Compassion Fatigue: The Cost of Kindness

“ There is a pain – so utter
It swallows substance up-
Then covers the Abyss with Trance-
So Memory can step
Around – across – upon it-
As one within a Swoon
Goes safely – when an open eye-
Would drop him – Bone by Bone ”
—Emily Dickinson

September 11, 2001 changed history for all of us in a profound way. Though the number of people that died was small by world calamity standards, the attack perpetrated a sense of vulnerability and retaliation that impacted people across the globe. Like many, I struggled with forces I could do nothing about, raged with helplessness at the industry created by terror, and witnessed in dismay the cruelty and bloody horror of war. But I was troubled by something I experienced in myself: an insatiable thirst for details of the awful events, a fascination with graphic images, and an addiction to the news.

One of the most important books for me at the time was War is a Force That Gives Us Meaning by Chris Hedges. Hedges was a journalist for the New York Times, who covered conflicts on every continent for almost twenty years. He had come to know first hand that war is a culture of its own, which wastes not just the body, but the heart and mind of those who engage with it. No matter which side of the spectrum one would fall in considering the need or the price of war, there is this fact: there are few winners; there is always death.

But Chris Hedges went on to point out that war is seductive in its quality of purposefulness. It creates a sense that one can rise above smallness and divisiveness. And initially, the selflessness of it mirrors that of love, the chief emotion war destroys.

For a time after September 11, we in the United States felt a short sweet camaraderie with the planet. However, for many, this quickly dissipated to other, darker places, when the rawness of grief gave way to insular protectiveness, fear, or rage. The nation’s response and the suffering involved on all fronts have been similar to its relationship with the Vietnam War, both in its conspicuous avoidance and intense preoccupation. However, for those who fight, their victims, and those who witness, it is far more complicated.

From the outside, nothing is so black and white as the drama of war. On the inside, it is not so simple. As Chris Hedges says, “unlike love, it gives nothing in return but an ever-deepening dependence, like all narcotics, on the road to self-destruction. War does not affirm but places upon us greater and greater demands. It takes a higher and higher dose to achieve any thrill. Finally, one ingests the war only to remain numb. The world we once understood and longed to return to stands before us as alien, strange, and beyond our grasp.”

Life in war is theatre. At a given point, it enobilizes the acts of violence, of valor, or resistance, even as it inflicts destruction. It feeds the myth that gives purpose to the player as well as their spectator. It also feeds upon itself, for war and the drama surrounding it can make those engaged feel more alive in the process. In this, there is a sense of righteousness and pride; there is often tremendous courage. But there may be secrets held or shared by the recipients of unimaginable trauma, or from being perpetrators of dark acts of unimaginable cruelty.

After covering the wars in Central America. Angola, and the Balkans, Chris Hedges the journalist left the battlefield. He found himself both horrified by and addicted to the business of war. Though he had become hollowed out with witnessing its ravages, he experienced his life away from the battlefront as vapid and void of purpose. He had become alienated from anything outside of it. When he realized this sordid fact, he had to pull out before his work destroyed him.

I found this story compelling, then quite chilling. As a psychotherapist, I recognized something reminiscent of my own life. And, as I thought about it, the more I realized what a powerful aphrodisiac my career had been on me.

We who have worked with survivors of trauma—sexual, physical, ritual abuse, children of alcoholics—are humbled daily by the stories of survivors of double speak, double bind cruelty. We who do the work, have much in common with those who are close to a battlefield. Human rights workers and therapists, emergency care givers, people who work hot lines, nurses and hospice workers, bear witness to the unbelievable and the unspeakable. Those who are survivors themselves, also often carry their own unwordable history. Invariably, it affects the work. I write this reluctantly because in so doing, I push into the pain of my own battlefield, and the price I paid by not attending to myself in the process of doing the work.

Years ago, I was in solo private practice with a full load of trauma history clients—persons with a varied assortment of character disorders, dissociative disorders, survivors of extreme sexual and physical torture and ritual abuse, holocaust survivors and the children of holocaust survivors—namely those most affected with early post traumatic stress, many easily diagnosed or demonized with the axis II term of Borderline. I also had six clients in advanced stages of multiple sclerosis and polio, all incidentally with trauma histories. I ran a group for women who were survivors of physical and sexual abuse, as well as one for male survivors. I also had a group for people with HIV. It was the early nineties. Persons in my AIDS group usually died within two years from initial diagnosis. One December, ten men from the group were buried in thirty days. I made an effort to be with each one near the time of his death, went to the funerals, and processed life and death with the survivors in group who were so very sick themselves.

During this time, my mother was at the end of a long complicated struggle with congestive heart failure and my father was unable to care for himself because of multi-infarct dementia. I was the only member of my family close enough to give any direct care to my parents. I did all of this, believing that I was also being a good wife and mother to my husband and two teenage children, who were struggling to keep afloat, and a middle school age daughter with such severe allergies and eczema that her skin was literally seeping off her body. I was very busy when I was not at work, taking them to therapists, doctors, and homeopaths. Meanwhile my husband was trying to manage a large grocery company and his own heart condition.

