Compassion Fatigue: An Expert Interview With Charles R. Figley, MS, PhD

October 17, 2005

Editor's Note:
Disasters such as Hurricane Katrina take a heavy emotional and physical toll not only on their primary victims, but also on the overworked professionals and volunteers who rush in to help in the aftermath. Medscape's Jessica Gould interviewed Dr. Charles Figley, Director of the Florida State University Traumatology Institute and President and Founder of the Green Cross Foundation, about the frequently overlooked trauma and stress experienced by those in rescue and help operations.

Medscape: Could you define compassion fatigue for us?

Dr. Charles Figley: Compassion fatigue is a state experienced by those helping people in distress; it is an extreme state of tension and preoccupation with the suffering of those being helped to the degree that it is traumatizing for the helper.

The helper, in contrast to the person(s) being helped, is traumatized or suffers through the helper's own efforts to empathize and be compassionate. Often, this leads to poor self care and extreme self sacrifice in the process of helping. Together, this leads to compassion fatigue and symptoms similar to posttraumatic stress disorder (PTSD).

Medscape: How did you begin working on compassion fatigue?

Dr. Figley: I've been doing this since the 1970s, meaning studying traumatized people. And I began to realize, in the late 1980s, that a lot of colleagues of mine who had worked in the field, primarily as practitioners, were no longer working in the field. In conversations with them, it became clear to me that it was not burnout, because burnout is more a lack of satisfaction with your job, too much stress, not enough pay. But what they were really talking about was the toxicity of the work.

The first study we did here at Florida State University focused on pediatric critical care nurses in the regional medical center. We figured that if anyone knew how to handle the emotional toxicity of people who were suffering, it would be these nurses. As we expected, there was considerable turnover among the nurses, and the people who were able to make it had done the kind of self-care that we talk about as ways of preventing and mitigating compassion fatigue.

What we realized is that you don't have to be a family member to get upset, you just have to be someone who really, deeply cares. So that's why we called it secondary traumatic stress reaction. Primary is when you were in harm's way, and secondary is when you are helping someone or care about someone who is in harm's way.

So I went to the literature and looked up synonyms for the sort of thing I was talking about and discovered Joinson's article in a nursing magazine,[1] and part of the title used compassion fatigue. It had never been used before, and I thought that was the essence of what we were finding.

Helping other people -- whether you're a volunteer or a medical doctor -- requires empathy and compassion. You have to see the world through an individual patient's perspective, and compassion in that you not only understand their world view, but you're motivated to assist them.

One of the defining criteria of PTSD is exposure to a stressor, which can be to yourself or to another. I made the point that the other should include those who are involved in care, whether they are professionals, volunteers, or family members.

I spent a long time studying combat veterans. Later, when I began to talk about compassion fatigue, my doctoral students told me that they had seen the symptoms in me. When I came back from my interviews with combat veterans, I was testy, short-tempered, a bit depressed, you know, that kind of thing. And it was not because I didn't get enough sleep. It was really because I was overwhelmed by the material. I think as a result I definitely had a case of compassion fatigue and I think it partly accounted for the end of my first marriage.

What I have attempted to do, really, is to develop tools and theories that are applicable to individuals coping with any overwhelming stressful event.

Medscape: Given this set of tools, can you tell me what we should be looking for as we seek to identify compassion fatigue in the wake of Hurricane Katrina?

Dr. Figley: A lot of these things are similar to PTSD. One is lack of sleep, due to the worker working too hard, and not leaving the work, putting in long hours, as well as not being able to separate from the work psychologically. So first and foremost, we should be asking people, "How much sleep did you get last night?" Some of them wear it as a badge of honor, saying, "Oh, I only got 2 hours of sleep." But, really, they can be a danger to people if they're not getting enough sleep.

The second thing has to do with a sense of humor. Nine-one-one operators often have a sick sense of humor, but at least it's a sense of humor. People who know these workers well should notice if people are joking around less; that's a sign that they need a break.

The third has to do with the unintended consequences of being tired and not being able to cope with the toxic emotional material. There are those who might try to cool off by drinking alcohol. But for these men and women who are there for the long haul, they may increase their alcohol consumption over time, which, of course, leads to all kinds of negative consequences. And I would include smokers in this group too. Smoking depletes your natural ability to spring back and it diminishes the immune system, which is already diminished, in this case, by stress.

Otherwise, it depends on people's personalities. If they tend to be withdrawn, they'll become more withdrawn. If they tend to be social, they'll also become more withdrawn than they normally are. The change in sense of humor becomes very apparent. The people who tend to ask for help, ask less, and those who don't, definitely don't. We've developed checklists for compassion fatigue prevention and mitigation, asking how often they've taken a break, how much sleep they have, do they skip meals.

Medscape: That brings us to the question of self-care that you referred to earlier. What kinds of self-care work to prevent compassion fatigue?

Dr. Figley: The main thing with regard to self-care is that those who are selfless and compassionate have an Achilles heel -- they don't pay enough attention to themselves. So we have to save them from themselves. I'm a psychologist working at a college of social work, and one of the reasons I'm here is because there's a calling among social workers to help mankind, and to help the less fortunate. The people who are drawn to that are extraordinarily vulnerable to compassion fatigue. The same is true for the faith community, for nurses, even certain specialties within the military, Red Cross volunteers. There's a tendency to be selfless and to help other people. So they have to recognize that they're more vulnerable than most people because they neglect their own needs, despite what their children or spouses say. And even when they recognize it, when they have a choice to put a victim, a client, or a survivor ahead of themselves, they do that. [See table below.]

Medscape: The news organizations have been talking about police officers in New Orleans who committed suicide as a result of the devastation there. Can we call these incidents compassion fatigue?

Dr. Figley: My sources, first responders and cops who have gone down to the areas hit by Hurricane Katrina, tell me that as many as 5 people committed suicide in the last week. Suicide is very complicated, and there's a potential for these folks to have done that anyway. God knows if you lose a family member, you lose a house, that clearly can spiral to a sense of hopelessness that may lead to suicide. What we're talking about here are people who are primary victims in addition to being secondary victims. In addition to being in harm's way, they've been harmed. And then when you add to that -- not only have they lost their homes, but they've lost their community. They've lost their physical and social structures. Then you add to that the extraordinary position of having to make snap decisions, in questions of looting, whether you should harm someone you've sworn to protect.

Medscape: What have you been doing in response to Hurricane Katrina?

Dr. Figley: When Katrina hit, I was coming in from Texas to Tallahassee. As soon as I knew it was this big, I began contacting my colleagues and speaking to people at the state chapter of the National Association of Social Workers in Louisiana. And I continued to talk to them through the week.

What became clear to me was that care being provided for the caregiver was not adequate. With Katrina, people are being displaced in huge numbers. That's the first thing. The second thing is that they need far more people than have ever worked in any disaster ever. So there were going to be newbies, people who had no training, who are just volunteering because they care, and are being thrown into the breach with no preparation, no education about self-care. So what you then have are these hordes of people who have never been involved in a disaster being inundated with all of these traumatized people.

Invariably, what we would predict from our models is that they will not only experience secondary traumatic stress reactions, but burnout, depression, substance abuse, overeating, or undereating as well. They're going to be exhausted. And because of that, there's going to be high turnover, and another group of volunteers will have to come in and pick up the slack.

Table. Academy of Traumatology/Green Cross Proposed Standards of Self Care

  1. Purpose of the Guidelines
    As with the standards of practice in any field, the practitioner is required to abide by standards of self care. These Guidelines are utilized by all members of the Green Cross. The purpose of the Guidelines is twofold: First, do no harm to yourself in the line of duty when helping/treating others. Second, attend to your physical, social, emotional, and spiritual needs as a way of ensuring high quality services to those who look to you for support as a human being.

  2. Ethical Principles of Self Care in Practice
    These principles declare that it is unethical not to attend to your self care as a practitioner because sufficient self care prevents harming those we serve.

    1. Respect for the dignity and worth of self: A violation lowers your integrity and trust.

    2. Responsibility of self care: Ultimately it is your responsibility to take care of yourself, and no situation or person can justify neglecting it.

    3. Self care and duty to perform: There must be a recognition that the duty to perform as a helper can not be fulfilled if there is not, at the same time, a duty to self care.

  3. Standards of Humane Practice of Self Care

    1. Universal right to wellness: Every helper, regardless of her or his role or employer, has a right to wellness associated with self care.

    2. Physical rest and nourishment: Every helper deserves restful sleep and physical separation from work that sustains them in their work role.

    3. Emotional rest and nourishment: Every helper deserves emotional and spiritual renewal both in and outside the work context.

    4. Sustenance modulation: Every helper must utilize self restraint with regard to what and how much they consume (eg, food, drink, drugs, stimulation) since it can compromise their competence as a helper.

  4. Standards for Expecting Appreciation and Compensation

    1. Seek, find, and remember appreciation from supervisors and clients: These and other activities increase worker satisfactions that sustain them emotionally and spiritually in their helping.

    2. Make it known that you wish to be recognized for your service: Recognition also increases worker satisfactions that sustain them.

    3. Select one more advocates: They are colleagues who know you as a person and as a helper and are committed to monitoring your efforts at self care.

  5. Standards for Establishing and Maintaining Wellness

    Section A. Commitment to self care

    1. Make a formal, tangible commitment: Written, public, specific, and measurable promise of self care.

    2. Set deadlines and goals: The self care plan should set deadlines and goals connected to specific activities of self care.

    3. Generate strategies that work and follow them: Such a plan must be attainable and followed with great commitment and monitored by advocates of your self care.

    Section B: Strategies for letting go of work
    1. Make a formal, tangible commitment: Written, public, specific, and measurable promise of letting go of work in off hours and embracing rejuvenation activities that are fun, stimulating, inspiriting, and generate joy of life.

    2. Set deadlines and goals: The letting go of work plan should set deadlines and goals connected to specific activities of self care.

    3. Generate strategies that work and follow them: Such a plan must be attainable and followed with great commitment and monitored by advocates of your self care.

    Section C. Strategies for gaining a sense of self care achievement
    1. Strategies for acquiring adequate rest and relaxation: The strategies are tailored to your own interest and abilities that result in rest and relaxation most of the time.

    2. Strategies for practicing effective daily stress reductions method(s): The strategies are tailored to your own interest and abilities in effectively managing your stress during working hours and off-hours with the recognition that they will probably be different strategies.

  6. Inventory of Self Care Practice -- Personal

    Section A: Physical

    1. Body work: Effectively monitoring all parts of your body for tension and utilizing techniques that reduce or eliminate such tensions.

    2. Effective sleep induction and maintenance: An array of healthy methods that induce sleep and a return to sleep under a wide variety of circumstances including stimulation of noise, smells, and light.

    3. Effective methods for assuring proper nutrition: Effectively monitoring all food and drink intake and lack of intake with the awareness of their implications for health and functioning.

    Section B: Psychological
    1. Effective behaviors and practices to sustain balance between work and play

    2. Effective relaxation time and methods

    3. Frequent contact with nature or other calming stimuli

    4. Effective methods of creative expression

    5. Effective skills for ongoing self care

      1. Assertiveness

      2. Stress reduction

      3. Interpersonal communication

      4. Cognitive restructuring

      5. Time management

    6. Effective skill and competence in meditation or spiritual practice that is calming

    7. Effective methods of self assessment and self-awareness

    Section C: Social/interpersonal
    1. Social supports: At least 5 people, including at least 2 at work who will be highly supportive when called upon.

    2. Getting help: Knowing when and how to secure help -- both informal and professional -- and that the help will be delivered quickly and effectively.

    3. Social activism: Being involved in addressing or preventing social injustice that results in a better world and a sense of satisfaction for trying to make it so.

  7. Inventory of Self Care Practice -- Professional

    1. Balance between work and home: Devoting sufficient time and attention to both without compromising either.

    2. Boundaries/limit setting: Making a commitment and sticking to it regarding.

      1. Time boundaries/overworking

      2. Therapeutic/professional boundaries

      3. Personal boundaries

      4. Dealing with multiple roles (both social and professional)

      5. Realism in differentiating between things one can change and accepting the others

    3. Getting support/help at work through

      1. Peer support

      2. Supervision/consultation/therapy

      3. Role models/mentors

    4. Generating work satisfaction: By noticing and remembering the joys and achievements of the work.

  8. Prevention Plan Development

    1. Review current self-care and prevention functioning

    2. Select 1 goal from each category

    3. Analyze the resources for and resistances to achieving goal

    4. Discuss goal and implementation plan with support person

    5. Activate plan

    6. Evaluate plan weekly, monthly, yearly with support person

    7. Notice and appreciate the changes


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