offered further opportunities to clear the bucket of 'stuffed' junk that you carry with you, and to reprogram your hard drive (which you let a little child program for you).

Clearing the vessel through which healing flows is a lifelong process. Compassion fatigue or any other, similar distress can become much less stressful, once caregivers are aware that current distress may be stirring old, buried hurts and are in the habit of clearing these as a matter of routine.

Ten year-old Charlie was traumatized by a shooting on the street in front of his home. He heard several shots and the sound of a car speeding off with screeching tires. Over the subsequent days and weeks he found he could not fall asleep at night unless the lights were on and a member of his family was present at his bedside.

When Charlie shared his story with me, my heart started pounding and I found myself much more agitated than I would have expected from previous experiences of having worked with other children who had been much more severely traumatized. From years of clearing issues, I recognized that his story had stirred something from my past. Later that day, allowing myself to feel again the anxiety when I focused on his story, I found memories of spending nights in a bomb shelter in Jerusalem when we were under siege in 1947-1948 and shells were falling nearby. Using WHEE, I was able to clear my buried anxieties and fears so that I could focus on Charlie's story without stirring my old emotional responses.

Inner child work may be appropriate in response to compassion fatigue. This is a special case of clearing the vessel, often with profound insights and clearings of old hurts. Childhood psychological residues often resonate with the situations that produce compassion fatigue, such as feelings of inadequacy to deal with stresses, being unable to adequately aid or cure people you want to help, and being overwhelmed with situations that defy explanation or full comprehension.

Conclusions

Secondary traumatic stress is a hazard that caregivers at all levels can prepare for and address - with the help of peer and therapist support as well as with many self-healing techniques. It is also an invitation to clear our own vessels of the old traumas which leave us vulnerable to stress responses.


References

Benor, Daniel J. Healing Research, Volume II: (Popular edition), How Can I Heal What Hurts? Medford, NJ: Wholistic Healing Publications 2005

Boss, P. Ambiguous Loss. Cambridge, MA: Harvard University Press 1999

Collins, S. and Long, A. Too tired to care? The psychological effects of working with trauma. Journal of Psychiatric Mental Health Nursing 2003, 10(1), 17-27.

Everly, George S. Jr. and Mitchell, Jeffrey T. A primer on critical incident stress management (CISM) http://www.icisf.org/inew_era.htm

Feinauer, L. Rape: A family crisis. American Journal of Family Therapy 1982, 10:4, 35-39.

Figley, C.R. Compassion fatigue: Psychotherapists' chronic lack of self care, Journal of Clinical Psychology 2002, 58(11), 1433-41.

Figley, C. R. The family as victim: mental health implications, Psychiatry 1985, 283-291.

Figley, C. R. (Ed.), Trauma and Its Wake, Volume I: The Study and Treatment of Post-Traumatic Stress Disorder, New York: Brunner/Mazel 1985.

Figley, C. R.  (Ed.), Trauma and Its Wake: Volume 2. Post-Traumatic Stress Disorder: Theory, Research, and Treatment, New York: Brunner/Mazel 1986.

Figley, C. R. Helping Traumatized Families, San Francisco: Jossey-Bass 1989a.

Figley, C. R. (Ed.) Treating Stress in Families. NY: Brunner/Mazel 1989b.

Figley, C. R. Compassion stress: Toward its measurement and management. Family Therapy News 1993.

Figley, C. R. (Ed.) Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. NY: Brunner/Mazel 1995.

Figley, C. R. (Ed.) Burnout in Families: The Systemic Costs of Caring, New York: CRC Press 1997.

Figley, C.R. Compassion fatigue: Psychotherapists' chronic lack of self care, Journal of Clinical Psychology 2002, 58(11), 1433-41.

Figley, Charles R. Compassion fatigue: an introduction, Green Cross Foundation 2003 www.greencross.org/_Research/CompassionFatigue.asp  (Accessed 12/18/05)

Figley, C. R. and McCubbin, H. I. (Eds.). Stress and the Family, Volume II: Coping with Catastrophe, New York: Brunner/Mazel 1983.

