Compassion fatigue

Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring.^[1] It is sometimes referred to as secondary traumatic stress (STS).^[1] According to the Professional Quality of Life Scale, burnout and STS are interwoven elements of compassion fatigue.^[2]

Compassion fatigue is considered to be the result of working directly with victims of disasters, trauma, or illness, especially in the health care industry.^[3] Individuals working in other helping professions are also at risk for experiencing compassion fatigue.^[4] These include child protection workers,^[5] veterinarians,^[6] clergy, teachers,^[7] social workers, palliative care workers,^[8] journalists,^[9] police officers,^[10] firefighters, paramedics, animal welfare workers, public librarians, health unit coordinators,^[11] and student affairs professionals.^[12] Non-professionals, such as family members and other informal caregivers of people who have a chronic illness, may also experience compassion fatigue.^[3] The term was first coined in 1992 by Carla Joinson to describe the negative impact hospital nurses were experiencing as a result of their repeated, daily exposure to patient emergencies.^[1]

People who experience compassion fatigue may exhibit a variety of symptoms including lowered concentration, numbness or feelings of helplessness, irritability, lack of self-satisfaction, withdrawal, aches and pains, or work absenteeism.^[1]

Journalism analysts argue that news media have caused widespread compassion fatigue in society by saturating newspapers and news shows with decontextualized images and stories of tragedy and suffering. This has caused the public to become desensitized or resistant to helping people who are suffering.^[13] Over a quarter of Americans have even changed where they get their news from due to compassion fatigue.^[14]

History

Compassion fatigue has been studied by the field of traumatology, where it has been called the "cost of caring" for people facing emotional pain.^[1]

Compassion fatigue has also been called secondary victimization,^[15][16] secondary traumatic stress,^[17] vicarious traumatization,^[18] and secondary survivor.^[19] Other related conditions are rape-related family crisis^[20] and "proximity" effects on female partners of war veterans.^[21] Compassion fatigue has been called a form of burnout in some literature. However, unlike compassion fatigue, “burnout” is related to chronic tedium in careers and the workplace, rather than exposure to specific kinds of client problems such as trauma.^[22] fMRI-rt research suggests the idea of compassion without engaging in real-life trauma is not exhausting itself. According to these, when empathy was analyzed with compassion through neuroimaging, empathy showed brain region activations were previously identified to be related to pain whereas compassion showed warped neural activations.^[23][24]

There is some recent academic literature suggesting that compassion fatigue is a misnomer and should be replaced with the term empathy fatigue. Evidence supporting this change comes from burgeoning literature examining the neurophysiology of empathy versus compassion meditation practices.^[25] Empathy can be defined as attempting to feel and understand ( or in other words attempt to experience) what another feels.^[26] This can result in cumulative negative effects over time that come from the accretion of the assumption of others' painful emotions and experiences. Compassion relates to a feeling of caring, loving, and having a desire to improve others. It requires awareness of others' feelings and emotions, as well as desiring for the subject to be free of suffering.^[27] Studies of training of compassion practices among health care providers has demonstrated positive effects compared to empathy practices which do not improve provider functioning.^[28]

In academic literature, the more technical term secondary traumatic stress disorder may be used.^[29] The term "compassion fatigue" is to some extent regarded as euphemistic.^[16] Compassion fatigue also carries sociological connotations, especially when used to analyze behavior in response to media coverage of disasters.^[30] Measures of compassion fatigue include the ProQOL (or Professional Quality of Life Scale), Secondary Traumatic Stress Scale, Compassion Fatigue Self Test for Helpers, and the Compassion Fatigue Scale—Revised.^[31][32]

Risk factors

There are four key attributes to an individual being at risk for compassion fatigue; these include diminished endurance and/or energy, declined empathic ability, helplessness and/or hopelessness, as well as emotional exhaustion can suffer from secondary traumatic stress.^[33] In addition, previous histories of trauma that led to negative coping skills, such as bottling up or avoiding emotions or having small support systems increase the risk for developing STS.^[34]

