By Edward M. Smink Ph.D
I am fascinated that compassion fatigue occurs because caregivers care – not an abnormality, which most in our culture may argue, but something very normal in the life of a caregiver. This was important to me for two reasons. The first was to understand more fully my own experience of burnout 25 years ago, and the second was to do research for my book The Soul of Caregiving: A Caregiver’s Guide to Healing and Transformation. I wanted to explore the implications of compassion fatigue, recognize its symptoms, and offer strategies for how to prevent it. My research led me to the pioneering work of Charles Figley on addressing compassion fatigue. He begins his book Compassion Fatiguewith these words: “There is a cost to caring. Professionals who listen to clients’ stories of fear, pain, and suffering may feel similar fears, pains, and sufferings because they care.”1 We as caregivers are the professionals who experience different degrees of compassion fatigue because we care. We experience both the joys and the sufferings that caregiving implies. We are the caregivers who also experience traumatic stress and trauma, which may lead to one of the sisters of compassion fatigue, secondary traumatic stress and burnout.Who, then, are the caregivers who experience compassion fatigue? We all are. Who are our clients and those we care for? Our children, our parents, our relatives, friends, clients, strangers, and patients are such examples. Our life experiences of caregiving transcend ourselves and those to whom we provide care and extend to the members of the community at large. The art of caregiving transcends any one culture or ethnic tradition, as its arms embrace all those in need. It is part of being human. Caregiving has universal and archetypal qualities about it and is enshrined in many spiritual and religious traditions. Caregiver specificity lies in the unique roles and actions that caregivers perform. These are skill specific. For example, there is a difference in how first responders, like police or firefighters, care. Likewise, those involved in the healing professions respond to and care for individuals according to their needs. Similarly, parents who care for their children and adult parents who care for their parents, as well as educators, also are caregivers. I like how Dr. Atul Gawande puts this into context as he asserts that there are three common elements of a profession: the expectation of selflessness, the expectation of skill, and the expectation of truthfulness. He also adds a fourth element that he calls team discipline, such as using a checklist to assure competency and team support for each other.2 We who are caregivers commit to these. We who are cared for expect truthfulness, selflessness, skills, and team efforts.More than a job, caregivers are privileged to enter into the mysteries of life such as birth and death, suffering and joy, wellness and illness, healing and transformation. Caregivers are trained to adapt and become responsive to the particular needs of those they serve. Day in and day out, personally and professionally, caregivers take to heart their unique call that motivates and sustains them. When we explore the meaning of the words compassion and fatigue, immediately we assume that compassion is good and fatigue, well, not so good. We have no time in our busy schedules to acknowledge that we may experience fatigue as a normal outcome of the work that we do. There were many times I left my shift as a registered nurse satisfied that I had done a good job. There were also times I felt exhausted, sort of discombobulated, so to speak, wondering if I had the energy to drive home. We as caregivers understand the demands that compassion places on us. To enter the world of the one who needs care is to enter a world of possible suffering, unanswered questions, doubts, fears, and pain. As such, we also experience suffering. Hence the meaning of the word compassion, Latin for with or together, com, and to suffer with, passion.This is an important point: compassion fatigue is not something extraordinary or a mental health stigma for a designated few. Compassion fatigue occurs because caregivers care. It is an integral side effect of being a caregiver. Caregivers struggle to show compassion. The question then becomes, how do caregivers deal with the fatigue and exhaustion that is normal for them? How do they prevent the extreme symptoms of fatigue and exhaustion and build up resilience? Compassion defines who we are. It is the tonic that refreshes humankind. On the other hand, we are not gods, even though we perform sacred work. We can and do run out of energy that needs to be replaced. There is an interior discipline and resilience that we must create to address the gremlins lurking about us. My gremlins were a lack of self-care and of setting appropriate boundaries.While most would agree that compassion is a value to be lived, its practice is often difficult in a culture that values competition and