The wide range of circumstances experienced by counselors and therapists leaves them open and vulnerable to experiencing compassion fatigue (Negash & Sahin, 2011).
Such a state of emotional exhaustion typically occurs in response to the depth of empathic involvement required to work with people seeking help for their mental health (Delgadillo, Saxon, & Barkham, 2018).
Compassion fatigue is widely recognized as a pathway to occupational burnout and is detrimental to physical and mental wellbeing. Not only that, the condition is damaging to the therapeutic process and harmful to the client.
This article explores the role of self-care in compassion fatigue and the tests, measures, and treatments that can reduce its likelihood and impact.
Before you continue, we thought you might like to download our three Self-Compassion Exercises for free. These detailed, science-based exercises will not only help you increase the compassion and kindness you show yourself but will also give you the tools to help your clients, students, or employees show more compassion to themselves.
Preventing Compassion Fatigue: Guide for Practitioners
“Compassion fatigue is a form of burnout,” often experienced by those providing support to others, including therapists and other mental health professionals (Negash & Sahin, 2011, p. 1).
Typically the result of exposure to secondary trauma through caring for individuals experiencing traumatic stress, it is experienced as stress and anguish, often with the following warning signs and symptoms (Negash & Sahin, 2011):
Chronic physical and emotional exhaustion
Loss of empathy
Loss of respect
Feelings of inequity
More broadly, someone experiencing compassion fatigue may have negative feelings beyond the therapeutic relationship, toward their profession and life in general.
While the term ‘compassion fatigue’ is often used interchangeably with ‘burnout,’ there are some differences. Unlike burnout, compassion fatigue can develop rapidly, resulting from secondary exposure to trauma or suffering and the “intensive empathic involvement with people who are in distress” (Delgadillo et al., 2018, p. 1; Negash & Sahin, 2011).
Preventing compassion fatigue requires understanding factors inside and outside therapy and the stresses and hazards faced by the practitioner.
How a therapist perceives their working conditions is linked to their degree of depersonalization and emotional exhaustion.
Overly hierarchical working environments with more significant caseloads, policies, and paperwork can be damaging.
Mental health practitioners benefit from seeking or building environments where they have the freedom to be flexible in their role while maintaining a stronger sense of job autonomy (Negash & Sahin, 2011).
Working with a high volume of clients with severe problems or specializing in emotionally draining therapy areas can be damaging to the therapist.
Therapists should consider the long-term impact of working with a high volume of clients, particularly those who have experienced suicidal tendencies, child abuse, and severe depression. Mental health professionals must consider whether they can find an appropriately balanced caseload and receive the support required for their areas of specialty (Negash & Sahin, 2011).
Personal trauma and grief
Trauma and grief counseling can be particularly difficult for therapists, draining their emotional resources. Feelings are heightened further when grief counseling is associated with the death of a child, increasing the therapist’s sense of empathy and commitment (Negash & Sahin, 2011).
Therapists should ensure that they do not use such settings to work through experiences from their own past, which could result in a loss of objectivity, over-identification with clients, and depression.
Separation of personal life and professional role
Therapists’ personal and family problems can surface during sessions, influencing treatment and their expectations of the client. Conversely, therapists’ personal and family life can also be affected by their experiences of their clients’ problems (Negash & Sahin, 2011).
Therapists may find themselves associating with their family as they do with their clients.
It remains crucial that therapists avoid taking their professional role into personal settings. Practitioners must set clear boundaries between their personal and professional lives to ensure that clarity and emotional control remain paramount.
The Important Role of Self-Care
While the work of a therapist or mental health practitioner can become emotionally, mentally, and physically draining, it is possible to reduce the likelihood or impact of compassion fatigue through the practice of self-care (Negash & Sahin, 2011).
When therapists don’t practice self-care, their ability to help others is compromised (Bush, 2015). Rather than a selfish act or a chore that gets dropped when time is tight, self-care is necessary to maintain a selfless, untroubled attitude with clients. According to Bush (2015), it is an ethical obligation for professionals working toward their clients’ mental health.
