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Compassion Fatigue: Psychotherapists’ Chronic
Lack of Self Care
1
䊲
Charles R. Figley
School of Social Work, Traumatology Institute
Florida State University, Tallahassee
Psychotherapists who work with the chronic illness tend to disregard their
own self-care needs when focusing on the needs of clients. The article
discusses the concept of compassion fatigue, a form of caregiver burnout
among psychotherapists and contrasts it with simple burnout and coun-
tertransference. It includes a multi-factor model of compassion fatigue
that emphasizes the costs of caring, empathy, and emotional investment
in helping the suffering. The model suggests that psychotherapists that
limiting compassion stress, dealing with traumatic memories, and more
effectively managing case loads are effective ways of avoiding compas-
sion fatigue. The model also suggests that, to limit compassion stress,
psychotherapists with chronic illness need to development methods for
both enhancing satisfaction and learning to separate from the work emo-
tionally and physically in order to feel renewed. A case study illustrates
how to help someone with compassion fatigue. © 2002 Wiley Periodi-
cals, Inc. J Clin Psychol/ In Session 58: 1433–1441, 2002.
Keywords: compassion fatigue; burnout; self-care for psychotherapists;
countertransference
Compassion Fatigue: Psychotherapists’ Chronic Lack of Self Care
There is a cost to caring for those with chronic illness just as there is a realization that
these clients will never fully recover. As psychotherapists, we learn to be on the one hand
objective and analytical in our professional role as helper. We must put our personal
feelings aside and objectively evaluate our clients and administer the best treatments
Correspondence concerning this article should be addressed to: Charles R. Figley, Ph.D., Professor, School of
Social Work and Director of the Traumatology Institute at Florida State University, 1303 Broome St., Tallahas-
see, FL 32301; telephone: (850) 656–7158; e-mail: cfigley@mailer.fsu.edu.
1This essay is dedicated to all those psychotherapists who have worked with clients over many sessions who
were diagnosed with some kind of chronic problem and it left a lasting impression on the psychologist. Also,
this is dedicated to those psychotherapists who either have a chronic illness or live with or love someone with
one.
JCLP/In Session: Psychotherapy in Practice, Vol. 58(11), 1433–1441 (2002) © 2002 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10090
according to best practice guidelines. But on the other hand we cannot avoid our com-
passion and empathy. They provide the tools required in the art of human service. To see
the world as our clients see it enable us to calibrate our services to fit them and to adjust
our services to fit how they are responding.
Case Illustration
“My professors think I need therapy . . . maybe they are right.” This statement greeted me
as I checked my voice mail Monday morning in April. It turned out to be a counseling
psychology Ph.D. student from a smaller university in the region. According to two of her
clinical supervisors she was not responding well to an assigned client. Although Jane (not
her real name) had five years of experience as a licensed mental health counselor, she was
missing important aspects of the client’s story. When Jane finally faced the fact that she
was failing in a profession she loved, she began to recognize that her clinical errors were
associated more with how the client’s story was upsetting her than her abilities as a
psychotherapist.
Jane’s client was a young, female college student who was away from home for the
first time and sought Jane’s help with adjusting to the changes. Only after more than a
half dozen sessions did Jane’s supervisors notice and mention to her that her client felt
guilty about leaving her mother; that the client had been over-functioning while the mother
had developed a considerable dependency that needed addressing. Jane most often shifted
the focus of therapy to other issues. Jane wanted to talk about and face these clinical
errors, her resentment toward the faculty members who challenge her, and, reluctantly,
her mother’s chronic illness. We quickly moved to Jane’s feelings of guilt about her own
mother’s condition and her inability to or ambivalence toward addressing her dysfunc-
tional relationship with her mother.
We will return to Jane shortly after introducing some terms and a conceptual model.
These are what I drew upon in treating Jane.
Compassion Fatigue
The very act of being compassionate and empathic extracts a cost under most circum-
stances. In our effort to view the world from the perspective of the suffering we suffer.
The meaning of compassion is to bear suffering. Compassion fatigue, like any other kind
of fatigue, reduces our capacity or our interest in bearing the suffering of others.
I first studied the consequences of helping the traumatized in 1971 (Figley, 2002b).
It was the first interview I conducted with a Vietnam War veteran named “Doc.” He
served as a corpsman, a nurse attached to a Marine Corps unit between 1969–1970. His
memories of the war were dominated by guilt and regrets associated with not saving or
not helping or not doing enough for his patients. These burdensome memories were
associated with lots of psychological problems that would later be diagnosed as war-
related Post-Traumatic Stress Disorder (PTSD).