Florida State University Psychosocial Stress Research Program.Compassion Fatigue Self-Tests,  An online test to determine if you are suffering from compassion burnout. www.ace-network.com/cftest.htm (Accessed 12/18/05)

Gist, Richard. A Critical View on Debriefing 1996 http://trauma-pages.com/cisdgist.htm (Accessed 12/18/05)

Hayward, Martin. Fast Company Feb. 2001 http://www.fastcompany.com/magazine/43/futurist.html (Accessed 12/23/05)

Hilfiker, D. Healing the Wounds: A Physician Looks at His Work, NY: Pantheon Books 1985.

Huggard, P. Compassion fatigue: How much can I give? Medical Education 2003, 37(2), 163-4.

Joinson C. Coping with compassion fatigue. Nursing 1992, 22, 116-120.

Jung, Carl. The Psychology of Dementia Praecox 1907.

Keidel, G.C. Burnout and compassion fatigue among hospice caregivers., American Journal of Hospice and Palliative Care 2002, 19(3), 200-5.  

Kinzel, A. and Nanson, J. Education and debriefing: Strategies for preventing crises in crisis-line volunteers, Crisis 2000, 21(3), 126-34.

Kottler, J. A. Compassionate Therapy: Working with Difficult Clients. San Francisco: Jossey-Bass 1992.

Maslach, C. Burn-out. Human Behavior 1976, 5 (9), 16-22.

Maslach, C. and Jackson, S. E. The measurement of burnout. Journal of Occupational Behavior 1981, 2, 99-113.

Maslach C, Leiter MP. The Truth About Burnout. San Francisco: Jossey-Bass 1997.

McCann, I. L. and Pearlman, L. A. Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress 1990, 3(2), 131-149.

McCubbin, et al. The returned prisoner of war and his children: Evidence for the origin of second generational effects of captivity. International Journal of Sociology of the Family 1977, 7, 25-36.

Nader, Kathleen. Guilt Following Traumatic Events www.giftfromwithin.org/html/guilt.html#1 (Accessed 12/18/05)

Pearlman LA, Saakvitne KW. Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy With Incest Survivors. New York: Norton 1995.

Penson, R.T. et al. Burnout: Caring for the caregivers, Oncologist 2000, 5(5), 425-34.

Pfifferling, John-Henry and Gilley, Kay. Overcoming compassion fatigue: When practicing medicine feels more like labor than a labor of love, take steps to heal the healer. American Academy of Family Physicians, April 2000 http://www.aafp.org/fpm/20000400/39over.html  (Accessed 12/9/05)

Radziewicz, R.M. Self-care for the caregiver, Nursing Clinics of North America 2001, 36(4), 855-69.

Remer, R. & Elliot, J. Characteristics of secondary victims of sexual assault. International Journal of Family Psychiatry 1988, 9(4), 373-387.

Rosenheck, R. and Thomson, J. 'Detoxification' of Vietnam war trauma: a combined family-individual approach. Family Process 1986, 25(4), 559-570.

Rowe, M.N. Teaching health-care providers coping: Results of a two-year

Selye, Hans. Attributed.

Stamm, B.H. (Ed.), Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers and Educators. Lutherville, MD: Sidran Press 1995.

White, P. N. & Rollins, J. C. Rape: A family crisis. Family Relations 1981, 30(1), 103-109.

Young, Marlene. Community Crisis Response Team Training Manual, 2nd Edition, National Organization for Victim Assistance - USA 1994 www.ojp.usdoj.gov/ovc/publications/infores/crt/ (Accessed 12/18/05) Excellent, well organized maual.


Resources

WHEE (Wholistic Hybrid of EMDR and EFT) http://wholistichealingresearch.com/Articles/Selfheal.asp 

WHEE for trauma and re-entry problems  http://www.heal911.com/C-6a.asp

Further references on Compassion Fatigue at http://wholisticHealingResearch.com/References/CompassionFatigue.asp


IN THIS ISSUE OF IJHC

Melinda Connor, PhD (a Reiki master) and colleagues at the University of Arizona searched out Reiki organizations with websites that mention Codes of Conduct. They compared and contrasted the commonalities and differences between the various codes, making suggestions for improvements.