Unfortunately, I was not attentive to my life, although I would have thought otherwise. I was everywhere I needed to be: every doctor’s appointment for my parents or my children, every performance and school function, and my own therapy, which was supposed to be self-care. I showed up for friends in need and looked after the dogs and the cooking and the house—but wasn’t present to anything and did not even know it. I could not understand why my teenagers were angry or spaced out, or why my youngest continued to be so sick despite how much we did to soothe her skin and cook for her in a mine field of life threatening allergies. I was working too much to try to figure it out.

My capacity for pain seemed boundless and the signals for self regulation lessened as time went by. When there were extra hours, I worked more, developing what social philosophers and performance artists call psychothenia, the phenomenon that occurs when an individual is so oversaturated with input that the capacity for metabolizing experience diminishes even as the thirst for stimulation increases. Like a person drinking salt water to quench my thirst, I was becoming more and more dehydrated.

Though I worried about my family constantly, I was too distracted to focus. I only felt centered and alive in the treatment room, bearing witness to story after story of torture and abuse, unaware of the impact this was having not only on my clinical work, but my life. When I got restless, I would find a new project. I started a group for kids at risk from the continuation school in my town. Naturally, they were almost all survivors of one kind of abuse or another.

The more fatigued I was, the less imagination I had to do anything different with my time. My creativity was diminishing. I could not play music and did not write. I lost my sense of humor, except perhaps for the dark gallows kind with my Aids patients. I was able to laugh with them at death, but could not feel what was dying in me.

Life seemed dull unless I was involved with the intensity of work, and, like Chris Hedges, nothing else seemed real to me except the battle.

The day my mother was buried, I left the cemetery and went back to work. The next afternoon, I closed my parent’s apartment and gave away every heirloom and precious keepsakes of my mother’s within forty-eight hours, without considering what to treasure or give to my own children. I had to get back to work. I did not cry, did not feel, could not grieve or pray. I could not reconcile the world of care and concern that I believed in with the evil that enthralled me.

The daily grind of dealing with so much abuse gave way to rage, then vulnerability. My body was beginning to catch up with me. I was having heart palpitations, anxiety attacks, insomnia, nightmares. I isolated from colleagues and friends, too exhausted to connect or to talk about what was happening to me. I had retreated from the affection of my incredible husband and kids. My sex life was in shambles.

Then one night in a group, I had a flashback of my own childhood sexual abuse and the whole house of cards began to collapse on top of me. Things seemed to decompensate after that, but in actuality it was a blessing. I would have been dead in a year.

I had already begun the difficult process of moving my family to the east coast. Once in Boston, removed by force from my work, it was like coming off a drug. I was so addicted to the work and utterly lost without it. Reluctantly, I began to write. I started to feel in my body what I had dissociated from with all those years in the trenches. It had been no accident why I had been attracted to work with survivors. But it was also becoming clear why I had missed so much in my own family and in myself.

I began to cry. It was as if all the grief and outrage in my life had been in storage. For the first time in memory, I actually began to feel what was happening to me without someone else’s trauma to deflect the experience. It was quite frightening.

Only then, did I begin to realize what I had done to myself. I made a decision NOT to get back into talk therapy, perhaps having the wisdom or exhaustion to avoid reentering a treatment room on either side of the couch until there was some period of time without words.

Laurie Pearlman, Karen Saakvitne, Charles Figley and others have done a masterful job explaining the impact of trauma on the caregiver. For those who work day after day in the trenches of trauma, it is important to differentiate between the burnout of compassion fatigue and actual vicarious trauma. Otherwise, there may be a profound unconscious impact on the caregiver, as well as their already overstimulated highly sensitized clients.

Compassion fatigue is the emotional residue of exposure to working with the suffering of others, particularly those experiencing the consequences of traumatic events. It is possible to have the beginning of burnout without vicarious trauma. However if there is an accumulation of exposure and fallout is unchecked, there may be a scalding impact, which can result in vicarious traumatization. This transformation in one’s inner experience can profoundly affect the psychological and spiritual life of the caregiver. This will inevitably change the work.

Compassion fatigue can manifest as numbness, boredom, mismanagement of caseloads and clients. When professionals are exhausted, it is easier to demonize clients, creating an us vs. them approach to the work. However, in the business of caregiving, over involvement or idealization of survivors are also harmful disservices to all parties. Simulacra is the seduction of other people’s lives being more compelling than one’s own. It is easy to get derailed from one’s own life when busy with the profound drama of others.

For those professionals with unprocessed personal abuse histories, it is possible to over or under respond, or to create unconscious reenactments of abusive relationships in the treatment room. Like war, those consumed by their profession or vocation can deform themselves by subverting passion and loyalty with an ego attachment to duty. The work of the caregiver can be radically dangerous, addictive in its purposefulness and perhaps as Christopher Lasch says, “a refuge from the terrors of one’s own inner life.”