We can approach self-care at two levels. Macro-self-care includes the bigger things in our lives: getting the sleep we need, eating well, taking vacations, focusing on relationships, and spending time doing the things we love. Each is important; taken as a whole, they are essential. Micro-self-care involves the small stuff that can easily fit into the busiest of days: taking a moment to breathe, strengthening self-awareness, and practicing self-compassion.
Coaston (2017, p. 285) recognizes therapists’ routine exposure to “painful situations and overwhelming emotions” and recommends developing an attitude of self-compassion, mindfulness, and regularly making time for oneself.
Self-care is crucial to therapists’ wellbeing and ability to function and continue to meet their clients’ needs, enabling them to “refill and refuel [themselves] in healthy ways” (Gentry, 2002, p. 48).
Ultimately, according to the American Psychological Association (2010, p. 3), psychologists should strive to maintain an awareness of their wellbeing and its potential impact “on their ability to help those with whom they work.”
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5 Tests, Scales, Checklists, & Questionnaires
Those in helping professions often consciously or unconsciously share the emotional burden of their traumatized clients as they encourage the healing process. As a result, it is easy to become overwhelmed and numb through secondary traumatic stress (Bride, Radey, & Figley, 2007).
For mental health professionals, it can be helpful to use questionnaires and tests to provide a more objective score of the degree of compassion fatigue currently being experienced.
Compassion fatigue assessment
The following 15 questions can help reflect on the degree of personal self-care and spot warning signs of compassion fatigue (modified from Kramen-Kahn, 2002; Barnett, 2014):
Do you appear competent and professional?
Do you appear warm, caring, and accepting?
Do you regularly seek case consultation with another professional while protecting confidentiality?
Do you frequently use self-talk to put aside the client’s thoughts at the end of a stressful day?
Do you maintain a balance between work, family, and play?
Do you nurture a strong support network of family and friends?
Do you use healthy leisure activities as a way of helping yourself relax after work?
Do you often feel renewed and energized by working with clients?
Do you continue to develop new interests in your professional work?
Do you perceive clients’ problems as interesting and look forward to working with clients?
Do you maintain objectivity regarding clients’ problems?
Do you maintain good boundaries with clients, allowing them to take full responsibility for their actions while providing support for change?
Do you use personal psychotherapy as a means of maintaining and improving your functioning as a psychotherapist?
Do you maintain a sense of humor?
Do you act in accordance with legal and ethical standards?
Early warning signs of compassion fatigue
The Society for Psychotherapy provides a list of compassion fatigue warning signs to watch for through self-reflection. Together, they give a good indication of whether you are meeting your self-care needs (modified from Barnett, 2014):
Ask yourself if the following warning signs apply:
My patterns of eating, sleeping, or concentration have changed.
I isolate myself from friends, family, and colleagues.
I don’t take regular breaks when working.
I am bored and disinterested, and I don’t enjoy my work as much as I did.
I am easily irritated by my clients.
I feel emotionally exhausted and drained after meeting some of my clients.
I am not taking good care of myself – overlooking my health and self-medicating.
I find myself thinking of being elsewhere when I am with my clients.
I find my work less rewarding than in the past.
I regularly feel depressed, anxious, or agitated.
I experience more headaches and other physical complaints.
I can’t concentrate and find myself staring into the distance.
Pay attention to the answers you give to each question and overall patterns; they may indicate you are burned out or experiencing compassion fatigue. Engaging in self-care is not a nice-to-have, but a necessity for your own and your patients’ wellbeing.
Compassion Fatigue Self-Test
The Compassion Fatigue Self-Test (CFST) is a widely used instrument for measuring compassion fatigue. It was initially developed based on clinical experience to assess both compassion fatigue and burnout. This 40-item questionnaire asks respondents to score between 1 (rarely or never) and 5 (very often) to assess themselves or their situation (Figley, 1995; Bride et al., 2007).
Sample statements about you include:
I force myself to avoid certain thoughts or feelings that remind me of a frightening experience.
I find myself avoiding certain activities or situations because they remind me of a frightening experience.
I have gaps in my memory about frightening events.
I feel estranged from others.
I have difficulty falling or staying asleep.
Sample statements about your clients and their families include:
I am frightened of things traumatized people and their family have said or done to me.
