Compassion Fatigue



Miles E. Drake, Jr., M.D.


Post-traumatic stress disorder is now well established as a medical and psychiatric diagnosis, and a clinical syndrome has been defined in those who have suffered or witnessed terrible events (American Psychiatric Association, 2013). A variant of post-traumatic stress is being increasingly recognized in members of various caring and helping professions, who are not generally subjected to horrific stress but who deal day in and day out with suffering and unhappiness and as a result repeatedly experience and then internalize feelings that are both psychologically and physically deleterious (Burgess, Figley, Friedman, Mitchell & Solomon, 1994). The principal effect of compassion fatigue is the exhaustion of compassion, sympathy for those who suffer and empathy with those who struggle, and this can have a significant adverse effect on a society in which it becomes prevalent (Smith, 2009). Compassion fatigue significantly interferes with the professional performance and personal adjustment of those who develop it (Adams, Boscarino & Figley, 2006), and there is evidence that its incidence is increasing both in the involved professions and in society at large (Dart Center for Journalism and Trauma, 2008). There is also a growing consensus, however, that the disorder is treatable by medical and psychological professionals, and often manageable by at-risk caregivers themselves (Smith, 2012).

History of compassion fatigue

The related concept of “burnout” in health care professionals was described in the 1960s and 1970s (Maslach, Schaufeli & Leiter, 2001). The term “compassion fatigue” was first applied in 1981 to the government’s anticipation of public impatience with illegal immigrants; in 1990 the term came to be applied to increasing public impatience with continued journalistic reporting of the plight of the homeless (Link, Schwartz, Moore, Phelan, Struening, Stueve & Colten, 1995). It was subsequently used to describe the exhaustion and alienation of emergency department nurses caring for severely traumatized patients (Joinson, 1992). It was in subsequent studies called “secondary victimization” (Figley, 1982), “secondary traumatic stress” (Stamm, 1999), “vicarious traumatization” (Pearlman & Saakvitne, 1995) and “secondary survivor” (Remer & Elliott, 1988), and analogous syndromes were described in victims of sexual assault, the “rape-related family crisis” of Erickson (1989), and the “partner” effect in the spouses of war veterans (Dekel, Goldblatt, Keidar, Solomon & Pollack, 2005). The syndrome is not unique to doctors, nurses, psychologists and social workers, but has been reported in veterinarians (Huggard & Huggard, 2008), attorneys who work with trauma victims (Putman & Lederman, 2008) and those involved with charitable fundraising after catastrophes such as the events of 9/11 (Phillips, 2009).

Clinical Features

An early survey of fatigued compassionate professionals found that 87 per cent of emergency response personnel had mental and sometimes physical symptoms after exposure to severely traumatized patients and highly distressing events, and 90 per cent of new physicians aged 30 to 39 reported that their family lives had suffered as a result of work experiences. Dissociation, distraction and physical signs of apprehension during caregiving or before appointments were frequent manifestations, and caregivers often reported developing the same symptoms as their patients or clients. Common psychological symptoms included anger, anxiety, dissociation, feelings of powerlessness, insomnia and nightmares. Body temperature change, dizziness, faintness, headache, hearing decrease, nausea and vasoconstriction were reported physical symptoms (Babbel, 2012).

Emergence in stressed caregivers of the traumatic symptoms of those they care for has been well documented. The emotional impact of repeatedly hearing horrific stories or witnessing physical suffering may be transmitted by the psychological processes that underlie empathy. In particular, unconscious empathy which is outside the caregivers’ awareness and control may come to have deleterious effects on professionals (Rothschild, 2006). The “somatic countertransference” has been applied to the therapist’s reaction to the client or patient through emotions, imagery and sensations that are detectable by body awareness rather than cognitive means. Such physiological responses can involve claustrophobia, dizziness, emptiness, fullness, hunger, pain, restlessness, sexual arousal or sleepiness, and are not well described in textbooks or literature or covered in many training programs, so may be difficult for professionals to recognize (Bernstein, 2013).

The terms “burnout” and “compassion fatigue” are often used interchangeably, but the two conditions are different. The term “burnout” was coined in 1974 and inspired by the 1960 Graham Greene novel of ennui and alienation, A Burnt-Out Case, which in turn derived its name from the term used for long-standing leprosy in which permanent mutilation has occurred. Job burnout is long-term fatigue and diminished interest in work, and occurs in many professions and settings; chiefly manifested by exhaustion, cynicism and inefficiency, it has been suggested to be the antithesis of engagement in work, and is often ascribed to repetitive, tedious or unfulfilling aspects of a job or career rather than to intense physical or psychological demands in the course of work. It can be identified in clinical evaluations with the Maslach Burnout Inventory (Maslach et al., 2001).

Compassion fatigue is estimated to affect between 15 and 85 per cent of health-care workers, and predominates in first responders, emergency medicine professionals and those involved with psychiatric patients and the terminally ill (Hooper, Craig, Janvrin, Wetsel & Reimels, 2010; Beck, 2011). It is most prevalent in situations where compassion is required toward individuals whose suffering is continuous and may be unresolvable, or when the illness or trauma intersects in some way with the caregiver’s own life experiences. This secondary traumatic syndrome is more likely to develop in perfectionistic and self-sacrificing professionals who are highly conscientious; the risk is further increased when caregivers have insufficient or maladaptive coping mechanisms, high levels of personal stress and low levels of social support. In addition, work situations in which continued confidentiality is mandatory or a “culture of silence” prevents the discussion of stressful events after they have occurred make the development of compassion fatigue very likely (Meadors & Lamson, 2008).

Recognizing and treating compassion fatigue

Compassion fatigue should be anticipated in health care, legal or law enforcement situations which combine the above characteristics. Presenting symptoms may include apathy and sadness, blaming of others, bottling up of emotions, complaining about administrative functions or being the subject of increasing complaints by others, compulsive behaviors (overeating, overspending, gambling, sexual addiction), denial of problems, deterioration of self-care, difficulty concentrating, isolation from others, legal or debt problems, mental or physical fatigue, preoccupation, recurrent physical illnesses or substance abuse. It can be identified with several self-administered testing instruments: Professional Quality of Life (ProQOL), Compassion Fatigue Self-test and Life Stress Self-test (B. Stamm, Higson-Smith, Hudnall, Piland & H.Stamm, 2014).

Care-giving facilities can identify elevated risk among employees for the development of compassion fatigue. Absenteeism, constant changes in the relationships among coworkers, desire of staff members to break rules, inability of teams to work together, inability of employees to complete assignments or meet deadlines, lack of flexibility, lack of vision for the future, negativism toward management, reluctance to change and unwillingness to believe that change is possible have been suggested as warning signs of stressful organizational dysfunction (Smith, 2009).

Prevention is strongly recommended, as there is no cure. Therapists generally advocate a holistic approach that integrates caregivers’ mental, physical and spiritual characteristics. This involves increased attention to self-care first and foremost, including regular, balanced and healthy meals, daily exercise and sufficient time with friends and family. Daily journaling, with particular attention to the day’s stressful or upsetting events but also with uplifting or affirmative content, is also recommended. Support groups of affected professionals are helpful, and in some cases support is available through local professional organizations, or courses or seminars in stress and compassion fatigue management are appropriate for professionals to take and organizations to offer. Thirty minutes a day for some self-care activity and a 10-to-15 minute break or nap during the workday are also recommended. Most importantly, prioritization, delegation and the willingness to ask for help when overwhelmed by caring are important skills for caregivers of all kinds to cultivate (Brassard, 2013).


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