Balancing The Burdens Of Caregiving:
Avoiding Compassion Fatigue
Rev. Jeffrey R. Funk, M.Div., P.C.C.
Healthcare Chaplains Ministry Association

Understanding Burnout/Compassion Fatigue Comprehending the Burden

Definition of Burnout and Compassion Fatigue
Burnout: Christina Maslach, a psychologist and early researcher of the problem, defined burnout as "a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do 'people work' of some kind."[1] Psychologist Herbert Freudenberger, who claims credit for the term, says that burnout is a depletion of energy and a feeling of being overwhelmed by others' problems. The word, as it is listed in Webster's New International Dictionary, has three examples for its use:

1. The burning out of the interior or contents of something, such as a building. You can probably visualize yourself being devoured from within by your fiery expenditure of energy until you have nothing left.
2. The breakdown of an electrical circuit owing to combustion caused by high temperatures. In this case, the high temperature produced by the electrical current burns out a conductor. Again, in application to yourself, your emotional energy supply becomes completely short-circuited due to the over-heating of constant stress.
3. The severe denuding of the forest floor as a result of a forest fire. Your resources to rejuvenate yourself have been utterly consumed by the stressful burdens so that renewal seems hopelessly difficult.

More specifically, burnout is associated with lots of sources of stress and hassles involved with your work (tensions with supervisors, work schedules, co-workers, paper work, equipment malfunctions, the bureaucratic system, etc.) and is a state of extreme dissatisfaction with your work as you work too long, too hard and under too much pressure. Burnout results in a loss of enthusiasm, energy, idealism, perspective and purpose on a mental, physical, emotional and spiritual level.

Burnout happens when helpers/caregivers become extremely dissatisfied with their work and become cynical, depressed, emotionally exhausted, irritable with supporters, and even impaired. Burnout requires professional help and discontinuing being a caregiver until the cynicism and impairment are gone.

Compassion Fatigue: Compassion Fatigue is the notion of being burned out by the kind of work that you do, the kind of patients and families that you deal with and the residue from ministering to those hurting people. It is not about problems and hassles at work, but it is about the stress associated with the clients you deal with. It represents the cost of caring about and for seriously ill patients and their families. It is the emotional residue of exposure to working with the suffering. It is the compassion-consuming calling of being a professional caregiver to seriously ill people.

Compassion fatigue happens when helpers/caregivers become emotionally drained because of hearing about all of the pain and trauma of their patients and families. The helpers still care and want to help, but they do not have the emotional energy to do so. Taking time off, getting professional help and nurturing self can usually help them return to being healthy, helpful caregivers.

Symptoms of Burnout
Physical Indications of Burnout:

1. A persistent sense of physical fatigue: feeling "run down" and exhausted and "keeping up to speed" becomes increasingly difficult.
2. Frequent headaches, migraines.
3. Chronic muscle tensions, especially of the head, necks and/or lower back.
4. Gastrointestinal problems (ulcers).
5. Decreased appetite (or a never-satisfied appetite).
6. Sleeplessness in spite of feeling fatigued.
7. High blood pressure.
8. Shortness of breath.
9. Nervous tics, tremors, teeth/jaw clenching.

Psychological Indications of Burnout:

1. Depression ("I don't care anymore!").
2. A dulling affect, mental fatigue ("I can't think straight anymore!").
3. Increased irritability, hostility ("I hate this job now!").
4. Decreased tolerance for frustration ("I can't take it anymore!").
5. Feelings of helplessness and an inability to see a way out of problems ("I dread going to work!").
6. Increased risk taking and impulsivity
7. Inflexibility of behavior and goals ("I can't adjust to this!").
8. Cynicism and negativism about self, others, work and the world in general ("I can't stand this anymore!").
9. Apathy ("I don't care anymore!").
10. Reduction and/or abandonment of recreational activities ("I'd rather stay home now!").
11. Decreased capacity for pleasure and social contacts ("I don't want to go out anymore!").
12. Withdrawal, detachment ("I'd rather be alone!").
13. Increased interpersonal and/or marital discord.

Spiritual Indications of Burnout:

1. Disillusionment and disappointment with God.
   1. You feel that God is powerless to help.
   2. You feel that God does not care.
   3. You feel that God has abandoned you, your patient and the family.
2. Discontinuance of religious practices.
   1. You stop worshipping-privately and corporately.
   2. You stop praying.
   3. You stop reading your Bible.
3. Development of spiritual apathy.

Performance Indications of Burnout:

1. Decreased efficiency.
2. Diminished initiative.
3. Reduced interest in work (as well as a general apathy).
4. Depleted ability to work under stress.
5. Difficulty concentrating or paying attention.
6. Increased irritation with colleagues.
7. Increased use of tranquilizers, alcohol, cigarettes.