I experience troubling dreams similar to a client of mine and their family.
I have experienced intrusive thoughts of interactions with especially difficult clients and their families.
I have suddenly and involuntarily recalled a frightening experience while working with a client or their family.
I am preoccupied with more than one client and their family.
Compassion Satisfaction and Fatigue Test
The Compassion Satisfaction and Fatigue Test (evolved from the CFST) explores the positive and negative effects of compassion felt for others in caring situations. The scoring, between 0 (rarely) and 5 (very often), provides an insight into the individual’s risk of burnout and compassion fatigue by asking about you,being a helper, and the environment in which you work. Here are some examples (Stamm, 2002):
I am happy.
I find my life satisfying.
I have beliefs that sustain me.
I feel estranged from others.
I find that I learn new things from those I care for.
About being a helper and your environment:
I like my work as a helper.
I feel like I have the tools and resources that I need to do my work as a helper.
I have felt weak, tired, and run down as a result of my work as helper.
I have felt depressed as a result of my work as a helper.
I have thoughts that I am a “success” as a helper.
Compassion Fatigue Scale
This 66-item questionnaire is a more extensive and revised version of the CFST that contains a series of positively oriented questions intended to measure compassion satisfaction and fatigue (Bride et al., 2007).
Statements scored include:
I have happy thoughts about those I help and how I could help them.
I have experienced intrusive thoughts of times with especially difficult people I helped.
I have suddenly and involuntarily recalled a frightening experience while working with a person I helped.
I am preoccupied with more than one person I help.
I am losing sleep over a person I help’s traumatic experiences.
I think that I might have been “infected” by the traumatic stress of those I help.
I think that I might be positively “inoculated” by the traumatic stress of those I help.
I remind myself to be less concerned about the wellbeing of those I help.
I have felt trapped by my work as a helper.
I have a sense of hopelessness associated with working with those I help.
How to Overcome Compassion Fatigue 101
Self-compassion is a vital component of the therapeutic relationship, but practitioners often fail to apply it to themselves (Coaston, 2017).
We can manage perceptions of inadequacy or failing through the gentle perception of “self-kindness, common humanity, and mindfulness” (Coaston, 2017, p. 285).
Directing compassion at yourself can be achieved by adopting a mindful self-compassion outlook that leads to an awareness of suffering while encouraging kindness. Such an outlook can be protective and reduce the likelihood of over-identification or becoming too emotionally involved (Coaston, 2017).
Other outlooks may also be protective or healing when encountering compassion fatigue.
Seeking and engaging in intellectual stimulation fosters engagement, curiosity, and enjoyment. From a growth and development perspective, embracing professional development can reduce boredom and increase objectivity to overcome compassion fatigue.
We may find additional benefits from attending to positives and savoring successes. While the client’s pain can be absorbing, we can find relief from reflecting on successes. While confidentiality remains paramount, it is possible to keep reminders of positive outcomes and emails, or share (anonymized) client progress with other therapists.
Coaston (2017) also recommends writing as a valuable intervention for helping therapists maintain good mental health. As long as care is taken regarding confidentiality, journaling and narrative and letter writing can be practical ways to externalize painful emotions and regain objectivity.
Self-Compassion Yin & Yang
The concept of the Yin-Yang symbol has its roots in ancient Chinese philosophy, which embodies the idea of opposing forces attracting each other.
According to Fang (2012), this symbol represents the duality of self-compassion, with its “masculine” and “feminine” aspects as described by Neff and Germer (2018). These different approaches to self-compassion can be categorized as internalized or externalized.
The internalized side, referred to as the Yin or feminine aspect of self-compassion, involves showing kindness to ourselves and our minds during times of need. This form of self-compassion is personal and directed solely towards ourselves.
In contrast, the Yang or masculine aspect represents an externalized form of self-compassion, where we take action in the world to protect ourselves.
For instance, consider a person experiencing compassion fatigue. The person may practice Yin by journaling about their work-related stress as a way to validate their thoughts or by taking a relaxing bath after a challenging day. On the other hand, they may engage in Yang self-compassion by speaking to their boss about reducing their workload or requesting time off.
3 Helpful Treatment Options
To overcome compassion fatigue, there are a few options, of which three is listed here.
