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. 2019 Sep;60(9):1004–1006.

Moving from compassion fatigue to compassion resilience Part 2: Understanding compassion fatigue

Debbie L Stoewen 1
PMCID: PMC6697064  PMID: 31523091

Introduction

The provision of companion animal veterinary care is a highly specialized field of care that offers immense joys and rewards — improving the health of animals, supporting the well-being of clients, and ultimately, preserving the human-animal bond. Caring for patients and clients can be tremendously satisfying, offering a sense of meaning, purpose, and difference-making incomparable to that which may be found in any other field, yet it can incur a cost, “the cost of caring,” (1) commonly known as compassion fatigue. Within the high care professions where empathy, compassion, and caring for others are at the core of practice, compassion fatigue is recognized as an occupational hazard (2). Almost everyone who cares for others in the high care professions will eventually experience some degree of compassion fatigue (3). As Remen (4) so aptly worded it, “The expectation that we can be immersed in suffering… and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet.”

The origin of compassion fatigue

The term compassion fatigue was first used in the context of a study of burnout in nurses nearly 3 decades ago. At that time, Joinson (5) coined the term to describe in nurses the “loss of the ability to nurture” (5,6). Since then, compassion fatigue has been recognized to affect not just nurses, but anyone who works in the caring professions including doctors, emergency care workers, hospice workers, police officers, firefighters, mental health workers, family therapists, and veterinarians and veterinary technicians, among others (6). The world renowned traumatologist, Charles Figley, who referred to compassion fatigue as “the cost of caring,” has defined it as “the deep physical, emotional, and spiritual exhaustion that can result from working day to day in an intense caregiving environment” (7).

Compassion fatigue as a manifestation of secondary traumatic stress and burnout

According to Beth Hudnall Stamm, a celebrated professor and researcher in the field of traumatic stress, compassion fatigue is thought to be a manifestation of secondary traumatic stress and burnout (8). Unsurprisingly, the definition of burnout is similar to that of compassion fatigue. The Mayo Clinic defines burnout as “a state of physical, emotional and mental exhaustion accompanied by doubts about one’s competence and the value of one’s work” (9). It’s the result of a chronic imbalance between the demands of the job and the resources one has to complete the job (10) causing long-term, unresolvable work-related stress (11). The other part of compassion fatigue, secondary traumatic stress, is also known as compassion stress. This is the psychological distress connected with being exposed to the suffering of others (12). As can be appreciated, compassion fatigue arises from stress — work-related stress and compassion stress. But as there is a synergistic effect among all forms of stress, keep in mind that primary traumatic stress (the stress related to directly experiencing or witnessing traumatizing events) both at work and outside of work, can contribute to, and increase, the risk of compassion fatigue.

Compassion fatigue can be further understood in relation to professional quality of life. Stamm developed the Professional Quality of Life Measure (ProQOL), the most commonly used measure of the negative and positive aspects of helping others who experience trauma and suffering (Proquol.org). Just as compassion fatigue is seen as the negative aspect, compassion satisfaction — the pleasure derived from being able to do one’s work well as a professional caregiver — is seen as the positive aspect (13). The relationships between these parts is shown in Figure 1.

Figure 1.

Figure 1

Model of professional quality of life.

Compassion fatigue as a manifestation of chronic empathic distress

There is another way of looking at, and understanding, compassion fatigue. Since first coined in the early ‘90s, compassion fatigue has been seen as just that, “compassion” fatigue. But with the advent of advanced neuroimaging technologies that expand our comprehension of brain structure, processes, and functioning, our understanding may be changing. The question has been raised that compassion fatigue might not really be “compassion” fatigue, but rather “empathic distress” fatigue (14). This was recently forwarded in an enlightening article by Dr. Trisha Dowling titled Compassion does not fatigue! (15). In this article, Dowling points to the evidence drawn from the social neurosciences research of Dr. Tania Singer and colleagues of the Max Planck Institute for Human Cognitive and Brain Sciences (14).

As mentioned in Part 1 of Moving from Compassion Fatigue to Compassion Resilience (16), compassion consists of 3 facets: noticing, feeling, and responding (17). “Feeling” refers to empathy, the social emotion that allows us to resonate with someone else’s feelings, regardless of valence (positive/negative), knowing that the other person is the source of this emotion (18). While the sharing of positive emotions can be pleasurable, the sharing of negative emotions can be difficult — and not always lead to sympathy, concern, and compassion. Exposure to the suffering of others can lead to 2 different emotional reactions, empathic concern, with sympathy and compassion, or empathic distress (19, Figure 2).