Causes of Burnout and Compassion Fatigue
Burnout: the personality traits of the individual who is likely to develop burnout may embrace:

1. Someone highly task and goal oriented.
2. A person who takes particular satisfaction in doing things neat and orderly (i.e., a perfectionist).
3. Someone with a high need for achieving "control" of self, others and/or the environment; is intensely competitive.
4. An individual who tends to be overly critical but cannot stand criticism.
5. Someone with a marked capacity to delay gratification (or perhaps an inability to allow personal satisfaction).
6. A person with excessively high personal expectations and exaggerated expectations of others.
7. Someone whose work and "productive" activity is overvalued and provides the major source of self-esteem and pleasure(doing is the key to being worthwhile.
8. An individual with a scarcity of non-work related interests in the form of recreation and hobbies.

Compassion Fatigue: the people who are most prone to compassion fatigue are:

1. Those who work with people who are in need, who are hurting, who have special problems going on in their lives and who have significant health issues; therefore, you are basically vulnerable to being overwhelmed by their experience as you absorb the trauma through their eyes and ears.
2. Those who are deeply sensitive, who care a lot about their patients, who are willing to work the extra time, who are willing to put more into their ministry than they put into almost any other aspect of their lives, who tend to identify with the patients and families, and who do a poor job of replenishing themselves physically, emotionally and spiritually.

Warning Signs of Burnout and Compassion Fatigue
Just as meteorologist can recognize certain signs as storm warnings of an approaching hurricane, so psychologists can recognize symptoms of approaching burnout. As Freudenberger notes, they involve:[2]

1. Exhaustion. A lack of energy associated with feelings of tiredness and trouble keeping up with one's usual activities.
2. Detachment. Putting distance between you and other people, particularly those with whom you have close relationships.
3. Boredom and Cynicism. You begin to question the value of friendships and activities-even of life itself.
4. Increased Impatience and Irritability. As burnout takes hold, your ability to accomplish things diminishes and your impatience grows and causes flare-ups with others.
5. A Sense of Omnipotence. You have thoughts such as "Nobody can do my job better than I can."
6. Feelings of Being Unappreciated. Burnout victims experience complex feelings of bitterness, anger, and resentment because they are not being appreciated more for their added efforts.
7. Change of Work-Style. Reduced results and conflicts with colleagues will eventually cause you to either withdraw from decisive leadership and work habits, or you will seek to compensate for the conflicts by becoming more tyrannical, demanding and inflexible.
8. Paranoia. Once burnout has taken a long-term hold, it's a small step from feeling unappreciated to feeling mistreated and threatened.
9. Disorientation. Long-term burnout increases difficulty with wandering thought processes.
10. Psychosomatic Complaints. Headaches, lingering colds, backaches, and similar complaints are often a result of the burnout victim's emotional stress.
11. Depression. In burnout, the depression is usually temporary, specific and localized, pertaining more or less to one area of your life.
12. Major Depression. This state is usually prolonged and pervades all areas of your life.
13. Suicidal Thinking. As the depression progresses, the result can be suicidal thoughts.

Implications of Burnout and Compassion Fatigue
Without a "pressure release valve," the holding tank will ultimately explode when the pressure gets too great. Can you feel the strain of the pressure building up inside you from your caregiving? If so, when and how will you "release" the pressure?

Without "recharging the battery" after continuous use, it will surely go dead and become useless. Can you sense that you are running low on physical, emotional and spiritual energy? If so, when and in what ways will you "recharge" yourself?

Without "changing the oil" in the car, damage will eventually be done to the engine the longer you drive it without maintenance. Can you feel the wear and tear of the many miles you have put on your self at work? If so, when and how are you going to schedule some routine "maintenance" on your life?

"Overloading the system" will inevitably lead to a serious breakdown. As a caregiver, can you feel the weight bearing down upon you, overloading your physical, emotional and spiritual systems? If so, when and in what ways are you going to "lighten/balance" the load?

Resolving Burnout/Compassion Fatigue: Countering the Burden

Examples from the Bible
An Old Testament Example--Elijah (1 Kings 18-19).

1. The Aggravation.
Burnout frequently occurs after intense "peak" experiences, such as Elijah's "mountain top" victory (1 Kings 18). Elijah had recently experienced the greatest success of his career: the ending of a famine, a revival among the people, the priests of Baal killed and his credibility restored. Then we see the despondency that can often follow prolonged intensity (1 Kings 19). Elijah demonstrates a classic example of Frudenberger's description:

It's the letdown that comes in between crises or directly after "mission accomplished." Frequently, following a triumph, high achievers (Elijah certainly qualifies) suffer periods of deep melancholia akin to the postpartum depression some women experience after giving birth. The feelings are remarkably similar: sadness, separation, sluggishness, and above all, emptiness.