Self-care is vital for treating compassion fatigue, emotional and physical fatigue, and feelings of being overwhelmed. But there is also a time to seek professional help. This may include going to see a family doctor, trauma specialist, therapist, or psychiatrist (Brennan, 2020).
Healthcare professionals are often the least likely to seek the help they need, yet they are some of the most likely professionals to benefit (Brennan, 2020).
Mindfulness and meditation
Research has confirmed that developing a mindful outlook and performing meditation can improve self-compassion and decrease compassion fatigue (Neff & Germer, 2012).
Whether performed on your own using a script, audio, or with a trained practitioner individually or in a group, mindful meditation is a powerful tool for grounding emotions, developing gratitude and kindness, and managing stress, with few (if any) side effects (Hevezi, 2016).
Progressive muscle relaxation
Progressive muscle relaxation involves tensing and quickly releasing muscle groups around the body in a particular order. While valued for managing stress and maintaining mental wellbeing, research has also found progressive muscle relaxation to be helpful in restoring quality of life and reducing compassion fatigue in caregivers and healthcare professionals (Semerci et al., 2020).
6 Exercises, Handouts, and Workbooks
Mental health professionals can practice restorative exercises, helpful in managing compassion fatigue and burnout, throughout the workday.
Here are some examples to try (modified from Bush, 2015):
All you need is love
This grounding exercise promotes feelings of love and connectedness.
When you wake and before you get up, imagine breathing in the word love. Include within it all the love you receive from your partner, children, parents, friends, and beyond.
Then, picture breathing out the word love and sending out the same feelings to those you care about. By focusing on life’s positive aspects, it is possible to promote feelings of connectedness.
We can all benefit from connecting to a larger purpose.
As you touch the handle to open the door and welcome your client into the room, think to yourself, “I do this because… ” and add your own reasons.
This exercise is a valuable reminder of why we continue helping others, turning feelings of helplessness into ones of purpose.
A positive intention set at the beginning of each day can set the scene and direction for what is to come.
Using the present tense, say to yourself, “Today, I live in awe of the beauty around me,” or “Today, I treat people with the love and respect we all deserve.”
While we can perform the following exercises individually, they can also be valuable in a group environment.
Connect with other caregivers
It can be valuable to see yourself as part of a larger group that gives their time and energy to help others.
Whether performed physically with others in a group setting or remotely, hold something in your hand that feels of value (it may simply be a feather or smooth stone) and say to yourself, “I belong to a network of people helping others,” or something similar.
Imagine all those working with similar goals across the globe and how you share that purpose. Performing this exercise with others in a room can be a powerful approach for building a sense of connectedness.
Turn the other cheek
Hold in your mind the thought that those who have shown anger and negativity toward you are suffering somehow.
Breathe in the wish to remove their pain and unhappiness, and breathe out and imagine them receiving your good wishes. The process can help you avoid becoming drawn into a spiral of negativity.
While we can perform this exercise individually, discussing thoughts and experiences in a group setting after completion can also be helpful.
How to manage compassion fatigue in caregiving - Patricia Smith
Resources From PositivePsychology.com
If you’re a helping professional looking to avoid or reduce the impact of compassion fatigue, why not show yourself some care with our free Self-Compassion Exercises Pack?
These exercises focus on identifying activities, behaviors, and ways of thinking that promote self-care:
Applying the Yin Yang of Self-Compassion
This exercise helps you discover the two sides of self-compassion, centering around both taking action and ways to simply be with oneself. In particular, you will consider ways you can protect, provide, and motivate yourself, as well as ways you can soothe, comfort, and validate yourself when needed.
Self-Care Vision Board
This exercise invites you to create a visual representation of what self-care might look like using a vision board. As part of the exercise, you will brainstorm possible self-care activities that fit your lifestyle and values, and collect words and images for your board reflective of these activities.
Learning to Rate Behavior Rather Than The Self
This exercise helps you systematically explore the negative self-talk that may flow from past regrets. In particular, you are invited to list 5-10 negative actions or mistakes from your past and consider how it feels to evaluate your whole self based on this event versus restricting your evaluation to just the behavior.
