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by Jan Chozen Bays, M.D.
STAYING HEALTHY IN THE MIDST
OF SUFFERING AND DISEASE
Jan Chozen Bays,
CARES NW, Legacy
Emanuel Children’s Hospital, Portland, Oregon
With optimism and compassion, people
enter occupations which involve daily encounters with disease, mental
illness, and abuse and neglect. Chronic exposure to human suffering turn
optimism into despair, kindness into resignation. Talented people may leave
the work before they planned or wanted to, with sadness, anger or
indifference. Or they don’t leave and remain indifferent, tired, just
putting in their time until retirement.
Counter transference: Our deep issues have not been resolved and the material we
encounter in our work with human suffering triggers old problems.
Burnout: Our minimum acceptable goals are too high or we insist that the world
should work the right way. We resist changing our goals in response to
feedback. The adaptation is to become negative, less empathic and to
withdraw. (“I’m the only one who can do this right.” I’m
We suffer the cumulative negative effect of experiencing
many scenes of trauma, many deaths with no time to grieve. Intrusive images
interfere with our clarity of mind and we disassociate from our work,
family and friends.
Compassion Fatigue: We suffer the cumulative emotional residue of continuously
working with suffering. In instead of withdrawing we keep trying harder to
give ourselves fully.
Every type of work
involves occupational hazards. If we chose to work with human pain, trauma,
suffering and grief, we must accept responsibility for educating ourselves
about the hazards associated with this work, monitor our exposure and
symptoms, and use appropriate tools to keep ourselves healthy.
FIVE PSYCHOLOGICAL NEEDS SENSITIVE TO DISRUPTION
Working with disease heightens the sense of personal vulnerability and the
fragility of life. Symptoms: imagined illnesses in ourselves and others,
preoccupation with cleanliness and safety, not letting any one babysit,
through exposure to the many ways people deceive, betray or violate the
trust of others, providers may become suspicious and cynical. “I used to
believe that the majority of people were trustworthy. Now I believe the
opposite.” Symptoms: Self criticism, not trusting one’s own instincts,
Esteem is defined as the need to perceive others as benevolent and worthy of
respect. Encountering so much human pain and suffering can shatter
providers’ world view and lead to cynicism, pessimism and anger at
individuals or mankind in general. Or it can lead to musing about the fate
of the human race.
Symptoms: degrading oneself or others (anyone not doing the work is useless),
over idealization of self and others (I’m the only one who can do this
A sense of alienation may emerge from exposure to pain, illness and death,
which cannot be shared with others, either because others pull away in
horror or disbelief, or because of confidentiality requirements. It is
particularly painful if your spouse cannot bear to hear what you are doing
in life or what is worrying you. A “club” develops, with a sense of distrust
of those outside who can never understand your world. Symptoms:
emotional numbing, withdrawal from intimacy.
Power or control:
Two reactions are seen with repeated exposure to patient’s powerlessness.
The first for a provider to try to increase their sense of power in the
world, by taking self-defense classes or by becoming more dominant. The
second is to experience despair about the uncontrollable forces of natural
or human violence. Symptoms: personal freedom restricted through fears
and measures to relieve anxiety about safety, loss of control at work or
Frame of reference:
“Why did this happen?” A
fundamental human need is to develop a meaningful frame of reference. We try
to explain or discover what we or the patient did wrong. Or we lose our
frame of reference and become pervasively uneasy. Symptoms: loss of
meaning or standards. Decision making becomes difficult or arbitrary.
SIGNS TO PAY
- intrusion of
patients’ issues into our imagination
- loss of
empathy for, and increased criticism of patients, self and others
numbing through addictive behavior (including work)
withdrawal from intimacy - spouse, friends, community
- new and
disturbing fears –Eg. of illness in self or loved ones
humor becoming a way of life, not just shared with co-workers
lateness, depression, low self-esteem, loss of joy
Balance a clinical caseload with
teaching and research.
Limit exposure: Balance medical and non
Set boundaries: limit weekend and night
work. Time really off.
Find a way to work for social change.
Don’t work alone.
Get support from professional
Supervision & consultation
Develop support groups where feeling
can be discussed separate from business.
healthy ways to mentally leave the past behind, remain in the present moment
and not obsess about future problems and events.
Understand that burn out and compassion fatigue are normal responses. Use
them for Growth.
Use individual therapy to work on areas
that are particular problems.
Strive for a balance between personal
and professional life.
time for non-patient related activities that renew a sense of hope and
optimism. The most common are exercise, rest, gardening, music, dance, art
work, pets, time with healthy children, travel, being outdoors, doing
Attend to empathy
Stay anchored in the present
Develop a sense of connection to
something beyond oneself
Seek spiritual renewal
From: Traumatic Stress: Countertransference and Vicarious
Victimization in Psychotherapy with Incest Survivors. Laurie Ann
Pearlman and Karen W Saakvitne. WW Norton & Co, New York, NY, 1995.