Other stress-related characteristics Elijah exhibited during his burnout were:

1. Rejection (v. 2).
2. Detachment (he ran away from everyone, v. 3).
3. Exhaustion (physically, v. 5-6, mentally, emotionally and spiritually).
4. Suicidal thoughts (an advanced stage of the depression and despair that result from burnout, v. 4).
5. Bitterness (he reminded God how zealous he had been, v. 10).
6. Feelings of being indispensable (v. 10).
7. Feelings of being mistreated (v. 10).
8. Feelings of self-pity (v. 10).
9. Feelings of persecution (he felt put upon and became increasingly suspicious of his environment).

2. The Adaptation.
We can learn much from what God did to minister to His servant's physical, emotional and spiritual needs during this time of compassion fatigue. Therapy came in the form of God's presence, His loving patience and His purposeful assignment. And Elijah was fully restored!

1. God provided time for sufficient rest and proper nourishment (v. 5-6).
2. God offered a "quiet time" for Elijah (v. 12).
3. God provided a sense of companionship (v. 18).
4. God gave him an assignment that he was capable of fulfilling (v. 16).

3. The Application.
Opening ourselves to God, our personal Counselor, can also change our perspective of our pressure. He does understand what we are going through. Hear His words of comfort through the pen of the Psalmist:

In my anguish I cried to the Lord,
and He answered by setting me free.
The Lord is with me; I will not be afraid.
What can man do to me?
The Lord is with me; He is my helper.
I will look in triumph on my enemies.
It is better to take refuge in the Lord
than to trust in man.
It is better to take refuge in the Lord
than to trust in princes.
(Psalm 118:5-9)

A New Testament Example--Jesus (Mark 6:7, 12-13, 30-32)
Jesus recognized that the stresses of life can lead to physical, emotional and spiritual symptoms of burnout; and he recognized that these stress levels need to be lightened so that recovery can begin. It is so easy to become so concerned with "getting the job done" that we lose sight of the needs of the people who are actually carrying on the work. A close examination of His brief statement shows there are three key elements that can relieve the stresses that lead to burnout.

1. A change in location--to experience peace and quiet.
2. A change in activity or responsibility--to rest up.
3. A certain amount of time--to take a break for a planned amount of time.

In applying this example to your own life, consider the following:

• Know your own "triggers" and vulnerable areas and learn to defuse them or avoid them.
• Resolve your own personal issues and continue to monitor your own reactions to other's pain.
• Be human and allow yourself to grieve when bad things happen to others.
• Develop realistic expectations about the rewards as well as limitations of being a helper.
• Set and follow appropriate limits and boundaries for yourself and tell them to others.

Physical Renewal

1. Through Exertion.
   1. Because ministry is normally a sedentary profession, you need to adopt a thirty to sixty minute program of regular (at least three times per week) physical activity-in the form of jogging, walking, bicycling, swimming, tennis, racquetball, basketball, working out at the local spa-anything, as long as you find the exercise interesting and it is strenuous enough to produce deep breathing and liberal perspiration.
   2. Be sure to consult with your physician for his recommendation of a safe level of exercise for you-especially if you are over forty years old or have any health complications.
2. Through Nutrition.
   1. You need to regularly eat a well-balanced diet when under a lot of pressure. Most nutritionists agree that the best diet is a balanced one that includes some of all the food groups.
   2. Foods you might want to limit when experiencing stress:
      1. Reduce the amount of caffeine-rich beverages you consume (e.g., coffee, colas, tea and cocoa).
      2. Decrease your intake of fat and sugar. It has been said that, "Our reserves in physical energy disappear proportionately as our waistline expands."
   3. Get enough fluids into your system throughout each day. The universal recommendation is six to eight glasses of water a day.
3. Through Relaxation.
   1. To sleep soundly for a full night is a valuable restorative gift. Proper rest allows your physical, mental and emotional self to regain lost energy. Rest restores us. Determine how much sleep you need to feel and function at your best (Most studies show that most adults need about eight hours per night!) and then determine to get it most nights during the week.
   2. You need to take appropriate breaks daily-not working for too long a period of time and not working on one situation for too long. You need weekly breaks-not working over fifty hours a week. You need to take a quarterly long weekend off and a yearly break of at least two weeks off.
4. Without Addiction.
   1. You must avoid using drugs and alcohol to help you cope with stress. Tranquilizers and sleeping pills should be used only under a doctor's care and with extreme caution.
   2. Drugs and alcohol merely numb the symptoms of the stress. They do nothing to help cure the cause. In fact, alcohol can actually cause stress. In laboratory tests, alcohol has been shown to trigger the release of stress hormones from the brain and pituitary and adrenal glands(the same reaction that might be brought on by money woes or marital problems.