individualism. Self-care is not being selfish but is the discipline or guardrails that channel compassion. Another word for discipline might be temperance, the ability to temper and guide one’s energy in making soulful decisions. Three aspects of compassion focus, first, on the caregiver and his or her response to the one in need; second, on the interchange between the caregiver and the one seeking care; and third, on the compassion that the caregiver needs to listen to the interior promptings of his or her Soul.Does the caregiver hear the cry of the one in need? Does the one in need have a story to tell and need a compassionate ear? Finally, does the caregiver take the risk of showing compassion for him- or herself in exploring what the stirrings of the Soul wish to articulate?We care, and this is the starting point of all that we do as caregivers. No matter how objective we believe we are, we experience the trauma, the pain, and the suffering of those we care for, even when we struggle to remain emotionally detached. Because we care, sometimes we get exhausted, and sometimes we need help to bear the burden of the emotional, physical, and psycho-spiritual experiences we carry. The cords that tie us up with the misconception that we have to do it all ourselves need to be loosened, and better to be loosened by our own methods and practice. It is better to make a connection with a family member, friend, colleague, or pastoral counselor than to have these cords cut in an emergent situation.Dr. J. Eric Gentry suggests that we have a compassion resiliency safety net where we empower one or two people who know us well and care about us. Choose those who are strong enough to withstand any deflection when we become symptomatic or when we become consistently divergent from the ways we normally act.3 No matter where we start, no matter what our unique philosophy or spiritual tradition may be, compassion is known universally around the world. Who do you know, or rather who are you drawn to, because of their compassion? If compassion fatigue, with its two sisters secondary traumatic stress and burnout, is a danger to caregivers, and if the very art of caregiving presupposes that we will experience pain and suffering, then how do we build the needed resiliency to protect ourselves? The easiest answer is one step at a time. And the first step is becoming aware that the simplest definition of fatigue is extreme exhaustion after a particular activity.Each of us can remember how exhausted we felt when we moved from one house to another. After the movers leave, we sort of plop on the couch, with every muscle of our body screaming for attention. When we speak of fatigue in the context of the caregiving we do, as hard as it is to say, we do get exhausted and fatigued by the day in and day out work of caregiving. Sometimes the fatigue is physical, and our bodies ache because of the particular demands of that day. Christina Maslach has discovered that the symptoms can be physical, emotional, and spiritual. Symptoms of physical exhaustion can be somatic complaints, weight loss or weight gain, gastric Intestinal distress, insomnia, and aches and pains, just to name a few.4Other times, we are emotionally exhausted because we are witnesses to a specific traumatic event or experience vicarious trauma because of the work that we do. Signs of emotional fatigue can be outbursts, emotional instability, anger, suicidal ideation, cynicism, irritability, racing thoughts, sarcasm, poor concentration, violent fantasies, fears, and anxiety. When the symptoms of compassion fatigue start rearing their ugly heads, we may isolate ourselves and deprive ourselves of interpersonal relationships that can support us. Relationship problems, becoming isolated, troubled relationships with coworkers, and fears of relating one’s experience to another are such examples of experiencing relationship fatigue. Instead of turning toward a loved one or colleague, one turns to isolation and self-medicating with drugs, alcohol, gambling, sex, or food addictions.5Also, of importance, our spiritual values may be challenged. We seem to be drifting out to sea, experiencing a loss of meaning and purpose, caught in a riptide where our spiritual values seem to get lost. Caregivers experience a loss of joy and happiness. They become like robots, appearing at work to do a job, but with the loss of the passion they once had. We all know through our own experiences with our peers that some members are on the precipice of falling into compassion fatigue, burnout, or secondary traumatic stress, even PTSD. I find an uncanny similarity between Maslach and the earlier definition by Freudenberger, who identifies burnout “as a state of fatigue or frustration brought about by devotion to a cause, or way of life, or to a particular relationship that fails to produce an expected reward.”6Where to begin? How do we, as caregivers, respond to those loving invitations from family, friends, and colleagues who knock gently at our door? I guess the