Many organizational attributes in the fields where STS is most common, such as the healthcare field, contribute to compassion fatigue among the workers. For example, a “culture of silence” where stressful events such as deaths in an intensive-care unit are not discussed after the event is linked to compassion fatigue.^[35] Lack of awareness of symptoms and poor training in the risks associated with high-stress jobs can also contribute to high rates of STS.^[34]

Compassion fatigue increases in intensity with increased interactions among the needy. Because of this, people living in urban cities are more likely to experience compassion fatigue. People in large cities interact with more people in general, and because of this, they become desensitized towards people's problems. Homeless people often make their way to larger cities. Ordinary people often become indifferent to homelessness when they see it regularly.^[36]

Family

Recent studies reveal that the "overall compassion fatigue and compassion satisfaction levels were moderate, thus highlighting the potential risk of compassion fatigue for family caregivers", indicating that primary family caregivers of patients could also experience compassion fatigue or STS.^[37]

In healthcare professionals^[38]

Between 16% and 85% of health care workers in various fields develop compassion fatigue. In one study, 86% of emergency room nurses met the criteria for compassion fatigue.^[39] In another study, more than 25% of ambulance paramedics were identified as having severe ranges of post-traumatic symptoms.^[22] In addition, 34% of hospice nurses in another study met the criteria for secondary traumatic stress/compassion fatigue.^[22]

There is a strong relationship between work-related stress and compassion fatigue which include factors such as: attitude to life, work-related stress, how one works, amount of time working at a single occupation, type of work, and gender all play a role^[40]

Compassion fatigue is the emotional and physical distress caused by treating and helping patients that are deeply in need. This can desensitize healthcare professionals to others' needs, causing them to develop a lack of empathy for future patients.^[41] There are three important components of Compassion Fatigue: Compassion satisfaction, secondary stress, and burnout.^[42] It is important to note that burnout is not the same as Compassion Fatigue; Burnout is the stress and mental exhaustion caused by the inability to cope with the environment and continuous physical and mental demands.^[43]

Healthcare professionals experiencing compassion fatigue may find it difficult to continue doing their jobs. While many believe that these diagnoses affect workers who have been practicing in the field the longest, the opposite proves true. Young physicians and nurses are at an increased risk for both burnout and compassion fatigue.^[44] A study published in the Western Journal of Emergency Medicine revealed that medical residents who work overnight shifts or work more than eighty hours a week are at higher risk of developing Compassion Fatigue.^[45] Burnout was another major contributor to these professionals who had a higher risk of suffering from Compassion Fatigue. Burnout is a prevalent and critical contemporary problem that can be categorized as suffering from emotional exhaustion, de-personalization, and a low sense of personal accomplishment.^[46] They can be exposed to trauma while trying to deal with compassion fatigue, potentially pushing them out of their career field. If they decide to stay, it can negatively affect the therapeutic relationship they have with patients because it depends on forming an empathetic, trusting relationship that could be difficult to make amid compassion fatigue. Because of this, healthcare institutions are placing increased importance on supporting their employee's emotional needs so they can better care for patients.^[47]

Studies compiled in 2018 by Zang et al.^[48] indicate that the level of education one obtains in the field of healthcare has an effect on levels of burnout, compassion satisfaction, and compassion fatigue. Studies show, it is indicated that those with higher levels of education in their respective field will experience lower rates of burnout and compassion fatigue, while also having increased levels of compassion satisfaction.

Another name and concept directly tied to compassion fatigue is moral injury. Moral injury in the context of healthcare was directly named in the Stat News article by Drs. Wendy Dean and Simon Talbot, entitled "Physicians aren’t ‘burning out.’ They're suffering from moral injury."^[49] The article and concept go on to explain that physicians (in the United States) are caught in double and triple and quadruple binds between their obligations of electronic health records, their student loans, the requirements for patient load through the hospital, and procedures performed – all while working towards the goal of trying to provide the best care and healing to patients possible. However, the systemic issues facing physicians often cause deep distress because the patients are suffering despite the physician's best efforts. This concept of moral injury in healthcare^[50] is the expansion of the discussion around compassion fatigue and burnout.

