Compassion fatigue: how much can I give?

An increasing number of publications

examine the disturbing effects on clini-

cians of witnessing or learning of trauma

experienced by their patients. This

vicarious traumatisation is described in

various terms, including secondary vic-

timisation, secondary survival, emo-

tional contagion, counter-transference,

burnout and compassion fatigue. It is

generally accepted that, while they have

significant similarities, there are also

differences between these phenomena.

Central to these processes is the use of

empathy by clinicians. What is the role

of empathy in the doctor)patient rela-
tionship?

Clues … were ignored, with the
doctor usually exploring the

diagnostic aspects of symptoms

The nature of empathy and its role in

a helping relationship has been debated

from a variety of theoretical viewpoints

over several decades. Reynolds’
1

review

of the role of empathy illustrates the

development of the construct and pre-

sents a view that it is multidimensional

and has emotive, moral, cognitive and

behavioural components. Definitions of

empathy vary. Gerald Egan,
2

reviewing

the work of Carl Rogers,
3

describes

empathy as ‘a way of being’, where the

helper, without judgement, enters the

private world of the client. Egan further

describes a deeper level of empathy,

where the helper gains an insight,

beyond that of the client, into the client’s

own story. A study by Suchman et al.
4

of

doctors working in a primary care setting

showed this empathic understanding of

the ‘story behind the story’ to be lacking.

The study found that both clues and

direct expression of affect were ignored,

with the doctor usually exploring the

diagnostic aspects of symptoms. Rey-

nolds
1

extends Rogers’ definition by

including the communication of this

understanding of the ‘story behind the

story’ to the client as a means of valid-

ating the client’s world. Other research

has indicated that there is a relationship

between clinicians’ empathy and

compassion and the quality of the care

they provide.
5

If this is the case, why is it

that empathy and compassion often

appear to be lacking in therapeutic

relationships?

Central to these processes is the

use of empathy by clinicians

Halpern
6

gives the following reasons

why doctors might seek detachment

from, rather than emotional engage-

ment with, their patients: protection

from burnout, improved concentration,

rationing of time, maintenance of im-

partiality, and that the fact that ‘emo-

tions are inherently subjective influences

that interfere with objectivity’. She also

reports that detachment does not pro-

tect doctors from burnout; rather, burn-

out can be linked to time pressures and

other organisational issues that prevent

the development of doctor)patient re-
lationships. Research on burnout has

shown that it is a process that begins

gradually and progressively worsens,

and that a key element of it is emotional

exhaustion.
7

Figley has researched the

field of stress related to the use of

empathy and compassion and has des-

cribed a stress response that emerges

suddenly and without warning and that

includes characteristics such as a sense

of helplessness and confusion, feelings

of isolation from supporters and symp-

toms that are often disconnected from

their real cause. However, there appears

to be a faster recovery rate from this

particular stress response than there is

from burnout. Figley uses the term

‘compassion fatigue’ to describe this

process, which he regards as secondary

traumatic stress, or the stress resulting

from the learning of, or witnessing of, a

traumatising event involving some other

significant person.

Detachment does not protect

physicians from burnout

While empathic engagement with

patients may be independent of the

development of burnout, Figley des-

cribes the use of empathy as one of the

particular reasons why trauma workers

are especially vulnerable to compassion

fatigue. While only a portion of clini-

cians is exposed on a frequent basis to

traumatic material, those who are may

experience emotions similar to those of

their patients. Elsewhere in Figley’s

book, the development of compassion

fatigue is described as being possibly

due to an over-intensive identification

with the survival strategies adopted by

patients, and inappropriate or lacking

personal survival strategies.

‘Compassion fatigue’, or secon-

dary traumatic stress, results

from the learning of, or witness-

ing of, a traumatising event

involving some other significant

person

Pearlman and Saakvitne
8

describe a

process for managing and treating com-

passion fatigue. Their interventions are

grouped into personal, professional and

organisational categories. Personal strat-

egies include identifying and making

sense of disrupted schemas, striking an

appropriate work)life balance, under-
taking personal psychotherapy, identify-

ing healing activities and attending to

Correspondence: Peter Huggard, Senior

Lecturer, Department of General Practice

and Primary Health Care, Faculty of Medical

and Health Sciences, University of Auckland,

PO Box 92 019, Auckland, New Zealand.