We were both in Washington, D.C., on a mission. We were both there as members of
the Vietnam Veterans Against the War in an effort to convince Congress to stop the war.
I found that I was far more effective as a researcher than as a war protestor.Although my
research expanded from combat veterans (Figley, 1978) to others exposed to distress in
the line of duty to civilians and victims who experienced a wide variety of calamities, I
never forgot Doc.
1434 JCLP/In Session, November 2002
In 1980, when the Diagnostic and Statistical Manual of Mental Disorders was pub-
lished, it contained for the first time the diagnosis of PTSD. Included in the description of
the diagnosis was the provision that one could be traumatized both by being in harms way
and by bearing the distress of others who are. This does not only include the family and
close friends of the suffering but also professionals involved in helping the suffering.
This includes those suffering from chronic illness.
In the first example, Jane is experiencing secondary traumatic stress reaction called
compassion fatigue associated with both her mother and her client. Jane must effectively
face and deal with it before she can effectively help her client.
Secondary Traumatic Stress is “the natural consequent behaviors and emotions result-
ing from knowing about a traumatizing event experienced by a significant other—the
stress resulting from helping or wanting to help a traumatized or suffering person (Figley,
1993)” (Figley, 1995b, p. 7). STSD is a syndrome with symptoms nearly identical to
PTSD, except that exposure to knowledge about the traumatizing event experienced by
the significant other is associated with the set of STSD symptoms, and PTSD symptoms
are directly connected to the sufferer, the person in harms way. Specifically, compassion
fatigue is defined as a state of tension and preoccupation with the traumatized patients by
re-experiencing the traumatic events, avoidance/numbing of reminders persistent arousal
(e.g., anxiety) associated with the patient. It is a function of bearing witness to the suf-
fering of others.
Prevalence of STS and STSD
A recent study (Meldrum, King, and Spooner, 2002) in Australia found 27 percent of
professionals who work with the traumatized experienced extreme distress from this
work. In all, 54.8 percent were distressed at the time of the study and 35.1 percent were
very or extremely emotionally drained. In another study 17.7 percent had STSD and 18
percent were just below cut off for the diagnosis. In a study of rural mental health pro-
fessionals, the prevalence rate was 24.1 percent for STSD and 21.4 percent sub-clinical.
In a study of Oklahoma City trauma workers (Wee & Myers, 2002), 64.7 percent
exhibited some degree of severity for posttraumatic stress disorder, as measured by the
Frederick Reaction Index (Fredrick, 1987). Among the findings were that 44.1 percent of
counselors exhibited “caseness” (scores at or above the 90th percentile for non-patient
norms on the SCL-90-R Global Severity Index score or two dimensional T scores greater
than or equal to 63). Most (73.5 percent) of counselors were rated as being at moderate
risk (23.5 percent), high risk (29.4 percent), or extremely high risk (20.6 percent) for
compassion fatigue, as measured by the Compassion Fatigue Self Test for Psychothera-
pists (Figley, 1995). Also most (76.5 percent) of counselors were rated as being at mod-
erate risk (35.3 percent), high risk (26.5 percent), or extremely high risk (14.7 percent)
for burnout, using the same Compassion Fatigue Self Test. Similarly, in a study (Myers &
Zunin, 1994) of Northridge Earthquake mental health workers, 60.5 percent met criteria
for PTSD.
Forms of Secondary Stress?
Some would argue that both Doc and Jane suffer from countertransference. Countertrans-
ference is from psychodynamic therapy and an emotional reaction to a client by the
therapist—irrespective of empathy, the trauma, or suffering. It is defined as the process
of seeing oneself in the client, of over identifying with the client, or of meeting needs
through the client (Corey, 1991). In contrast to compassion fatigue, countertransference
Compassion Fatigue: Psychotherapists’ Chronic Lack of Self Care 1435
is chronic attachment associated with family of origin relationships and has much less to
do with empathy toward the client that causes trauma. In the case of Jane it had more to
do with Jane’s exposure to a traumatic event involving her mother than to attachment
issues.
In contrast to compassion fatigue, simple burnout is “. . . a state of physical, emo-
tional, and mental exhaustion caused by long term involvement in emotionally demand-
ing situations” (Pines & Aronson, 1988, p. 9) rather than the specific exposure to the
trauma and suffering of a specific client. Neither Jane nor Doc reported characteristic
symptoms of burnout. These symptoms go far beyond the symptoms of traumatic stress
reactions.