Figure 2.

Figure 2

Model that differentiates between 2 empathic reactions to the suffering of others (adapted from reference 19).

Whether we respond with empathic concern (compassion) or empathic distress may depend on our ability to tolerate distress. Distress tolerance is defined as “the ability to tolerate difficult emotions in oneself when confronted with someone else’s suffering without becoming overwhelmed by them” (20). If we over-identify with the suffering of others, and become personally distressed, we may feel the need to get away from them or reduce our awareness of their distress, which would prevent a compassionate response. If we become too focused on our own discomfort, our ability to help becomes hindered. The critical element in this is “self-other” differentiation. Empathy involves accurately feeling with the other while at the same time maintaining an emotionally separate sense of self (21).

If the distinction between “self ” and “other” becomes blurred and the emotional pain of the other is taken on as one’s own, the result is empathic distress (22). Empathic distress is an aversive and self-oriented response, motivating the desire to withdraw from the situation in order to protect one’s self from the pain rather than move towards the situation and attempt to relieve the pain. Whether exposure to the suffering of others leads to empathic concern (and altruistic motivation) or to empathic distress (and withdrawal) depends upon the capacity for “self-other” differentiation (22,23).

Neuroimaging has shown that a “self “orientation with empathic distress activates the brain areas involved in the processing of threat or pain — the insular cortices, the anterior medial cingulate cortex, and the amygdala (23). With chronic empathic distress, the dopamine levels within the brain circuits that mediate reward and motivation become depleted (24). The ongoing depletion of dopamine from repeated episodes of empathic distress leads to burnout (25). Adopting an “other” orientation, with empathic concern (compassion), activates different areas of the brain. In contrast to empathic distress, compassion activates the brain areas associated with dopaminergic reward and oxytocin-related affiliation processes (26) — the ventral striatum, nucleus accumbens, ventral tegmental area, medial orbitofrontal cortex and subgenual anterior cingulate (22). Compassion activates areas of the brain linked to reward and affiliation, and generates positive emotions towards suffering, all of which motivate — not hinder — helping behavior. Compassion may even thus be viewed as an emotion-regulation strategy that buffers or counteracts the negative emotions through the generation of positive emotions (22).

As forwarded by Klimecki and Singer (14), compassion fatigue may be understood as empathic distress fatigue. Interestingly, this perspective is supported by some recent research on the prevalence of compassion fatigue among veterinary students in Australia (21). Using the ProQuol scale (by Stamm), this study found that empathic (personal) distress was positively associated with secondary traumatic stress. The same finding was reported in a previous study with clinical social workers (27). This finding suggests that empathic distress may increase vulnerability to secondary traumatic stress. And as we know, from the traditional way of understanding compassion fatigue, secondary traumatic stress, alongside burnout, leads to compassion fatigue. Altogether, we may best understand compassion fatigue — and be able to manage it — by embracing both conceptualizations, as the manifestation of secondary traumatic stress and burnout (8), and as the manifestation of chronic empathic distress (14).

Learning about compassion fatigue may be one of the most important things that we do

Compassion fatigue is recognized as “the greatest threat to personal, professional and financial success among those who truly provide compassionate care” (28). Learning about compassion fatigue may be one of the most important things that we do as veterinary professionals. It may nearly be thought of as requisite, as a professional responsibility. We are the center of all that we do, and empathy, compassion, and caring for others are at the core of what we do, yet the ability to work in a compassionate manner can wane. Almost everyone who cares for others in the practice of medicine will experience some degree of compassion fatigue, and the consequences cannot be underestimated. The more we learn about this nearly unavoidable occupational hazard, the better — for ourselves, our patients, our clients, and our practices.

Having focused on the significance of compassion (16) and understanding compassion fatigue, the next article will focus on the causes of compassion fatigue, specifically the many realities of life in practice that make us so susceptible. This will deepen our understanding of compassion fatigue as it relates to the kinds of stressors that lead to the stress and distress that can culminate as compassion fatigue.

Footnotes

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office (hbroughton@cvma-acmv.org) for additional copies or permission to use this material elsewhere.

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