first step is to listen to those stirrings, and if we don’t hear them, can we trust a loving person to mirror them to us? Gentry suggests three skills that are effective in resolving current symptoms and preventing future problems.7 The first is to connect with a friend, family member, coach, counselor, or colleague for support. Simply ask them if they could listen to what is stirring and may be causing anguish in your Soul. You may suggest that you don’t want them to solve or fix anything. Being able to articulate your inner stirrings, as best you can, is already a step on the road to recovery. Those in pain need to break the silence and take the risk to seek help as well as be open to those who care about them and offer to help. We always have our answer pat when we hear the greeting “Hello, how are you doing?” and then we respond, “Fine,” even when we really are feeling shitty that day. “Fine” allows us to share a greeting and get on our way.Second, as you reach out to someone, you already are entering into the realm of storytelling. How far back do you remember a story told to you? Was it at a grandparent’s house, or around a campfire at a Scout camp, or was it listening to a client in need? We all have stories to tell, so it's not that we have to rack our brains for one. Most of them are on the tips of our tongues. I am amused that many of my friends comment, “Just give him a stage and he will perform.” When was the last time you felt you were listened to and that someone was really interested in what you had to say? Stories allow us to reflect, and to envision new possibilities. Storytelling becomes a powerful means of looking at oneself from a safe and alternate perspective. There is no script for how to tell a story. I'm sure you are a pro, especially after a beer or two. No babble, just your willingness to tell your story. You simply start. Someone wants to hear your story, and as you relate it verbally, or in writing, what you will discover is that the story becomes a mirror reflecting back the real you.The third skill that helps one deal with the symptoms of compassion fatigue is creating a practice of relaxation. I love hearing that I have the luxury of time and it is possible to develop periods and spaces in my day, week, or month. I finally took that cooking class and did sign up with a writer’s group. What about time to read that book about travelling in Europe or planning for that fishing trip you have always put off? Do you remember being invited to learn a new form of meditation by a member of your church or synagogue? Are you willing to go to that workshop on centering prayer and learn more about your spirituality? Where do you find those opportunities to discover more about yourself as a caregiver? Can you pause and reflect on who and what gives meaning to you? Do you have or want to develop a spiritual practice? How many times do you rationalize that you are too busy? Do you put off taking that walk each morning with your friends around the neighborhood or going to the local park or the gym? Do you want to join that hiking or bicycle club?Recovery from and avoidance of the triggers and symptoms of compassion fatigue is possible. These three practices help us, as caregivers, to develop a resilience that allows us to be faithful to that original call to be a caregiver, where we find meaning and spiritual support. We can continue to have a passion for our work because in so many ways our caregiving defines who we are. In strengthening our relationships, in allowing ourselves to be vulnerable, we rediscover the value of those who support and sustain us. Each step forward is one more step where we gain self-confidence and resilience in times of stress. I know: I have recovered from burnout.Excerpts taken from The Soul of Caregiving, A Caregiver’s Guide to Healing and Transformation, by Edward M. Smink, Ph.D., now on Amazon in hard copy and soon to be on Kindle.Edward M. Smink, Ph.D., understands the strengths and pitfalls of a caregiver. He has worked across the continuum of healthcare as a registered nurse, chaplain, pastoral counselor, and executive healthcare leader for over 40 years. He spends his retirement in Central California writing and doing life coaching.He can be reached through his website: http://www.soulofthewoundedhealer.com1 Figley,Charles. Compassion Fatigue. New York: Routledge, 1995.2 Gawande, Atul. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan, 2009.3 Gentry, J. Eric. International Association of Trauma Professionals, Certified Compassion Fatigue Professional PESI Digital Course, Eau Claire,WI, January 20184 Maslach, Christina. Burnout: The Cost of Caring. Englewood Cliffs, NJ: Prentice-Hall, 1982.5 Maslach, Christina, and Michael Leiter. The Truth About Burnout: How Organizations Cause Personal Stress and What To Do About It. San Francisco: Jossey-Bass, 1997.6 Freudenberger, Herbert J., and Geraldine Richelson. Burnout: The High Cost of High Achievement. Garden City, NY: Anchor Press, 1980.7 Gentry, op. cit.