Let me have war, say I; it exceeds peace as far as day does night;
it's sprightly, waking, audible, and full of vent.
Peace is a very apoplexy, lethargy: mulled, deaf, sleepy, …
—Coriolanus Act 1V, Scene V

There are signals of compassion fatigue: rage attacks, dissociation, work mania, addiction to the drama and pain of others as well as one’s own, depression, isolation, body triggers. Exhausted caregivers can become myopic, unable to access creativity or perspective in their work with survivors. Instead of finding meaningful connections, they might isolate from clinical supervision or a supportive professional community, or perhaps, only seek out those who are in the battlefield and share the same addiction to the work. Over identified with their profession, they might also assume that those not working with survivors or on issues of social reform are shallow or ignorant.

Like war, the ideal of compassion is high. However, grandiosity abounds when one feels indispensable. There is so much to do, too many people to save. Feeling indispensable stops them from stopping, even when it is harmful to the people they are serving.

The allure of service and heroism also runs the risk of cynicism and hopelessness. The work shapes one’s sense of identity, one’s signifiers, one’s sensitivities. And, like soldiers returning to the “unreality” of civilian life, nothing else seems safe or trustworthy. One must still contend with a sense of meaning in the face of suffering and death, with the problem of evil or God.

Restoration from compassion fatigue is difficult. For some, the cost of returning to the same ole’ thing is too high. But there are ways to soothe the heart and tend the spirit long before one burns to a crisp.

We must recognize the signals of exhaustion before we feel the pain. By the time one feels this kind of fatigue, it might be too late to come back quickly. We must use our observant eye to notice the small things that hook us back in and pay attention to what might be restorative instead of palliative. Certain foods, drinking, reality television, violent films may feed- but not nourish. It is more important than ever to consider what one takes into one’s body and psyche; it is vital to exercise, listen to music or silence, to giggle, or to sometimes do nothing whatsoever.

Finding truly safe spaces to be vulnerable and talk about one’s own experiences of confusion, shame, or darkness are often difficult. But safety is as imperative for caregivers to do the work with clarity and vigor as it is to those they tend. This is frankly not so easy to find in professional communities. It is worth one’s while to do whatever it takes to find experienced supervisors and individual therapists, to contain and process the material we bring with exquisite sensitivity and brutal honesty.

Recovery might mean changing the kind of client load or the amount of hours in the field. Perhaps it may initiate a new way of working or another profession altogether. This can create a crisis for those who struggle with hanging too much on their identity as caregivers. Not returning to old habits may actually be stressful or even shameful at first. This requires a deepened space for understanding what it means to give. Recovery is not comfortable. It can be terrifying. But, is that not what we say to others who are trying to heal?

There are signals of recovery that let us know things are better: when we don’t think about abuse all day, when sex is just sex, when we can laugh sometimes at the ironies of life and death.

We struggle to remember the large picture. Hope, joy, and authentic living require deep soulful tending in spite of the impossibility of fixing all that is broken.

There is a Greek term, ekpyrosis, which means to be consumed by a ball of fire. It is easy to be pulled back into the heat. One can easily get hooked again, especially when moving too fast or too much to soothe the soul.

In the process of recovery, it becomes far more difficult for me to multi-task than it used to be. I must confess, at times I miss the mania. I admit my struggle with the thorny issue of shame and self care and continue to be outraged about the problem of evil, denial, or the diminishment of those abused by individuals, churches, governments. Often there is little tolerance for other’s apathy, or my own occasional numbness. Because of what happened, I am terrified of doing harm to loved ones and clients if I do not pay attention to myself. I want to push the envelope and grow in ways I have not even dreamed about yet, but must remember to be still.

We must reconcile the fact that nothing is ever the same after great violence and pain. In Tibetan Buddhism, there is a practice to cultivate fearlessness called tonglen. It is a way to confront the pain that we experience by taking it in, owning instead of avoiding it, then breathing out the fear and resistance. In the face of suffering, we are, more often that not, stuck with our own addictions, aggression, condescension. To practice taking in the pain with softness like this takes honesty and self-vigilance-and practice. It is not such an easy task. It also requires something difficult for caregivers: compassion for ourselves and a vigorous sense of humor.

I know and easily forget that I cannot do this work without some way to nourish my heart. I cannot dismiss the need for sleep, or real food, for love and friendship, for nature, for goofiness. I must try to remember that real self-care is not self-indulgence.

It takes some courage to be less than perfect, to seek a balance, or to occasionally say ‘no’ even when there may be no one else to fill the void. It takes compassion to laugh at times in the face of darkness, stare often into space and be useless, to ride the waves of restlessness: to make a way to be silent, to breathe, to walk, to sing, to sweat.

I live without the hope of settling scores-
yet love life unreasonably and will until the day I die,
though I cannot reckon what I have lost

Foot Notes

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