Compassion Fatigue and Burnout: History, Definitions and Assessment

Don’t suffer in silence, be aware of the symptoms and seek professional help when needed.
Tad B. Coles, DVM, MRSS-P, CCFP
Published: October 27, 2017
Burnout and compassion fatigue continue to be hot topics in veterinary medicine, but many people don’t really understand the difference between them. One thing is for sure: If you’re suffering from either, the best thing to do is reach out and get help.

Denial is a strong force at play in veterinary professionals who may be suffering from burnout or compassion fatigue. The first step, however, is in admitting that there is a problem. The information presented in this article is meant to arm veterinary professionals with valuable tools to navigate these potentially devastating challenges and return to practice feeling refreshed and remembering why you entered the field in the first place.

Burnout
The first time the term “burnout” was used in a psychological sense was in 1974 by German-born American psychologist Herbert J. Freudenberger,1 who used the term to describe symptoms he himself had experienced: “exhaustion, disillusionment and withdrawal resulting from intense devotion to a cause that failed to produce the expected result.”2 Although Freudenberger was in a thriving New York practice, he suffered from perfectionism and had a self-imposed, missionary zeal to help addicts. He worked from 8 a.m. to 7 p.m. in a ritzy area on the Upper East Side and then went to a free clinic in the Bowery and worked until 2 a.m.3

Soon after the publication of “Burnout: The High Cost of High Achievement,” Freudenberger’s seminal text on the topic,4 the Maslach Burnout Inventory (MBI) was constructed to measure the syndrome.5 Eventually, the MBI (which is available for purchase at mind garden.com) was designed to assess three components of burnout: emotional exhaustion, depersonalization and reduced personal accomplishment.6 Maslach found that burnout was the result of mismatches in at least one of six areas7 (Figure 1).

There is considerable interaction among these six areas, often with values playing a central, mediating role that varies with the individual and his or her particular circumstance. For example, people may be more willing to accept workload mismatch if they are compensated well financially and socially.



Burnout is often associated with depression and decreased job satisfaction. People who are more prone to depression are also more prone to burnout, but empirical studies have demonstrated a clear distinction between depression and burnout in that the latter is always job related.7 Although job dissatisfaction and burnout are correlated and linked, they are not identical. Certainly, job dissatisfaction can lead to burnout and vice versa, but both may be affected by other factors, such as heavy workload, improper tools, ineffective training and poor working conditions. 

Burnout studies focus on relationships usually between the health care provider and client but also between the provider and coworkers, friends and family.7 While detachment by clinical distance has often been advised as a method of protection, excessive detachment results in cynicism, callousness and even dehumanizing interaction with clients.Initial studies of burnout involved only health care professionals; then, in the 1990s, the concept of burnout was used in the educational field and a variety of other professions, some of which are not people oriented.7 Thus, one difference between burnout and compassion fatigue is that burnout can occur without empathy and compassion, but compassion fatigue cannot. Freudenberger and fellow psychologist Gail North developed a description of the 12 phases of burnout8 (Figure 2).

Compassion Fatigue
Compare the 12 phases of burnout with the following five phases of compassion fatigue,9 and you may notice symptomatic overlap:
  1. Zealot: The caregiver is motivated by ideal- ism and ready to serve and problem solve, wants to contribute and to make a difference, volunteers to help and is full of energy and enthusiasm. 
  2. Irritability: The caregiver begins to cut corners, avoid client contact, mock peers and clients, denigrate his or her own efforts at wellness, lose concentration and focus and distance oneself from others.
  3. Withdrawal: The caregiver loses patience with clients, becomes defensive, neglects self and others, is chronically fatigued, loses hope, views self as a victim and isolates self.
  4. Zombie: The caregiver views others as incompetent or ignorant; loses patience, sense of humor, and zest for life; dislikes others; and becomes easily enraged.
  5. Pathology and victimization or maturation and renewal: “In this phase, the caregiver can choose pathology and victimization or maturation and renewal. Pathology and victimization result when no action is taken.”9 Maturation and renewal are possible only when the caregiver acknowledges the symptoms of compassion fatigue and takes direct action to overcome it. If the caregiver chooses pathology and victimization, he or she becomes overwhelmed and may leave the profession or develop somatic illness. On the other hand, if the caregiver chooses maturation and renewal, he or she becomes strong, resilient and transformed.

The overlap is interesting, but one differentiation is that burnout tends to be chronic and generalized, whereas compassion fatigue is acute, associated with a particular relationship and centered around compassion and empathy.

The term compassion fatigue was first coined in 1992 when registered nurse Carla Joinson described a unique form of burnout that affected caregivers and resulted in a “loss of the ability to nurture.”10,11 This form of burnout (1) was related to a variety of stressors, including long hours, heavy workload and the need to respond to complex patient needs such as pain, trauma and emotional distress; (2) resulted in nurses feeling tired, depressed, angry and detached; and (3) was associated with ineffective performance.11

The terminology describing compassion fatigue is imprecise. It is common for authors to define terms within specific studies to clarify what they mean.

In an extensively researched thesis on the topic of compassion fatigue and associated terms, Amanda Depippo, a graduate student from the University of South Florida, stated in her dissertation that the term “secondary traumatic stress” (STS) was originally used by professor and trauma expert Charles R. Figley, PhD, to describe compassion fatigue.12,13 Dr. Figley stated that compassion stress, compassion fatigue, STS and secondary traumatic stress disorder (STSD) are equivalent terms.14 He also considered compassion fatigue, STS and STSD to be nearly equivalent to post-traumatic stress disorder (PTSD), “except that exposure to a traumatizing event by one person becomes a traumatizing event for the second person.”14

Dr. Figley suggested that “perhaps PTSD should stand for primary traumatic stress disorder, rather than posttraumatic stress disorder because every stress reaction is ‘post’ by definition.”14

He wrote, “Caring people [sometimes] experience pain as a direct result of their exposure to another’s traumatic material.... This situation — call it compassion fatigue, compassion stress or secondary traumatic stress — is the natural, predictable, treatable and preventable unwanted consequence of working with suffering people.”14

The idea that working with people in pain could cause problems for the caregiver is not new. Transference of emotions from the suffering patient to the therapist is common, as is countertransference — the redirection of the therapist’s feelings toward the patient.

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