C.N.A.s/Caregivers

Caregivers for dependent people can also experience compassion fatigue, which can become a cause of abusive behavior in caring professions. It results from the taxing nature of showing compassion for someone whose suffering is continuous and unresolvable. One may still care for the person as required by policy, however, the natural human desire to help them is significantly diminished, causing desensitization and lack of enthusiasm for patient care.^[51] This phenomenon also occurs among professionals involved in long-term health care, and for those who have institutionalized family members. These people may develop symptoms of depression, stress, and trauma. Those who are primary care providers for patients with terminal illnesses are at a higher risk of developing these symptoms. In the medical profession, this is often described as "burnout": the more specific terms secondary traumatic stress and vicarious trauma are also used.

Mental health professionals

Many that work in fields that require great amounts of empathy and compassion are exposed to these stressful experiences in their day-today work activities.^[52][53] These fields mentioned include: social workers, psychologists, oncologists, pediatrics, HIV/AIDs workers, EMS, law enforcement, and of course, and general healthcare workers like nurses, etc.^[54] Social workers are one group that can experience compassion fatigue or STS from experiencing a singular trauma or it can be from traumatic experiences building up over the years.^[55] This can also occur because of a connection with a client and a shared similar traumatic experience.^[55] Overall, healthcare professionals in general are finding that they are burnt out with the price of empathy and compassion, otherwise known as, Compassion Fatigue. Most often describe feelings of “running on empty”.^[54] The importance of the contribution of education and recognition cannot be negated in its import  of counter of compassion fatigue.^[54] Other evidences support theories that meditation and reflection techniques such as Mindful-Based Stress Reduction Training and Compassion Cultivation Training, along with the support of administrators helps to fight and reduce STS^[54][56]

Critical care personnel

Critical care personnel have the highest reported rates of burnout, a syndrome associated with progression to compassion fatigue. These providers witness high rates of patient disease and death, leaving them to question whether their work is truly meaningful. Additionally, top-tier providers are expected to know an increasing amount of medical information along with experienced high ethical dilemmas/medical demands.^[57] This has created a workload-reward imbalance—or decreased compassion satisfaction. Compassion satisfaction relates to the “positive payment” that comes from caring.^[58] With little compassion satisfaction, both critical care physicians and nurses have reported the above examples as leading factors for developing burnout and compassion fatigue.^[59] Those caring for people who have experienced trauma can experience a change in how they view the world; they see it more negatively. It can negatively affect the worker's sense of self, safety, and control.^[60] In ICU personnel, burnout and compassion fatigue has been associated with decreased quality of care and patient satisfaction, as well as increased medical errors, infection rates, and death rates, making this issue one of concern not only for providers but patients.^[46] These outcomes also impact organization finances.^[58] According to the Institute of Medicine, preventable adverse drug events or harmful medication errors (associated with compassion fatigue/burnout) occur in 1% to 10% of hospital admissions and account for a $3.5 billion cost.^[61]

There are a total of four factors that are used to describe the underlying reasons for burnout, STS, and compassion fatigue: depressive mood, primary traumatic stress symptoms, responses to their patients' trauma, and sleep disturbances.^[62]

Those with a better ability to empathize and be compassionate are at a higher risk of developing compassion fatigue.^[63] Because of that, healthcare professionals—especially those who work in critical care—who are regularly exposed to death, trauma, high stress environments, long work days, difficult patients, pressure from a patient's family, and conflicts with other staff members- are at higher risk.^[61] These exposures increase the risk for developing compassion fatigue and burnout, which often makes it hard for professionals to stay in the healthcare career field. Those who stay in the healthcare field after developing compassion fatigue or burnout are likely to experience a lack of energy, difficulty concentrating, unwanted images or thoughts, insomnia, stress, desensitization and irritability.^[51] As a result, these healthcare professionals may later develop substance abuse, depression, or commit suicide.^[64] A 2018 study that examined differences in compassion fatigue in nurses based on their substance use found significant increases for those who used cigarettes, sleeping pills, energy drinks, antidepressants, and anti-anxiety drugs. Unfortunately, despite recent, targeted efforts being made to reduce burnout, it appears that the problem is increasing. In 2011, a study conducted by the Department of Medicine Program on Physician Well-Being at Mayo Clinic reported that 45% of physicians in the United States had one or more symptoms of burnout. In 2014, that number had increased to 54%.^[46]