Emotional Renewal

1. With a Friend.
   1. Through Talking.
      A common ingredient among people who experience burnout is the fact that they do not have a friend to whom they are close enough to share their personal feelings and still feel loved and accepted. Studies show that people with social networks handle crises better. You need to cultivate a confidant with whom you can openly and honestly discuss what is going on in your heart and mind. The very worst way to deal with burnout is to bury it inside. The lack of a feedback system is not a sign of strength, but a sign of being foolish. You need someone to listen attentively while you share your concerns and heartaches and who can honestly respond to you with supportive comfort and counsel. Regularly discussing your frustrations and fears with someone you trust can provide substantial relief from pressure-even if it seems that at times nothing at all can help. Simply being able to put words to your feelings in the presence of a supportive person can be very freeing-it can even reenergize you.
   2. Through Laughing.
      A wise man once compared a cheerful heart to good medicine (Proverbs 17:22). Humor, if you use it well, can be one of the most helpful things you can do to relieve tension. Being able to laugh about something often helps to put it into proper perspective. Ask yourself: "Have I laughed several times today?" If not, then do something to make yourself laugh: read a joke book, watch a comedy, look at old photos, whatever, as long as it will make you smile. Enjoy life!
   3. Through Support.
      Find opportunities to acknowledge, express and work through your experiences in a supportive environment. Seek assistance from other colleagues and caregivers who have worked in a similar environment and have remained healthy and hopeful. Develop a healthy support system to protect you from compassion fatigue and emotional exhaustion.
2. With Yourself-Through Journal Writing.
   Personal journal writing is a consummate prescription for self-discovery, problem solving and healing emotional wounds. Our inner world may be clarified, calmed and comforted by revealing our feelings on paper (or a word processor).

Spiritual Renewal
Your spirituality-your sense of belonging to God completely and of God's abundant life in you-is, in my opinion, the most important element in coping with stress in your life. And Dr. Frederick Flack, in his book Resilience: Discovering a New Strength at Times of Stress, agrees: "I believe the most vital ingredient of resilience is faith." In the words of David A. Ruch, M.Div., M.A., a licensed clinical professional counselor:

Our limitations as healers should draw us constantly back to dependency on God not only for power and faith to continue but for comfort and perspective when we feel defeated. When we recalibrate ourselves based on his sovereignty rather than our circumstances, we have new hope.

1. Through Adoration.
   1. There is something uplifting and rejuvenating from spending time in praise and worship with a group of people who share your beliefs.
   2. There is therapeutic power for physical, emotional and spiritual renewal in listening to and singing inspirational music. For example, a hymn based on an early Greek hymn that dates as far back as the eighth century encourages us with these words:
      
      Art thou weary, art thou languid,
      Art thou sore distressed?
      "Come to me," saith One, "And coming
      Be at rest."
      Hath He marks to lead me to Him
      If He be my Guide?
      In His feet and hands are wound-prints,
      And His side.
      Finding, following, keeping, struggling,
      Is He sure to bless?
      Saints, apostles, prophets, martyrs,
      Answer, "Yes." [3]
      
      
   3. When pressing situations are upon you, you need to take time out to get spiritually oriented in order to refocus your attention on the "Problem Solver" who is greater than any of your pressures. Worship is one way to experience a rejuvenating supply of wisdom and strength and peace from God. Come to Him and unload your cares. He can handle it.
2. Through Education.
   1. Read an Inspirational Book.
      Stimulate your soul as you gain understanding, find encouragement and revitalize your hope through the experiences and lessons of others.
   2. Read a Devotional Book.
      Acquaint yourself with your spiritual source of hope and renew your faith through the reading of the Scriptures associated with your belief system. Meditating on the Word of God allows God to speak to us personally through the words that apply, in one way or another, to all of us. The words in Isaiah 40:27-31 or Lamentations 3:17-26 or Matthew 11:28-30 are especially good to read when you feel weary and faint from the burdens pressing down upon you. You can experience hope and renewal when your attention is focused beyond your circumstances to the all-sufficient character of the eternal, faithful, all-powerful, ever-present, gracious Creator.
      