2
However, both Jane and Doc had the characteristic pattern of compassion fatigue, in
contrast to burnout and countertransference (Figley, 2002a): Compassion fatigue and
countertransference have a faster onset of symptoms. Compassion fatigue and standard
burnout have a faster recovery from symptoms. Compassion fatigue, in contrast to both
burnout and countertransference, is associated with a sense of helplessness and confu-
sion; there is a greater sense of isolation from supporters. The symptoms disconnected
from real causes and are triggered by other experiences. Burnout may require changing
jobs or careers. However, compassion fatigue is highly treatable once workers recognize
it and act accordingly.
Etiological Model
Since the publication of the first book on compassion fatigue (Figley, 1995) there has
been an emergence of newfound appreciation for the costs of caring, and the relationship
between the role of empathy and previous traumatic experiences. A model first intro-
duced in 1995 and revised subsequently offers a way for those most susceptible to com-
passion fatigue to prevent and mitigate it quickly.
This model is based on the assumption that empathy and emotional energy are the
driving force in effective working with the suffering in general, establishing and main-
taining an effectively therapeutic alliance, and delivering effective services including an
empathic response (Figley, 1995; Figley, 2002a). However, being compassionate and
empathic involves costs in addition to the energy required to provide these services.
Following are the eleven variables that, together, form a causal model that predicts com-
passion fatigue. Herein lies both an appreciation for what causes compassion fatigue and
what is required to prevent and treat it.
Empathic Ability is the aptitude of the psychotherapist for noticing the pain of others.
The model suggests that without empathy there will be little if any compassion stress and
no compassion fatigue. However, without empathy there will be little if any empathic
response to the suffering clients. Thus, the ability to empathize is a keystone both to
helping others and being vulnerable to the costs of caring.
Empathic Concern is the motivation to respond to people in need. The ability to be
empathic is insufficient unless there is motivation to help others who require the services
of a concerned psychotherapist. With sufficient concern, the empathic psychotherapist
2Burnout symptoms are categorized as Physical Symptoms (e.g., physical exhaustion, Sleeping difficulties, and
Somatic problems); Emotional Symptoms (e.g., irritability, anxiety, depression, guilt, and a sense of helpless-
ness); Behavioral Symptoms (e.g., Aggression, Callousness, Pessimism, Defensiveness, Cynicism, Avoidance
of clients, Substance abuse); Work-Related Symptoms (e.g., Quitting the job, Poor work performance, Absen-
teeism, Tardiness, Constantly seeking avoidance of work, and Risk-taking), and; Interpersonal Symptoms (e.g.,
Perfunctory communication, Inability to concentrate, Social withdrawal, Lack of a sense of humor, Dehuman-
ization, and Poor patient interactions)
1436 JCLP/In Session, November 2002
draws upon her or his talent, training, and knowledge to deliver the highest quality of
services possible to those who seek it.
Exposure to the Client is experiencing the emotional energy of the suffering of cli-
ents through direct exposure. One of the reasons why those in direct practice of human
services become supervisors, administrators, or teachers in mental health professions is
due directly to the costs of direct exposure to clients. Some make the shift for direct
practice because of additional pay, improved working conditions, and higher status. How-
ever, the costs of direct exposure to the suffering of others is high and it is impossible to
know how many have chosen to abandon direct practice because the price was too high
for them.
Empathic Response is the extent to which the psychotherapist makes an effort to
reduce the suffering of the sufferer through empathic understanding. This insight into
feelings, thoughts, and behaviors of the client is achieved by projecting one’s self into the
perspective of the client. In doing so, the psychotherapist might experience the hurt, fear,
anger, or other emotions experienced by the client. Therein lie both the benefits and the
costs of such a powerful therapeutic response. The benefits are immediately obvious to
every graduate student who practices her or his new skills with another. The costs are
rarely discussed and must be experienced to elicit efforts on the part of the psychother-
apist to guard against or mitigate the effects on the self.
Compassion Stress is the residue of emotional energy from the empathic response to
the client and is the on-going demand for action to relieve the suffering of a client. Like
any stress, with sufficient intensity it can have a negative impact on the human immune
system and the quality of life in general. Together with other factors it can contribute to
compassion fatigue unless the psychotherapist acts to control compassion stress. There
appear to be two major sets of coping actions that can do this.
Sense of Achievement is one factor that lowers or prevents compassion stress and is
the extent to which the psychotherapist is satisfied with his or her efforts to help the
client. A psychotherapist with a sense of achievement regarding the delivery of services
Figure 1. Compassion Stress and Fatigue Model (Figley, 1995, 1997).
Compassion Fatigue: Psychotherapists’ Chronic Lack of Self Care 1437
to the client demands a conscious, rational effort to recognize where the psychothera-
pists’ responsibilities end and the client’s responsibilities begin.
Disengagement is the other factor that lowers or prevents compassion stress. It is the
extent to which the psychotherapist can distance himself or herself from the ongoing
misery of the client between sessions in which services are being delivered. A psycho-
therapist’s ability to disengage the client also demands a conscious, rational effort to
recognize that she or he must “let go” of the thoughts, feelings, and sensations associated
with the sessions with the client in order to live their own life. Disengagement is the
recognition on the part of the psychotherapist for importance of self-care and to carry out
a deliberate program of self-care.
If compassion stress is permitted to build, despite the psychotherapist’s effort at
disengagement and a sense of work satisfaction, the psychotherapist is at a greater risk of
compassion fatigue. Three other factors play a role in increasing compassion fatigue.
Prolonged Exposure is the ongoing sense of responsibility for the care of the suffer-
ing, over a protracted period of time. The longer the period of time between breaks the
better—at least a day of appointments and as much as a week’s vacation. These breaks are
specifically viewed as such; a respite from being compassionate and empathic toward
clients; a break from being a professional service provider.
Traumatic Recollections are memories that trigger the symptoms of PTSD and asso-
ciated reactions, such as depression and anxiety. These memories may be from the psy-
chotherapist’s experiences with other, rather demanding or threatening clients or clients
who were especially sad or suffering. These memories are events that, when recalled,
cause an emotional reaction. These memories can be provoked by certain types of clients
and client experiences that have a connection to the traumatic events experienced by the
therapist.
Life Disruption is the unexpected changes in schedule, routine, and managing life
responsibilities that demand attention (e.g., illness, changes in life style, social status, or
professional or personal responsibilities). Normally such disruptions would cause a cer-
tain but tolerable level of distress. However, when combined with the other seven factors,
these disruptions can increase the chances of the therapist developing compassion fatigue.
Managing and Treating Compassion Fatigue
Just as this model of compassion fatigue can help to predict its onset, the model can also
help in preventing and mitigating this fatigue. With Doc or Jane or any psychotherapist
who works with the suffering, there are five implications derived from this model to
do so.
First, if it is clear that the therapist has compassion fatigue, providing a comprehen-
sive overview of compassion fatigue for educational purposes is vital. A copy of this
article could be the first step. The therapist can find more on the Web, at the library, and
in professional journals, such as Professional Psychology.
Second, it is important to desensitize the therapist to traumatic stressors. In doing so,
she or he has greater ability to face and work through the various issues associated with
causing and retaining the traumatic stress reactions. The methods for desensitization
psychotherapists are no different that those for other traumatized clients. There should be
a good match between the preferences of the therapist-client and the desensitization method
utilized by the treating therapist. The method should minimize the degree of discomfort
and should maximize the exposure to the stimuli which most accounts for the distressing
reactions. The result of such methods, of course, should substantially decrease or elimi-
nate the unwanted emotional reactivity linked to the traumatic stressor(s). In Jane’s case,
1438 JCLP/In Session, November 2002
it was female clients’ disclosures about their mothers, particularly a sense of responsibil-
ity, or a fear for safety. In Doc’s case it was any reminders of the war and especially war
casualties.
The third issue is associated with exposure dosage. There is considerable evidence
that the primary active ingredient in effective desensitization is exposure (Figley, 2002b).
Utilizing the right therapeutic dosage of exposure is challenging. One effective method is
to combine exposure with relaxation, thereby activating the reciprocal inhibiting reflex.
A number of treatment methods are effective primarily because of this reflex (Figley,
2002b).
A fourth issue in treating compassion fatigue is assessing and enhancing social sup-
port. Psychotherapists gradually view themselves as others view them: someone who is
an expert at helping others cope with life’s challenges. They seem to forget that they are
human beings as well. A physician sometimes gets sick and needs another physician’s
services, for example. Often the therapist has a rather limited social support system com-
posed of colleagues and only a few intimate relationships. It is vital to increase the
therapist’s support system in both numbers and variety of relationships so that she or he
is viewed apart from the therapist persona. Moreover, some relationships may be a source
of strain and stress. These toxic relationships are an additional demand and should be
addressed (Figley, 1997).
Mitigating Jane’s Compassion Fatigue
In returning to Jane’s case, we quickly moved in the initial interview to Jane’s feelings of
guilt about her mother’s condition and her inability to address her ambivalence toward
confronting her dysfunctional relationship with her mother.