Tel: 00 64 9 373 7599; Fax: 00 64 9 373

7006; E-mail: p.huggard@auckland.ac.nz

Arts and humanities

� Blackwell Publishing Ltd M E D I C A L E D U C A T I O N 2003;37:163–164 163



spiritual needs. Professional strategies

include undertaking regular professional

supervision with an experienced senior

colleague where patients can be dis-

cussed and the clinician’s own responses

to them examined without embarrass-

ment and fear of censure, engaging in

appropriate self-care practices, develop-

ing and maintaining professional net-

works, having a realistic tolerance of

failure, and being aware of work and

personal goals. Organisational strategies

include developing a workplace envi-

ronment that is as comfortable as poss-

ible, and ensuring a culture of support

and respect within the workplace that

relates to employees as well as to

patients.

Compassion fatigue is described

as being possibly due to inap-

propriate or lacking personal

survival strategies

What are the requirements of a med-

ical education programme that will pre-

pare doctors to manage the effects of

processes such as compassion fatigue?

Public opinion since ancient times has

required that doctors be equipped with

such characteristics as integrity, sacrifice

and compassion. The quality of com-

passion is one of the key components in

the development of the humanistic

doctor.
9

Although the ‘fatigue of

compassion’ can be managed as des-

cribed above, to do so requires the

development of skills in self-awareness

that enable medical students and doc-

tors to more effectively engage empa-

thetically with their patients and to gain

insight into their own responses to their

patients’ stories. This path of personal

growth will lead to greater well-being,
9

to greater use, by doctors, of themselves

as therapeutic agents
10

and to an

increased capacity on the part of doctors

to give of themselves in their therapeutic

relationships with their patients. The

humanistic educator-physician can have

a major influence as a role model at one

of the most important and impression-

able times of a young doctor’s life –

namely, during their medical education.

In ‘caring for the carers’, the chal-

lenge for health care organisations lies in

developing respect and care for their

employees in the same way that they

require their employees to care for

patients. In doing this, health care

organisations will support and assist

their employees in sustaining and fur-

ther developing their humanism.

Health professionals will then be able

to give of themselves in the therapeutic

relationship in a manner that enhances

the physician)patient relationship and
the lives of both the care-giver and the

patient.

Peter Huggard

Auckland, New Zealand

References

1 Reynolds WJ. The Measurement and

Development of Empathy in Nursing.

Aldershot: Ashgate Publishing 2000.

2 Egan G. The Skilled Helper. California:

Brooks ⁄ Cole Publishing Co 1994.
3 Rogers CR. A way of being. Boston:

Houghton Mifflin 1980.

4 Suchman AL, Markakis K, Beckman

HB, Frankel R. A model of empathic

communication in the medical inter-

view. JAMA 1997;277:678–82.

5 Bellet PS, Maloney M. The importance

of empathy as an interviewing skill in

medicine. JAMA 1991;266:1831–2.

6 Halpern J. From Detached Concern to

Empathy: Humanising Medical Practice.

Oxford: Oxford University Press 2001.

7 Figley CR. Compassion Fatigue. New

York: Brunner ⁄ Mazel 1995.
8 Pearlman LA, Saakvitne KW. Treating

therapists with vicarious traumatisation

and secondary traumatic stress disor-

ders. In: Figley CR, ed. Compassion

Fatigue. New York: Brunner ⁄ Mazel
1995;150–77.

9 Novack DH, Epstein RM, Paulsen RH.

Towards creating physician-healers.

Fostering medical students’ self-aware-

ness, personal growth and well-being.

Acad Med 1999;74:516–20.

10 Novack DH, Kaplan G, Epstein RM,

Clark W, Suchman AL, O’Brian M et al.

Personal awareness and professional

growth: a proposed curriculum. Med

Encount 1997;13:2–8.

Compassion fatigue: How much can I give? • P Huggard164

� Blackwell Publishing Ltd M E D I C A L E D U C A T I O N 2003;37:163–164