In student affairs professionals

In response to the changing landscape of post-secondary institutions, sometimes as a result of having a more diverse and marginalized student population, both campus services and the roles of student affairs professionals have evolved. These changes are efforts to manage the increases in traumatic events and crises.^[65]

Due to the exposure to student crises and traumatic events, student affairs professionals, as front line workers, are at risk for developing compassion fatigue.^[66] Such crises may include sexual violence, suicidal ideation, severe mental health episodes, and hate crimes/discrimination.^[67]

Some research shows that almost half of all university staff named psychological distress as a factor contributing to overall occupational stress. This group also demonstrated emotional exhaustion, job dissatisfaction, and intention to quit their jobs within the next year,^[68] symptoms associated with compassion fatigue.^[69]

Factors contributing to compassion fatigue in student affairs professionals

Student affairs professionals who are more emotionally connected to the students with whom they work and who display an internal locus of control are found to be more likely to develop compassion fatigue as compared to individuals who have an external locus of control and are able to maintain boundaries between themselves and those with whom they work.^[66]

In lawyers

Burnout and compassion fatigue can occur in the profession of law; it may occur because of "a discrepancy between expectations and outcomes," or thinking one may have a larger task to achieve than provided resources and support.^[70]

Recent research shows that a growing number of attorneys who work with victims of trauma are exhibiting a high rate of compassion fatigue symptoms. In fact, lawyers are four times more likely to suffer from depression than the general public. They also have a higher rate of suicide and substance abuse. Most attorneys, when asked, stated that their formal education lacked adequate training in dealing with trauma. Besides working directly with trauma victims, one of the main reasons attorneys can develop compassion fatigue is because of the demanding case loads, and long hours that are typical to this profession.^[71]

Prevention

In an effort to prepare and combat compassion fatigue, especially within healthcare professions, many have been implementing resiliency training, educating workers in coping during stressful situations, being aware and conscious in their duties, working with integrity, creating a support system that includes individuals and resources that can provide understanding and are sensitive to the risks of compassion fatigue, and finally workers are learning how to decompress and destress, utilizing self-care, are all components.^[72]

Personal self-care

Stress reduction and anxiety management practices have been shown to be effective in preventing and treating STS. Taking a break from work, participating in breathing exercises, exercising, and other recreational activities all help reduce the stress associated with STS. There is evidence that journaling and meditation can also mediate the effects of STS.^[73] Conceptualizing one's own ability with self-integration from a theoretical and practice perspective helps to combat criticized or devalued phase of STS. In addition, establishing clear professional boundaries and accepting the fact that successful outcomes are not always achievable can limit the effects of STS.^[74]

Social self-care

Social support and emotional support can help practitioners maintain a balance in their worldview.^[75] Maintaining a diverse network of social support, from colleagues to pets, promotes a positive psychological state and can protect against STS.^[74] Some problems with compassion fatigue stem from a lack of fundamental communication skills; counseling and additional support can be beneficial to practitioners struggling with STS.^[76]

Self-compassion as self-care

In order to be the best benefit for clients, practitioners must maintain a state of psychological well-being.^[77] Unaddressed compassion fatigue may decrease a practitioners ability to effectively help their clients. Some counselors who use self-compassion as part of their self-care regime have had higher instances of psychological functioning.^[78] The counselors use of self-compassion may lessen experiences of vicarious trauma that the counselor might experience through hearing clients stories.^[79] Self-compassion as a self-care method is beneficial for both clients and counselors.^[80]

Mindfulness as self-care

Self-awareness as a method of self-care might help to alleviate the impact of vicarious trauma (compassion fatigue).^[81] Students who took a 15-week course that emphasized stress reduction techniques and the use of mindfulness in clinical practice had significant improvements in therapeutic relationships and counseling skills.^[82] The practice of mindfulness, according to Buddhist tradition is to release a person from “suffering” and to also come to a state of consciousness of and relationship to other people's suffering. Mindfulness utilizes the path to consciousness through the deliberate practice of engaging “the body, feelings, states of mind, and experiential phenomena (dharma).”^[83] The following therapeutic interventions may be used as mindfulness self-care practices:

• Somatic therapy (body)
• Psychotherapy (states of mind)
• Emotion focused therapy (feelings)
• Gestalt therapy (experiential phenomena)^[84]

Scales Used for Assessment	Administration	Measure	Accessible
Professional Quality of Life Measure ProQOL^[85]	self-test	compassion satisfaction, burnout, and secondary traumatic stress	online, available
Compassion Fatigue and/Satisfaction Self Test for Helpers^[86]	self-test	compassion fatigue	online, available
Maslach Burnout Inventory^[87]	administered	burnout	available for purchase

Compassion fade

Main article: Compassion fade

Compassion fatigue is defined as “the physical and mental exhaustion and emotional withdrawal experienced by those who care for sick or traumatized people over an extended period of time”.^[88] Compassion fatigue usually occurs with those whom we know; whether that is because of a personal relationship or professional relationship.^[89] Compassion fade is defined as terminology to describe the way in which an individual’s compassion and empathy are reduced due to the amount or intricacy of the issue.^[90] This also includes when the need and tragedy in of the world goes up and the amount of desire to help goes down (similar to a see-saw).^[91] For example, an individual is more likely to donate more money, time, or other types of assistance to a single person suffering, than to disaster aid or when the population suffering is larger.^[89][90][92] It is a type of cognitive bias that helps people make their decision to help.^[93]

See also

•  Psychology portal

• Bystander effect
• Caregiver stress
• Compassion fatigue in journalism
• Countertransference
• Diffusion of responsibility
• Donor fatigue
• Post-traumatic stress disorder
• Self-licensing
• Alexander Mitscherlich / Margarete Mitscherlich: wrote about the "inability to mourn".

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Further reading

• Adams, R.; Boscarino, J.; Figley, J. (2006). "Compassion Fatigue and Psychological distress among social workers: a validation study". American Journal of Orthopsychiatry. 76 (1): 103–108. doi:10.1037/0002-9432.76.1.103. PMC 2699394. PMID 16569133.
• Barnes, M. F (1997). "Understanding the secondary traumatic stress of parents". In C. R. Figley (Ed). Burnout in Families: The Systemic Costs of Caring, pp., 75–90. Boca Raton: CRC Press.
• Beaton, R. D. and Murphy, S. A. (1995). "Working with people in crisis: Research implications". In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized, 51–81. NY: Brunner/Mazel.
• Figley, C. R. (1995). "Survival Strategies: A Framework for Understanding Secondary Traumatic Stress and Coping in Helpers". Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. NY: Brunner/Mazel. pp. 21–50. ISBN 9780876307595.
• Hall, J.; Rankin, J. (2008). "Secondary Traumatic Stress and Child Welfare". International Journal of Child and Family Welfare. 11 (4): 172–184.
• Kinnick, K; Krugman, D.; Cameron, G. (1996). "Compassion fatigue: Communication and burnout toward social problems". Journalism & Mass Communication Quarterly. 73 (3): 687–707. doi:10.1177/107769909607300314. S2CID 144481370.
• Kottler, J. A. (1992). Compassionate Therapy: Working with Difficult Clients. San Francisco: Jossey-Bass.
• Joinson, C (1992). "Coping with compassion fatigue". Nursing. 22 (4): 116–122. doi:10.1097/00152193-199204000-00035. PMID 1570090.
• Phillips, B. (2009). Social Psychological Recovery, Disaster Recovery. (p. 302). Boca Raton, FL: CRC Press - Taylor & Francis Group.
• Putman, J.; Lederman, F. (2008). "How to Maintain Emotional Health. When Working with Trauma". Juvenile and Family Court Journal. 59 (4): 91–102. doi:10.1111/j.1755-6988.2008.00023.x.

External links

•   Media related to Compassion fatigue at Wikimedia Commons
• Compassion Fatigue Awareness Project
• ProQOL.org, Professional Quality of Life Organization
• Mirrored emotion by Jean Decety from the University of Chicago.
• Compassion Fatigue: Being an Ethical Social Worker by Tracy C. Wharton, from The New Social Worker, Winter 2008.
• The Signs Symptoms and Treatment of Compassion Fatigue