Addressing compassion fatigue

Early in her career, Marla Vannucci, PhD, was working with veterans in an intensive trauma unit when she started having nightmares about war and violence. Over time, she struggled to connect with family and friends and began isolating herself from others as her migraines, intrusive thoughts, and fatigue intensified.

“The place where I worked had a ‘pull yourself up by your bootstraps’ mentality and a value on toughness, so there was not a lot of space to process the feelings I was having,” said Vannucci, who now owns a small group practice in Chicago. “I didn’t feel like I could reach out to colleagues for support.”

Vannucci was suffering from compassion fatigue, or the burnoutopens in new window and stress-related symptoms experienced by helping professionals in reaction to working with traumatized people over an extended period of time. Charles Figley, PhD, founder of the Traumatology Institute at Tulane University, developed the concept of compassion fatigueopens in new window when he started focusing on trauma workers and mental health professionals who seemed to vicariously experience the effects of trauma. Symptoms can range from physical conditions including headaches and digestive problems to emotional issues such as mood swings, restlessness, irritability, and oversensitivity, according to the Professional Quality of Lifeopens in new window scale. Providers may dread working with certain patients or colleagues and lose a sense of purpose.

All too often, mental health clinicians view these reactions as a sign of weakness, said Kerry Schwanz, PhD, a psychology professor at Coastal Carolina University in South Carolina who studies compassion fatigue. When these symptoms are dismissed for too long, Schwanz and other experts have seen mental health providers question their ability to work in the profession and sometimes leave the field.

The good news is that awareness of the condition can mitigate and even prevent this form of exhaustion, and research suggests there are strategies for building resilience to compassion fatigue. Psychologists are leading efforts in behavioral health and integrated care teams to develop safety support practices that reduce the risk of developing symptoms that are often a natural consequence of working with traumatized patients. “Having a name for compassion fatigue empowers clinicians to recognize it and do something about it so they can continue to do the work that they love,” Schwanz said.

Before practitioners start searching for strategies to address compassion fatigue, Schwanz urges them to evaluate their attitudes about the concept of self-care. “Sometimes our own beliefs about self-care may negate the positive effects,” she said. If therapists take a walk or spend time gardening for self-care but feel guilty during the activity because they are not attending to their professional responsibilities, the positive mental and emotional benefits will be stifled, said Schwanz.

In a recent study, she and her colleague developed an instrument to measure self-care beliefs with questions such as, “I feel selfish when I put myself before others,” and “I enjoy taking time out of my day for myself.” The data showed that high ratings of feeling selfish, guilty, preoccupied, and counterproductive when taking time for oneself was a significant predictor of secondary traumatic stress (STS), or emotional distress from hearing the first-hand trauma of others ( Journal of Wellness opens in new window , Vol. 3, No. 3, 2022), and STS is a component of compassion fatigue.

If clinicians have negative beliefs about self-care, Schwanz suggests peer supervision or finding a self-care buddy to honestly reflect on the level of stress and experiences with practicing self-care. “Many people don’t realize they have negative beliefs about taking care of themselves, so the first step is being aware when those negative thoughts surface and challenging them,” she said.

With increased awareness about the importance of healthy self-care beliefs, therapists are more equipped to discover which self-care practices help them reduce or prevent symptoms of compassion fatigue. Research suggests that an important first step is reflection, or intentional, critical examination of a clinician’s practice experiences for the purpose of obtaining insight, self-awareness, direction, and competence (Glassburn, S., et al., Reflective Practice opens in new window , Vol. 20, No. 6, 2019). For therapists, this includes considering how their practice reflects and affects who they are.  

Vannucci encourages therapists to try reflective journaling to consider their reactions and feelings in response to exposure to patient trauma. They can also write about how their work connects with their purpose, such as being someone who notices other people’s pain, cares deeply, and wants to help.

Finding colleagues who can support each other through supervision or group consultation has also been a critical tool for Vannucci, who leads Blue Sage Psychotherapy, a group practice in Chicago with nine other clinicians. During 90-minute weekly meetings, team members discuss cases and if needed, seek support. “We are paying attention when our feelings seem too intense because this can be an early warning sign,” she said. “This can include feeling too close to a patient and stretching boundaries or feeling apathetic.”

During one meeting, Vannucci shared about her response to an LGBTQ+ patient who had recently experienced violence as a result of his sexual identity. “I started feeling a lot of anxiety and unsafety when I was out in the community,” she said. “I also felt more emotional with this client and like I could cry.” At first, Vannucci felt self-conscious about these emotions, but colleagues in the group were supportive and shared similar experiences. With increasing numbers of patients expressing their fears related to basic human rights, health care, and the economy in the last few months, the risk of compassion fatigue is even higher, Vannucci said.