Whenever we have high standards for our self or others, we also have the
inner voice of the Critic. When it is in balance it is a voice of
discerning wisdom, but when it is out of balance it becomes a voice which
relentlessly, ruthlessly points out our failures. Hallmarks of an out of
control Inner Critic:
It speaks with absolute authority.
It cannot be pleased no matter what you do.
You cannot feel successful when the Inner Critic is out of control.
It can find something to criticize any time, any place and about any
It always plays a part in depressed or angry emotions.
It almost equally criticizes you (inner states) and every thing else
It can be managed but never completely disappears.
It can become an internal killer or be transformed to discerning wisdom.
Awareness is the first most essential tool in working with an out of
Transform the Self-punishing Inner Voice
Develop a self-care
program that involves these four elements:
SPEND TIME ALONE
RECONNECT TO A SPIRITUAL
RECHARGE YOUR BATTERIES
DAILY (eat quietly, exercise, go out
into nature, pray or meditate)
HOLD ONE FOCUSED
MEANINGFUL CONVERSATION A DAY (time
with friends and family)
SOME DON’T s
Don’t go for a quick fix
(addictive behaviors) Don’t make big decisions
It feels good briefly but
causes more trouble and Don’t complain or blame others
(Specifically, don’t hire a lawyer.)
Summary of this article:
Compassion fatigue is common in the helping professions. 54% of office based
physicians had experienced a time when they felt they had no more compassion to
give, even after a restful weekend. Finding a balance of empathy and objectivity
is important, as is not attributing CF to a character flaw.
Additional summary PDF articles:
COMPASSION FATIGUE-STAYING HEALTHY IN THE MIDST
Caring for Caretakers handout form Chapter 72 Jan
Chozen Bays .pdf Jan shares her
own experience and solutions.
Child Abuse and Neglect: Diagnosis, Treatment and Evidence edited by
Carole Jenny and published by Elsevier in 2011. It is Chapter 72, Caring for the
(1) Victim Assistance Online Resource Center
This is a great source of
articles, self-tests for compassion fatigue versus burn out, and references.
Compassion Fatigue: When practicing medicine feels more like labor than a
labor of love, take steps to heal the healer. Family Practice Management April
2000. (Includes a self assessment quiz. Reprinted at
\h \r 1
\h \r 1 (1) Anderson DG. Coping
Strategies and Burnout Among Veteran Child Protection Workers, Child Abuse &
Methods: 151 frontline
workers with > 2 years’ experience (average 7.5 years)
66% planned to stay in the
work indefinitely. Only 6% planned to leave in 6 months.
Administered CSI (coping
strategies inventory) and MBI (Maslach Burnout Inventory).
Typical burn out profile
included: high emotional exhaustion, a high level of depersonalization, and a
low sense of personal accomplishment.
Strategies (problem solving,
restructure how you see it, seek social support, express emotions and
Strategies (avoid thinking or talking
about it, withdraw personally, wishful thinking, self criticism).
Findings: Workers who
rely on active, engaged coping strategies feel less depersonalization with their
clients and a greater sense of accomplishment at work.
Workers who use avoidant
strategies are more likely to suffer emotional exhaustion, feelings of
depersonalization and a lower sense of personal accomplishment.
The most effective
strategy to prevent burnout is a combination of expressing & releasing emotions,
and seeking emotional support from colleagues, friends & family.
(2) Cheung M & Boutte-Queen,
NM. Emotional Responses to Child Sexual Abuse: A Comparison Between Police &
Social Workers. Child Abuse & Neglect 2000;24:1613-1621.
responses can affect how they interact with clients. A common process is counter
transference, in which the professional experiences identification with the
client. This identification is based on empathy, a valuable trait. However, the
professional must maintain the tension of opposites between the
empathy needed to relate well to the client’s world and needs, and the
impersonal objectivity needed to carry out the requirements of the job.
A study of 100 child abuse
professionals showed that emotional responses to child abuse are to be expected.
Training about these responses can have a preventive and therapeutic effect. The
most common responses are: 1) anger with the perpetrator and 2) empathy with the
Law enforcement reported
significantly more ambivalence about rescuing the child, ambivalence about
punishing the perpetrator, and also a feeling of revenge against the
perpetrator. Social workers reported significantly more embarrassment with the
perpetrator, fear of being inadequate for the job, titillation from involuntary
responses to the sexual material involved in the investigation, and empathy with
the child’s plight.