      
3. Through Meditation.
   Prayer is the spontaneous, heartfelt sharing by needy human beings with God, who is able and willing to help. Bringing your pressures to God can change your perspective-it can keep you from becoming myopic-and help you to cope. Through prayer and meditation you can sweep the mind of all turmoil. In place of our exhaustion and spiritual fatigue, God will give us rest. All He asks is that you spend time with Him, meditating on Him, talking to Him, listening in silence, occupying yourselves with Him (Hebrews 12:3).
   
   
4. Through Absolution.
   1. Confession.
      Ignoring transgression (when you have "crossed the line") in your life will tend to place a great emotional, spiritual and physical burden on yourself. God's forgiveness is always sufficient and immediately available (1 John 1:9). He welcomes repentance with open arms.
   2. Forgiveness.
      If you do not forgive others, you will tend to turn your anger inward, which results in bitterness, and then depression, and finally you will experience burnout symptoms. Forgiveness involves an act of the will-it is choosing to no longer hold a grudge against an offending party. Freedom from bitterness (through forgiveness) is necessary for effective recovery from burnout.

Diversional Renewal

1. Through Relaxation.
   1. Maintaining good mental health often involves learning to relax. There are many books, tapes and seminars that can help teach you personal techniques on learning to mentally and physically relax yourself. When the sympathetic nervous system is quieted by these practices, muscle tension decreases, the heart rate slows and a feeling of well being often occurs.
   2. Here is one progressive muscle relaxation method: Isolate yourself from all noises and distractions (like the phone, TV, etc.). Sit in a comfortable chair with your feet flat on the floor (or, if you are in a recliner chair, resting comfortably on the footrest) and your hands resting comfortably in your lap or upon the armrests. Close your eyes. Make a deliberate effort to relax all your muscles. Begin with your head, then relax all your neck and back muscles. Let your chest and stomach muscles release their tension. Feel your arms becoming limp. Allow your legs and feet to completely relax. Spend about ten to fifteen minutes relaxing all your muscles as you feel the tension drain from your body.
2. Through Recreation.
   1. Have a life beyond your professional work that nurtures you personally. Leisure is free activity, whereas labor is compulsory activity. In leisure you do what you like, but in labor you do what you must. In your labor you meet the objective needs and demands of others, but in leisure you scratch the subjective itches within yourself. Some recommend engaging in some form of enjoyable recreation (leisure time) at least three times per week-something not connected with your usual line of work. Watching make-believe characters on TV is never a substitute for experiencing life yourself.
   2. Take Mini-Vacations.
      1. If you are "vacating" only once a year (like many people), that block of time almost suffocates in the desperate attempt to cram a whole year's worth of happy escape into two weeks. You would fair much better to plan more consistent and more frequent breaks, each with a different purpose, to meet the various needs of your family. You need to break the habit of looking in the TV guide for your happiness each weekend.
      2. During your lunch break (a respite time) you might include: going on a picnic, going for a walk around the block, buying some flowers for the desk, or reading from a good book. After dinner could involve: playing a table game, singing a song together as a family, doing finger painting together, going swinging in the park, or watching the sunset from a hill top.

Organizational Renewal

1. Through Position-Your Priorities.
   1. What are your priorities? You must try and keep a tight reign on your priorities, especially at times of greatest anticipated stress.
   2. You are likely to be an over-estimator as to what you can realistically do. You probably find it difficult to say "No"(both to yourself and others who may place demands on you. You must be rigorous in your assessment of priorities concerning meeting the needs of others. You need to practice saying no to activities of lesser priority-regardless of how worthwhile they may seem. Think about the idea that if you never say "no", what is your "yes" worth?
   3. Set and keep healthy boundaries for work. Ask yourself, "Will the world fall apart if I step away from my ministry for a day (or a week)?"
2. Through Intentions-Your Plans.
   1. What is your plan for using your time wisely? Organizing your life may appear like a tall order with which you have difficulty at times, but you can learn to plan ahead. When you know what needs to be done, you are not as prone to experience surprises in your life. If emergencies do arise, then they are easier to cope with. While it is not necessary to become a slave to a schedule, getting organized can help you run your life more smoothly and efficiently.
   2. Part of organizing your life involves planning "time outs" or mini-vacations. This is necessary for your survival. Consider creating small "buffer zones" between some of your obligations to allow yourself ten to fifteen minutes to close your eyes, pray, reorient your priorities and defuse your tension.
   3. Time can work for or against you, depending on how you choose to use it. You can allow yourself to procrastinate and then rush to meet deadlines, you can leave little time to finish projects and you can hurry from one activity to another without taking a moment to catch your breath or utter a prayer. But when you organize your time by setting priorities and planning accordingly, you stay directed and live a purposeful life that is much less stress-filled.

Endnotes: