[The following is a presentation I gave at a conference sponsored by the Center for Faith and Health at Samford University, November 2017.]
Introduction
Burnout and compassion fatigue are known occupational hazards for caregivers. The causes of these conditions are more complex that mere physical exhaustion. In this presentation, I suggest three ideas that can provide assistance to caregivers for the prevention of burnout and compassion fatigue: a sense of vocation, sufficient margin, and positive social networks.
I spent much of my career in campus ministry, working as a college chaplain on six different university campuses. My first such job was in 1990. I would wager that my professional experience is similar to many of yours in several key ways. Chaplains are typically generalists, not specialists, because we often work with a small staff (or no staff) and limited resources. Chaplains wear many hats. In 25 years, I have worn many hats: pastor, preacher, teacher, professor, lecturer, counselor, advisor, mentor, supervisor, manager, administrator, coordinator, event planner, travel agent, cook, caterer, editor, chauffeur, sound technician, stage lighting engineer, web designer, graphic artist, photographer, videographer, historian, accountant, DJ, mechanic, pop culture expert, etc. The skills required to continue this work year after year include a willingness to learn quickly, to change readily, and to grow continually. But maybe more importantly, the job requires determination, endurance, and grit. We spend long hours, nights, and weekends, dealing with student crises, emotional meltdowns, financial burdens, family dysfunctions, addictions, mental illnesses, academic struggles, and relationship drama. And honestly, we don’t get paid that well, yet we still love our work and the people at the center of it. Caregiving in my field requires 10% intelligence and 90% endurance; a little bit of inspiration, a whole lot of perspiration.
I suspect that this sounds familiar to most caregivers, so I also suspect that it comes as no surprise that among the most common occupational hazards of caregiving are burnout and compassion fatigue. A survey published in 2014 on the prevalence of depression found that over 14% of professionals working in the social services and health care sector suffered from episodes of major depression, the third worst rate of any of the 55 occupations studied. [1] Frequent interaction with distressed clients and patients, high levels of stress, and low levels of physical activity were found to correlate with depression rates among professionals. Rates of burnout and compassion fatigue in the healthcare sector could be as high as 60%, further pointing to the costs associated with caregiving.[2] Additionally, a 2009 study found that nearly 66 million Americans were providing unpaid care for at least one family member.[3] The emotional, psychological, and spiritual costs of caregiving represent significant personal and professional challenges to many. In my experience, we pay close attention to the details of caregiving, but far less attention to caring for the caregivers.
Burnout and Compassion Fatigue
The concept of burnout was first identified in the mid 1970s by the German-born Jewish-American psychologist Herbert J. Freudenberger. He identified burnout as consisting of (1) feelings of overwhelming exhaustion, including physical and/or emotional depletion, (2) interpersonal detachment or cynicism characterized by intense negative feelings toward aspects of one’s job, and (3) a sense of ineffectiveness or lack of achievement and productivity at work.[4] Compassion fatigue, also know at Secondary Traumatic Stress (STS), is a condition similar to but distinct from burnout. STS is described as a state of extreme stress, tension, or preoccupation with the suffering of others to a degree that is traumatizing for the caregiver. The key factor distinguishing STS from burnout is the presence of trauma in those for whom one is providing care, although burnout is frequently a symptom of STS, along with frustration, anger, depression, sleep difficulties, fear, intrusive thoughts, debilitating anxiety, and decreased feelings of compassion and empathy over time. Caregivers at high risk of STS include those who are regularly involved in emotionally charged or traumatic situations, such as first responders, trauma unit workers, oncology caregivers, hospice nurses, public defense attorneys, and military chaplains.[5]
Some of the research on the prevalence of burnout and STS may shed some light on its causes. Studies indicate, for example, that in many caregiving professions, young caregivers are at significantly greater risk of burnout than older ones. This seems counter-intuitive, does it not? Female and unmarried caregivers are also at greater risk than male or married ones, suggesting that a sense of control over one’s life and work plays a role in preventing burnout and STS.[6] Additionally, caregivers who report being “quite a bit” to “extremely” religious had lower levels of diminished empathy and emotional exhaustion than those who were less religious.[7]
The key point here is that burnout and STS involve more than mere physical exhaustion. These conditions result from an absence of meaning, the lack of belief that one’s work is important or significant, and a sense of hopelessness in the face of life’s demands.[8] These conditions are emotional, psychological, and spiritual as much as physiological, and so a holistic approach to their prevention and treatment seems clinically advisable and arguably unavoidable.
I think you agree that solutions to the problems of burnout and STS involve more than mere rest from caregiving, otherwise I would simply recommend that you go somewhere and take a nap! But that’s not my recommendation, so it seems to me that my task as a presenter is to help provide you with some emotional, psychological, and even theological resources to help you who are caregivers for people in crisis stay in this profession and remain effective over the long-term.
Vocation
The first helpful resource that I would like to discuss is vocation. An oft-quoted passage from the American Presbyterian writer and theologian Friedrick Beuchner serves as an effective introduction to the concept of vocation:
“Vocation comes from the Latin vocare (to call) and means the work a person is called to by God. There are all different kinds of voices calling you to all different kinds of work, and the problem is to find out which is the voice of God rather than of society, say, or the superego, or self-interest. The kind of work God usually calls you to is the kind of work (a) that you need to do and (b) that the world needs to have done. If you find your work rewarding, you have presumably met requirement (a), but if your work does not benefit others, the chances are you have missed requirement (b). On the other hand, if your work does benefit others, you have probably met requirement (b), but if most of the time you are unhappy with it, the chances are you have not only bypassed (a) but probably aren’t helping your customers much either. The place God calls you to is the place where your deep gladness and the world’s deep hunger meet.”[9]
The concept of vocation is rooted in the claim that you are the happiest and most energized when you are doing the work that bring you joy and meets a genuine need. [e.g. cigarette sales and cardiology] No doubt, the world needs caregivers, but if Beuchner is correct, you are not going to last very long at it unless you find some level of gladness in it. Vocation frees you to think about your work as a calling rather than merely a job. Your vocation and your job need not be the same thing identically. St. Paul, the missionary who authored a considerable portion of the New Testament, was a tentmaker by trade, a job that allowed him to pursue his missionary vocation. A job is meaningful only to the degree that it allows you to pursue your calling, and can be stifling if it does not. A series of jobs strung together over a lifetime we call a career, and careers typically follow the paths of ambition and upward mobility.[10] But they need not do so.
Henri Nouwen and Albert Schweitzer provide two examples of people who forsook the enticements of career for the rewards of vocation. Nouwen was a Dutch-born Catholic Priest who left a successful academic career that included two decades of teaching at prestigious universities such as Notre Dame, Yale, and Harvard. He left the academy at the age of 53 to live and work with physically and mentally handicapped people in a small community in Richmond Hill, Ontario, Canada. Schweitzer, a German organist, theologian, and medical doctor left behind a brilliant music career in Paris at the age of 30 and became a medical missionary in what is now Gabon, Africa. During his first 9 months on the continent, he treated thousands of patients and performed hundreds of surgical procedures with the help of his wife, a trained anesthetist, in a hospital that he built on his own out of corrugated iron.
These men left behind prestigious careers to become caregivers. They traded ambition for vocation. Their work was not easy and they were not perfect – Nouwen struggled with depression and Schweitzer with exhaustion – but their stories illustrate the powerful pull of a call. Are you called? Do you think that you have merely inherited your work by accidental necessity? Or do you believe that there is a divine providence that organizes our universe by matching others’ necessity with your ability? Vocation reminds you that you are here for a reason, created for a purpose, and equipped for that purpose.
Margin
I first encountered the concept of margin in a 1995 book by that title, written by the physician Richard A. Swenson. Swenson describes margin as “the space that exists between ourselves and our limits.”[11] Swenson observes that the stresses of modern life devour margin. Technological progress helps us do things faster, but simultaneously gives us more to do and increases the pace of life. Every space is filled with clutter. Every moment is filled with noise. Every dollar is spent, and probably a few more. We have not a minute to spare. Our relationships with family and friends weaken, we limp through life physically exhausted, sleep deprived, and emotionally drained. We lack the time to practice genuine reflection and build true virtue. So although scientific progress benefits us in many ways, it may also make us less likely to experience lives of meaning and purpose. As a medical doctor who restructured his own life and practice in order to create margin, Swenson’s prescription for what he calls “overload syndrome” is fairly predictable: work less, earn less, spend less, accumulate less, exercise more, sleep more, rest more, etc. (That actually sounds like vacation to me.) In other words, we regain margin not by making a few small behavioral changes, but by transforming the way we live entirely.
Good caregiving requires margin, doesn’t it? We need margin for emergencies, for unexpected or unwelcomed interruptions, for serendipitous opportunities to show kindness, and for timely conversations. Genuine compassion is difficult to schedule because caregiving is the ministry of interruptions. Add to that the fact that many of us in this room chose our professions for reasons other than earning potential, so we are particularly subject to the economic pressure to spend more than we earn, and the resulting pressure to work harder and longer in order to earn more. So in a profession in which margin is sorely needed, the evidence suggests that it is sorely lacking. We need change, individually, institutionally, and culturally.
What Swenson is suggesting, and what I am suggesting, is not unlike what Christian theologians have commended for centuries. In the Christian classic Celebration of Discipline, Richard Foster notes that “superficiality is the curse of our age.” By contrast, “the classical disciplines of the spiritual life call us to move beyond surface living into the depths so that we have the capacity to “be the answer to a hollow world.”[12] Foster’s prescription for the shallow life consists of three sets of practices: the inward disciplines (meditation, prayer, fasting, and study), the outward disciplines (simplicity, solitude, submission, service), and the corporate disciplines (confession, worship, guidance, celebration). But who has the time, or the discipline, for all of these disciplines? Just glancing at this list of disciplines makes me tired. And here is the irony: how many of us seek to reclaim some margin by avoiding the practice of margin-giving disciplines? We have become very much like the proverbial woodchopper who has little time to sharpen his axe. We know we could work more efficiently with a short break, but we feel as if we will fall hopelessly behind if we take one. And so we continue to chop, with decreasing effectiveness, until exhaustion overtakes us, and the blade becomes almost irreparably dull. All the while the disciplines of religious faith call to us, or more accurately, God calls to us. “Come to me, all who are weary and heavy burdened, and I will give you rest.” If we cannot claim the time to respond to that call, to care for our own souls, then we will not likely care well for others for very long.
Positive Social Networks
Let us turn our attention now to the network of people that you need to survive as a caregiver long-term. In a 2012 book entitled When Our Leaders Do Bad Things, social worker and clinical psychologist Mangal Dipty argues that people fall into three categories in terms of their impact on us. There are positive, negative, and neutral people. Positive people are those who, on the whole, contribute more to us relationally than they cost us. Every relationship costs you something, but positive people make a net contribution to your coping resources and your margin. Negative people, on the other hand, cost more than they contribute. Neutral people cost about what they contribute, for zero net gain or loss relationally. Admittedly, you cannot quantify relationships with exact precision, and relationships change such that people who were once positive can become negative and vice versa. That said, I still find this idea persuasive, that you need a critical mass of positive and neutral people in your life so that you can help negative people. We cannot and arguably should not spend all of our time with positive people. Most healthy adults consider helping others an essential part of life, so we should spend some time with negative people. The key strategy is to balance the negative people with positive to maintain balance.
The problem for us caregivers is that we are particularly at risk of spending much of our time with relationally negative people. Notice that I am not necessarily talking about the attitude of the people who need care. Some may have quite positive attitudes, but relationally they likely require more of us than they can give to us. And if we surround ourselves with mostly negative people most of the time, then we will eventually be of little help to anyone. Excessive relational negativity can lead to what University of Washington psychologist John Gottman refers to as “negative sentiment override,” a condition in which a relationship becomes conflicted to the degree that even positive messages are interpreted negatively.[13] When you reach this state, your environment has become toxic and your physiological response to that environment changes biochemically. Your blood pressure and heart rate increase, your brain’s ability to process information is reduced, hormones trigger your body’s most basic fight or flight instinct, and compassionate care becomes almost impossible. Emotionally, physically, and spiritually you cannot sustain critical levels of relational negativity. They have the power to taint your vocation and ruin your career.
The bottom line is that we need relationships that nourish us. All caregivers need caregivers. We are incapable of surviving long-term in these demanding fields without resources that we simply cannot get on our own. We are fallible and dependent creatures. Until we admit this, we are in trouble. When we admit this, then we are free to seek in humility what can save and sustain. The Christian tradition calls this grace. And I know that other religious traditions provide comparable resources. The forgiveness and compassion that was hard earned by Christ is offered to us freely, so that we in turn can offer it to others. Grace is the relational resource that feeds our vocation, giving us the margin to run with endurance the race set before us.
Conclusion
Three years ago I took up trail running. I have been a runner and cyclist for many years, but with age I have slowed. So, when the Red Mountain trail system opened just seven minutes from my home here in Birmingham, I found a new hobby. Trail running requires of me physically what my vocation requires of me spiritually. Many trail races are longer than marathons (usually 50k or longer) and as a result, trail running is less about raw speed and more about steady progress. Trail runners must carefully balance nutritional intake with the strategic expenditure of energy for long hours over difficult terrain. Even the best trail runners walk or fast hike up steep inclines in the mountains. At mile 30, every runner wants to quit and every runner needs a good reason to keep going, a calling to continue. Slow and steady wins the race, or at least finishes it. Strangely enough, trail running energizes me. A weekend without a few hours on the trail seems empty, almost wasted. The physical depletion that accompanies a dozen miles in the July heat also includes for me a reconnection with God’s creation, a time for reflection, and a rejuvenation of the soul. Everyone needs his or her version of a good trail run.
For the surgeon and author Richard Seltzer, it is the library. And now I’d like to quote a brief excerpt from an essay that appears in Seltzer’s book entitled Letters to a Young Doctor that will conclude and I think captures the heart of my talk today. The essay that I abridge here is called “Toenails.”
It is the custom of many doctors to withdraw from the practice of medicine every Wednesday afternoon. Some doctors spend Wednesday afternoon on the golf course. Others go fishing. I go to the library where I join that subculture of elderly men and women who gather in the Main Reading Room to read or sleep beneath the world’s newspapers, and thump through magazines and periodicals, educating themselves or just keeping up.
How brave, how reliable they are! So unbroken is their attendance that, were one of them to be missing, it would arouse the direst suspicions of others. And of me. For I have, furtively at first, then with increasing recklessness, begun to love them. Either out of loyalty to certain beloved articles of clothing, or from scantiness of wardrobe, they wear the same things every day. For the first year, this is how I identified them. Old Stovepipe, Mrs. Fringes, Neckerchief, Galoshes – that sort of thing.
Neckerchief is my favorite. He is a man well into his eighties with the kind of pink face that even in July looks as though it has just been brought in out of the cold. A single drop of watery discharge, like a crystal bead, hands at the tip of his nose. His gait is stiff-legged, with tin, quick, shuffling steps accompanied by rather wild arm swinging in what seems an effort to gain momentum or maintain balance. One day, as I held the door to the Men’s Room for him, he pointed to his knees and announced, by way of explanation for his slowness: “The Hinges is rusty.” From that day, Neckerchief and I were friends. I learned that he lives alone in a rooming house eight blocks away, that he lives on his Social Security check, that his wife died a long time ago, and the he has no children.
One day I watched as Neckerchief , having raided the magazine rack, journeyed back to his seat. As he passed, I saw that his usually placid expression was replaced by the look of someone in pain. Each step was a fresh onslaught of it. His lower lip was caught between his teeth. His forehead had been cut and stitched into lines of endurance. He was hissing. I waited for him to take his seat, which he did with a gasp of relief, then went up to him. “The Hinges,” I whispered. “Nope. The toes.” “What’s wrong with your toes?” “The toenails is too long. I can’t get at ‘em. I’m walkin’ on ‘em.”.
I left the library and went to my office. “I need the toenail cutters. I’ll bring them back tomorrow,” I said to my nurse. Neckerchief was right where I had left him. “Come down to the Men’s Room,” I said. “I want to cut your toenails.” I showed him my toenail clippers, the heavy-duty kind that you grip with the palm, and with jaws that could bite through bone. One of the handles is a rasp. I gave him a ten-minute head start, then followed him downstairs to the Men’s Room. “Sit here.” I pointed to one of the booths. He sat on the toilet. I knelt and began to take off his shoes. “Don’t untie ‘em,” he said. “I just slide ‘em on and off.” The two pairs of socks were another story, having to be peeled off. The underpair snagged on the toenails. Neckerchief winced. “How do you get these things on?” I asked. “A mess, ain’t they? I hope I don’t stink too bad for you.”
The nail of each big toe was the horn of a goat. Thick as a thumb and curved, it projected down over the tip of the toe to the underside. With each step, the nail would scrape painfully against the ground and be pressed into his flesh. There was dried blood on each big toe. It took and hour to do each big toe. The nails were too thick even for my nail cutters. They had to be chewed away little by little, then flattened out with the rasp. Now and then a fragment of nail would fly up, striking me in the face. The other eight toes were easy. Now and then, the door opened. Someone came and went to the row of urinals. Twice, someone occupied the booth next to ours. They’ll just have to wonder, I thought.
I wet some toilet papers with warm water and soap, washed each toe, dried him off, and put his shoes and socks back on. He stood up and took a few steps, like someone who is testing the fit of a new pair of shoes. “How is it?” “It don’t hurt,” he said, and gave me a smile that I shall keep in my safety-deposit box at the bank until the day I die. “That’s a Cadillac of a toe job,” said Neckerchief. “How much do I owe ya?” “On the house,” I said.
The next week I did Stovepipe. He was an easy case. Then, Mrs. Fringes, who was a special problem. I had to do her in the Ladies’ Room, which tied up the place for half an hour. A lot of people opened the door, took one look, and left in a hurry. I never go to the library on Wednesday afternoon without my nail clippers in my briefcase. You just never know.
[1] Lawson Wulsin, Toni Alterman, et al, “Prevalance Rates for Depression by Industry,” Journal of Social Psychiatry and Psychiatric Epidemiology (2014): 49:1805-1821.
[2] Bernie Monegain, “Burnout Rampant in Healthcare,” Healthcare IT News (April 30, 2013) online at http://www.healthcareitnews.com/news/burnout-rampant-healthcare. Accessed July 31, 2015.
[3] Lauren G. Collins and Kristine Swartz, “Caregiver Care,” American Family Physician (June 1, 2011): 83 (11): 1309-1317.
[4] H. J. Freudenberger, “Staff Burnout,” Journal of Social Issues (1974) 30:159-165.
[5] L. R. Simpson and D. S. Starkey (2006), “Secondary traumatic stress, compassion fatigue, and counselor spirituality: Implications for counselors working with trauma.” Retrieved July 2015, from http://www.counseling.org/resources/library/Selected%20Topics/Crisis/Simpson.htm.
[6] L.L. Emanuel, F.D. Ferris, C.F. von Gunten, and J. Von Roenn eds. Education in Palliative and End-of-life Care for Oncology (Module 15: Cancer Doctors and Burnout). Chicago, IL: The EPEC Project, 2005. Retrieved July 2015, from http://www.medscape.org/viewarticle/754366.
[7] K.M. Kash, J.C. Holland, W. Breitbart, et al. “Stress and Burnout in Oncology,” Oncology (2000) 14:1621-1633.
[8] A. M. Pines, “Burnout: An Existential Perspective” in W. Schaufeli, C. Maslach, and T. Marek, eds. Professional Burnout: Recent Developments in Theory and Research. Washington, DC: Taylor and Francis, 1993.
[9] Friedrick Beuchner, Wishful Thinking: A Theological ABC, Harper & Row, 1973, page 95.
[10] Brian J. Mahan, Forgetting Ourselves on Purpose: Vocation and the Ethics of Ambition, San Francisco, CA: Jossey-Bass, 2002, pages 9-14.
[11] Richard A. Swenson, Margin: Restoring Emotional, Physical, Financial and Time Reserves to Overloaded Lives, Navpress, 1995. A newer edition of this book was published in 2004.
[12] Richard J. Foster, Celebration of Discipline: The Path to Spiritual Growth, San Francisco: Harper Collins, 1978.
[13] John Gottman, The Seven Principles for Making Marriage Work, New York: Three Rivers Press, 1999, page 21.
Matthew Kerlin 