After the first session, Jane completed a battery of tests including the Purdue Social
Support Scale (Burge & Figley, 1987; Figley, 1989), the Compassion Fatigue Self Test
(Figley, 1995; Stamm & Figley, 1999; Stamm, 2002), and a measure of PTSD. She also
completed a structured clinical interview to determine her current relationship with her
mother and the degree of systemic enmeshment. Her results confirmed our (Jane and the
treating team’s) assessment that she was suffering from compassion fatigue, a restricted
social support network, and from considerable traumatic stress. But rather than being the
classic struggle between mother and daughter, it became obvious that there was some
secret she had not disclosed yet. This secret was the fact that her mother was attacked by
a dog and nearly killed.
During the next session we shared the results with Jane, discussed the treatment
options, and agreed upon a treatment plan. The plan entailed increasing her self-soothing
and stress management skills (e.g., workbooks, video training), enhancing the number
and variety of social supporters (e.g., through volunteer work and involvement in extra-
curricular activities), and utilizing cognitive-behavioral therapy that minimized exposure
and clinical time that would result in desensitization (i.e., reduction or elimination of
traumatic stress). She selected the Eye Movement Desensitization and Reprocessing
(EMDR) as the method for addressing the secondary traumatic stress associated with her
own experiences that were affecting her effectiveness as a professional. EMDR proce-
dures call for the client to select a “target memory” that represents the worst and most
stressful aspect of the trauma. She selected the dog attack as the initial experience. As an
indicator of success, we would use the same case material she used in class (the young,
female college student adjusting to being away and feeling guilty about leaving her mother).
For the next five sessions, using EMDR, Jane worked through the dog attack, the
first signs of her mother’s chronic illness, Jane’s sacrifices, feelings of resentment toward
Compassion Fatigue: Psychotherapists’ Chronic Lack of Self Care 1439
her mother, and the embarrassments she felt—particularly during her teenage years—
having to take care of her mother.
By the final session Jane’s symptoms subsided (desensitization). She shifted from
self-blame and self-hatred to a more realistic view of herself and her mother. Discus-
sions about the clinical cases she found challenging were now interesting but rather
routine. Jane recognized that she still has work to do. She still is reactive around her
mother and knows that patience and practice are necessary to be fully differentiated
from her mother emotionally and, as a result, it will be easier to love and appreciate
her. Her test scores showed significant reductions in symptom prevalence and inten-
sity, confirming what we could see ourselves. At our request she checks in with us
periodically. After more than a year she is thriving in both her own practice and her
personal life.
How We Help Our Fellow Therapists?
There are things that we can do to help our colleagues who work with clients with chronic
illnesses. The first is to speak openly about our own struggles with compassion stress and
compassion fatigue. The conspiracy of silence among the profession about this compas-
sion fatigue is no different than the silence about family violence, racism, and sexual
harassment in the past. Today there are videotapes, books, and articles on the topic. Of
special note have been the series of articles published in Professional Psychology in the
last several years. Have these handy and available to our colleagues who are interested or
should be. The first step is completing the Self Test for Psychotherapists that is available
free on the Internet at www.greencross.org/selftest4psychotherapists.pdf. The test will
provide a rough estimate of the respondent’s level of satisfaction with their work as a
psychotherapist, their risk of burnout, and their risk of compassion fatigue. Hopefully, the
results will motivate the psychotherapists to take action to correct any concerns and
enhance satisfaction for their work.
Stress management and self-soothing techniques are critical for surviving modern
work—no matter the focus of the work. In Jane’s case and with other psychotherapists
experiencing compassion fatigue burnout, it is vital to be able to gain mastery of distress.
This is true during sessions when working directly with clients or outside the session in
the privacy of one’s office, automobile, or home.
The psychotherapist also needs ways to desensitize from distressing memories; mem-
ories that invoke traumatic stress symptoms and are the hallmark of compassion fatigue.
Most often, the psychotherapist needs the services of another to effectively treat this
through some type of desensitization program.
Summary
It is vital that today’s psychotherapist continue to work with empathy and compassion.
Yet, there is a cost to this work that is obvious to any one practitioner working with the
suffering. As the evidence mounts proving the negative consequences of a lack of self-
care and the presence of compassion fatigue, so will the ethical imperative for the suf-
fering practitioner to do something, or something will be done for them. We cannot afford
to not attend to the mistakes, misjudgments, and blatant clinical errors of psychothera-
pists who suffer from compassion fatigue. It is, therefore, up to all of us to elevate these
issues to a greater level of awareness in the helping professions. Otherwise we will lose
clients and compassionate psychotherapists.
1440 JCLP/In Session, November 2002
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Compassion Fatigue: Psychotherapists’ Chronic Lack of Self Care 1441