Additionally, if you’re looking for more science-based ways to help others develop self-compassion, this collection contains 17 validated self-compassion tools for practitioners. Use them to help others create a kinder and more nurturing relationship with the self.
A Take-Home Message
It is perhaps unsurprising that mental health professionals experience compassion fatigue.
Helping those in need requires empathic involvement and commitment to the therapeutic process and the goals set.
The effect of compassion fatigue can be far reaching. While disastrous for the mental and physical wellbeing of the therapist, it can also reduce what they offer to their clients.
While not uncommon, compassion fatigue is not a certainty. We can avoid compassion fatigue with the right mindset, self-care practices, and a supportive work environment.
Spend time attending to your state of mind, and understand its impact on your professional and personal life. Then reflect on what changes you could make to bring self-compassion, kindness, and balance back into your life.
Fostering curiosity through development and learning is a powerful way to motivate and improve objectivity while driving forward the therapeutic process.
Finally, consider the use of mindfulness and meditation to ground and still your busy mind after each session, and prepare for the next client or the next day.
American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from https://www.apa.org/ethics/code
Barnett, J. (2014). Distress, therapist burnout, self-care, and the promotion of wellness for psychotherapists and trainees. Society for the Advancement of Psychotherapy. Retrieved from https://societyforpsychotherapy.org/distress-therapist-burnout-self-care-promotion-wellness-psychotherapists-trainees-issues-implications-recommendations/
Brennan, D. (2020). Compassion fatigue: Symptoms to look for. WebMD. https://www.webmd.com/mental-health/signs-compassion-fatigue.
Bride, B. E., Radey, M., & Figley, C. R. (2007). Measuring compassion fatigue. Clinical Social Work Journal, 35(3), 155–163.
Bush, A. D. (2015). Simple self-care for therapists: Restorative practices to weave through your workday. W.W. Norton & Company.
Coaston, S. C. (2017). Self-care through self-compassion: A balm for burnout. The Professional Counselor, 7(3), 285–297.
Delgadillo, J., Saxon, D., & Barkham, M. (2018). Associations between therapists’ occupational burnout and their patients’ depression and anxiety treatment outcomes. Depression and Anxiety, 35(9), 844–850.
Fang, T. (2012). Yin Yang: A new perspective on culture. Management and organization Review, 8(1), 25-50.
Figley, C. R. (1995). Compassion fatigue. Coping with secondary traumatic stress disorder. Brunner/Mazel.
Gentry, J. E. (2002). Compassion fatigue: A crucible of transformation. Journal of Trauma Practice, 1(3–4), 37–61.
Hevezi, J. A. (2016). Evaluation of a meditation intervention to reduce the effects of stressors associated with compassion fatigue among nurses. Journal of Holistic Nursing, 34(4), 343–350.
Kramen-Kahn, B. (2002). Do you “walk your talk”? The Maryland Psychologist, 44(3), 12.
Neff, K., & Germer, C. (2018). The mindful self-compassion workbook: A proven way to accept yourself, build inner strength, and thrive. Guilford Publications.
Neff, K. D., & Germer, C. K. (2012). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of Clinical Psychology, 69(1), 28–44.
Negash, S., & Sahin, S. (2011). Compassion fatigue in marriage and family therapy: Implications for therapists and clients. Journal of Marital and Family Therapy, 37(1), 1–13.
Semerci, R., Öztürk, G., Akgün Kostak, M., Elmas, S., İhsan Danacı, A., & Musbeg, S. (2020). The effect of progressive muscle relaxation exercises on compassion satisfaction, burnout, and compassion fatigue of nurse managers. Perspectives in Psychiatric Care, 57(3), 1250–1256.
Stamm, B. H. (2002). Measuring compassion satisfaction as well as fatigue: Developmental history of the compassion satisfaction and fatigue test. In C.R. Figley (Ed.), Treating compassion fatigue. Taylor & Francis/Brunner-Mazel.
About the author
Jeremy Sutton, Ph.D., is a writer and researcher studying the human capacity to push physical and mental limits. His work always remains true to the science beneath, his real-world background in technology, his role as a husband and parent, and his passion as an ultra-marathoner.