Brief group huddles have been a lifeline for Tai Mendenhall, PhD, LMFT, a medical family therapist in the Department of Family Medicine and Community Health at M Health Fairview in Minnesota. “Compassion fatigue is a high risk in this setting,” he said. He regularly faces emotionally painful situations in the integrated care clinic, such as patients who experienced sexual abuse, intimate partner violence, drug overdose, or loss of a loved one by suicide. “I love this work, but it became clear early on that I had to take care of myself, or I could not stay in the field,” Mendenhall said.

To support one another, the team—which includes physicians, family practice residents, nurses, medical assistants, pharmacists, and mental health providers—meets for 15 minutes at the beginning of the day as well as anytime a team member requests a short meeting. “It gives us the sense that we are in it together,” Mendenhall said. “If someone just had a horrible situation when they had to tell a couple about their fourth failed pregnancy or a tell parent that the child won’t be the same after a diagnosis, we can support each other—and even cry, sometimes—as we process our feelings as a group.”

Although clinicians are trained to use psychological interventions to help patients, engaging the same techniques for self-care can reverse a downward spiral into compassion fatigue. Psychologist Esther Deblinger, PhD, co-director of the CARES Institute at Rowan Medicine in New Jersey, was teaching mental health providers throughout the nation how to provide trauma-focused cognitive behavioral therapy (TF-CBT) for children when she noticed that there were high turnover rates among the direct service providers. “When you listen day in and day out to stories of trauma, abuse, and violence, it takes a toll,” she said. “I realized the people I was training liked helping children, but the work was really stressful.”

She developed a virtual self-care and relationship-care curriculum called the PRACTICE course for personal and professional well-being. The course helps clinicians use the trauma-focused CBT skills they were teaching to children and caregivers for their own self-care. PRACTICE is an acronym for the skills and activities associated with TF-CBT as well as the self-care course. For example, the "P" stands for “praise,” which supports relationship building by expressing appreciation for someone who is important to the clinician. “R” stands for “relaxation,” which includes skills like focused breathing, particularly when facing a stressful situation.

In a pilot study, at the end of the course participants reported a significant increase in use of PRACTICE coping skills as well as significant reductions in burnout and secondary traumatic stress ( Psychological Trauma: Theory, Research, Practice, and Policy opens in new window, Vol. 16, Supplement 3, 2024). Deblinger’s more recent research suggests that course participants also showed improved confidence in implementing trauma-focused CBT with patients.

Another valuable tool for combating compassion fatigue is intentionally devoting time to focus on the pleasure and satisfaction associated with working in a helping profession. By highlighting the rewarding, meaningful aspects of the job, clinicians can foster what is known as “compassion satisfaction.”

“We have all gone into this field for a reason, and making an effort to remember that we are doing valuable work can go a long way to reducing compassion burnout,” said Melissa Brymer, PhD, director of terrorism and disaster programs at the UCLA-Duke National Center for Child Traumatic Stress. She encourages organizations that employ providers to consistently celebrate positive moments and other accomplishments.

According to data from Schwanz’s study, compassion satisfaction was associated with lower levels of compassion fatigue. Brittany Trauthwein, PsyD, a therapist at Bridgepoint Psychology Center in Chicago, learned to nurture compassion satisfaction in her work with patients who experience grief and loss or have a medical diagnosis, but she was not as resilient in the early stage of her career. During the first few years in the field, she saw more than 30 patients per week. “I had a lot of book knowledge about grief and loss, but school did not prepare me for what it would be like to sit with someone who was dying,” she said.

At home she felt overwhelmed, and at work she felt less present with patients. “I noticed I was not connecting to what people were sharing,” she said. She continued thinking about what patients had shared after their sessions and how long she would have left with them. After engaging with patients all day, she noticed a lack of empathy when talking to family or friends, and she needed more time alone. 

For her, self-care included reducing her overall caseload and limiting the number of patients who were dealing with terminal illnesses. Reducing her caseload enhanced her ability to provide focused, meaningful support to patients nearing end of life, reinforcing her sense of purpose in the work. She learned to give herself permission to grieve when patients died, and she created rituals to help her remember the positive aspects of working with these patients. She has mementos in her office from different patients, and she attends funerals if family members invite her.

These routines help her to foster compassion satisfaction and motivate her to continue helping patients who are often facing complex emotional experiences. She has also learned that gardening and going to nearby Lake Michigan are critical well-being strategies. “Even though this work is really hard, there is something very fulfilling about helping people feel that they are ready to die,” she said. “But if I am not engaging in self-care practices, I have learned that is a red flag that needs my attention.”