Bernie Siegel, MD is a remarkable surgeon who listens to his patients and has written wonderful books on the healings in which he has been privileged to participate. He shares here some of his personal healing experiences that have opened doors into spiritual awarenesses. He also shares how he helps people through drawings to understand some of the issues that may be important on their road to healing.

Cindy Clair is the director of a remarkable program of volunteers who sit with people who are dying - when there in no one else to be with them for this transition. She and others in the program share their experiences and how they themselves are moved and helped through this work.

Spiritual healing can be offered in many different ways, as illustrated in a spectrum of reports in this issue of IJHC.

Meredith Jordan tells the story of her difficult childhood - how it made her sensitive to the suffering of others and how she developed a tradition in her family of helping others who find themselves in difficult circumstances.

Steven Gaynor, a foot surgeon, unexpectedly developed strong healing gifts. When all other conventional medical approaches failed, he describes how he found healing to be effective for one person's chronic, excruciating foot pain. The healing involved prayer, bioenergy work, imagery and spirit releasement (with the help of two other experts in this form of treatment). Gaynor's excellent book is also reviewed in this issue of IJHC - detailing how he explored integrating healing in his medical practice but then left to work just as a healer.

J. C. Hugh MacKimmie is a chiropractor who developed his healing gifts early in his long career. He tells us a little about his understanding of how healing works - as a Divine gift that is facilitated by angels. He is a facilitator for healing, initiating the process and watching as it unfolds in ways that are way beyond the limits of what ordinary chiropractic has to offer. MacKimmie's outstanding book is also reviewed in this issue of IJHC, rich in the wisdom of a very gifted healer and intuitive, spiced with numerous clinical tales of physical and psychological problems that responded to a broad spectrum of healing approaches.

Vivian Amis also found that her healing developed spontaneously. She was bemused when I asked her to have some of her healees write about their responses to her healing - because she firmly believes that she doesn't do the healing.

Karin Nemri's healing abilities blossomed after her near-death experience. This has developed into a system of healing she calls Aiijii, in which the healer's presence invites shifts of bioenergies that are guided by spirit beings.

I am always pleased to find new approaches in wholistic healing, from individual work to policy-making at governmental levels.

John Hall, PhD reviews the regulation of complementary/ alternative medicine in Australia, where the government has a much more accepting attitude for these approaches than in most other Western countries.

Richard Welch developed an amazing method of Brain Management¨ for developing intuitive reading and other intuitive abilities. Using this method, you can read as fast as you can turn the pages, with up to 100 percent, permanent retention. As you develop confidence in your intuitive capacities, you may develop healing and other abilities.

Susanna Luebke, MD is one of the three German developers of Emotional Body Healing. In this approach, you invite your fears to say whatever they wish, offering them love. Within minutes, issues that may have plagued you for many years may dissolve and disappear. (See also: EmotionalBody Process, Parts I and II, describing the same approach under a slightly different name.

The creative arts offer an enormous opportunities to shift our awareness and energies. Two very different articles offer doorways into appreciating these approaches.

Samuel Avital is a teacher of mime in Boulder, Colorado. He has adapted techniques of movement and mime that he teaches as ways for achieving insight and learning new ways of relating to one's body, emotions and spirit. Avital also has a strong grounding in Kabbalah, and manages to introduce teachings from this tradition as well in his workshops.

CristÓbal S. Berry-Cabán teaches and researches epidemiology at Xavier University School of Medicine, Netherlands Antilles in the Caribbean. He was fascinated by the story of Virginia Woolf, who suffered from depression throughout much of her life. In this article he discusses this struggle and its effects on her career, ending in her suicide.

Poetry and humor are again featured in the marvelous 'One-liners' drawings of Ric Masten that counterpoint his trenchant poetry. (See also the review of his new book, Words & One-Liners, Take 2.)

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