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Compassion Fatigue

by Jan Chozen Bays, M.D.

                                                             STAYING  HEALTHY  IN  THE  MIDST


Jan Chozen Bays, M.D.

CARES NW, Legacy Emanuel Children’s Hospital, Portland, Oregon 97227



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 irreplaceable.)


Vicarious Traumatization: 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.




Safety: 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, hypervigilance.


Trust: 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, isolation.


Esteem: 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 right).


Intimacy: 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 with patients.


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.




- intrusion of patients’ issues into our imagination

            - loss of empathy for, and increased criticism of patients, self and others

            - self numbing through addictive behavior (including work)

            - withdrawal from intimacy - spouse, friends, community

            - new and disturbing fears –Eg. of illness in self or loved ones

            - dark humor becoming a way of life, not just shared with co-workers

            - chronic lateness, depression, low self-esteem, loss of joy





1.         Environmental


                        Balance a clinical caseload with teaching and research.

                        Limit exposure: Balance medical and non medical work.

                        Set boundaries: limit weekend and night work.  Time really off.

                        Find a way to work for social change.


2.         Interpersonal


                        Don’t work alone.

                        Get support from professional colleagues.

                        Supervision & consultation

                        Develop support groups where feeling can be discussed separate from business.


3.         Personal


Find 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.

Make 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 nothing!


4.         Spiritual


                        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:


1.                  It speaks with absolute authority.

2.                  It cannot be pleased no matter what you do.

3.                  You cannot feel successful when the Inner Critic is out of control.

4.                  It can find something to criticize any time, any place and about any person.

5.                  It always plays a part in depressed or angry emotions.

6.                  It almost equally criticizes you (inner states) and every thing else (outer world).

7.                  It can be managed but never completely disappears.

8.                  It can become an internal killer or be transformed to discerning wisdom.

9.                  Awareness is the first most essential tool in working with an out of control critic.

Explore Transform the Self-punishing Inner Voice


Develop a self-care program that involves these four elements:




RECHARGE YOUR BATTERIES DAILY (eat quietly, exercise, go out into nature, pray or meditate)





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 a downward spiral.                                                                 (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:



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 Caretakers.


Additional links:





 (1) Victim Assistance Online Resource Center

This is a great source of articles,  self-tests for compassion fatigue versus burn out, and  references.


(2) Overcoming 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 )




 SEQ CHAPTER \h \r 1

 SEQ CHAPTER \h \r 1 (1) Anderson DG. Coping Strategies and Burnout Among Veteran Child Protection Workers, Child Abuse & Neglect 2000;24:839-848.


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.

Differentiated between:

Engaged Coping Strategies (problem solving, restructure how you see it, seek social support, express emotions and

Avoidant Coping 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.


Professionals’ emotional 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 victim.


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.


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