Burnout has been described as a complex syndrome comprised of a lack of feelings of worth and accomplishment, interpersonal decline, intrapersonal dissociation, and emotional exhaustion. Some have also referred to this complex of mind/body symptoms as compassion fatigue. This phenomenon has received a lot of attention in recent years as an aging population requires an increasing amount of care and this need for care requires an incredible capacity of those providing it to put their own lives on hold in the service of another. This includes both healthcare workers and loved ones.
Numerous factors have been cited as contributing to this decline in caretaker life satisfaction including lack of autonomy, lack of support, increased burden of the care of daily activities, and increased interpersonal strain when the caretaker role dynamic is suddenly shifted as in the case of children caretaking for elderly parents. As the caretaker becomes overburdened they may feel that others begin to react with disgust, asking what happened to empathy and compassion. This creates a vicious cycle of blame, guilt, and shame that will cause further internal stress and breakdown of the connections between people.
Research shows that this feeling of burnout or compassion fatigue is even more common in women. This is presumably because women have a learned tendency towards more selfless subservience to the needs of others and are more programmed to feel that a lack of ability to suppress their own personal needs represents a failure of personal character.
In a small series of articles, I want to describe for you what I believe is contributing most to burnout and what can be done about it.
First of all, I will start with an overview of some of the factors contributing to emotional exhaustion or empathic distress (compassion fatigue is a misnomer for this phenomenon), interpersonal objectification and depersonalization, intrapersonal dissociation, and diminished feelings of accomplishment. In the following articles I will address each in more complete detail and recommend solutions on a personal level to alleviate suffering in each dimension.
The first characteristic of burnout is lack of feelings of accomplishment or feelings of failure. Anything that decreases autonomy or perceived autonomy will cause a diminished sense of accomplishment and joy in the endeavor. Many people who are caretakers, or who work in service professions may not have the boundaries they need to accomplish establishing autonomy in any relationship. They may feel compelled to be good children, workers, etc.. and in an effort to feel worthy and wanted they have learned to subjugate their needs to the needs of others. The feeling of lack of control in of itself creates a significant degree of distress and learned helplessness and hopelessness. In order for anyone to be able to find joy and meaning in their work and other activities, they need to be able to find a state known as flow while performing that work. The state of flow has been described in detail in the work of Mihaly Csikszentmihalyi, and he describes work as being flow inducing when the level of challenge is matched to the level of skill, the work has a defined outcome, and when the worker has adequate autonomy. Based on this definition it is easy to see why many can no longer find flow within their work or their lives. It is important for anyone suffering from burnout to set up clear personal boundaries and to define what those mean to them. This will create the foundation for healthy relationships, increase autonomy, and decrease stress that leads to the feelings of burnout.
The second characteristic of burnout is emotional exhaustion or empathic distress. The first step in empathy is always an awareness of suffering. Because of mirror neurons within our brains all of us are born with the innate ability to empathize or to share in the suffering of another. This is why you cringe when you see the man break his leg when he blocks a kick from his opponent. You can literally feel his pain within your own mind because of your mirror neurons. Many studies have shown that women, especially adult women, are more empathetic than adult men. This is likely more due to childhood programming than an innate physical quality of women, but that is a subject that will be covered in more detail in a future article. For the purpose of this overview it is important to know that the automatic empathic response in the brain can have two outcomes that are learned over time. One is to over identify with the suffering of another person which leads to emotional overload, distress, and eventually exhaustion. The other is to systematically, over time, reduce the empathic response to something that causes less suffering. That is to take a feeling process, affective empathy, and turn it into a mental process, cognitive empathy. This cognitive empathy has less of a feeling of warmth attached to it and can be a contributing factor to the next characteristic of physician burnout, interpersonal objectification and depersonalization. When a person becomes trapped in the experiencing of empathy and does not move forward to the action of compassion and release of the trapped emotion, then fatigue will ensue. This is why “compassion fatigue” is actually a misnomer for empathic distress. Compassion is the cure to this particular facet of this ailment.
When a person has a hypoempathic response due to repeated trauma and suffering, that person begins to separate themselves from the person or persons causing the suffering by using decision making based on assumptions and implicit bias. This implicit bias may take the form of bias against certain groups or against people in general. While we know bias and assumption has negative correlations on outcomes and well-being, for the caretaker it serves as a protective mechanism against empathic distress and emotional exhaustion. Instead of seeing other people as someone “just like me” they start to use bias as a way to distance themselves from the response of their own mirror neurons to the suffering of the person in front of them. The work of Susan Fiske describes the dimensions of warmth, or sameness, and competence as necessary for the engagement of empathy and compassion. Over time a chronic caretaker may lose warmth and may also feel that other people are incapable of caring for themselves. When the other person is deemed to lack the competence and agency to care for themselves, this creates a situation where the caretaker is burdened with being the sole provider of whatever caretaking the other person needs. Societal standards have adopted this view of paternalistic caretaking as commonplace, with the majority of the burden falling on women.
The burned-out individual may also begin to suffer from dissociation. Dissociation is a defense mechanism that prevents one from over experiencing stress including conflict and trauma. It is important to note that trauma can be cumulative and is described as being a psychological, emotional and physical response to any distressing or disturbing experience. Dissociation in the sense of depersonalization is common in all people and it results in a feeling of detachment from the body or inability to experience the body’s physical sensations. Depersonalization is at the root of many autoimmune disorders and may also play a role in the development of cancer and numerous other diseases. Depersonalization, dissociation, and stress also causes a plethora of diseases related to dysregulation of the hypothalamic-pituitary-adrenal axis and increased cortisol production.
All of these causes and characteristics can seem overwhelming and the pursuit of a remedy may seem at best daunting and at worst futile; however, I believe there is hope for anyone suffering from burnout. I believe we are living in a time where emotional exhaustion, lack of job or life satisfaction, dehumanization, and dissociation are the new normal and its leading us down the path of addiction, suicide, and homicide at an alarming rate. The cure to caretaker burnout is the cure to human burnout, and it’s going to take all of us to create the conditions of healing necessary for recovery. To be continued…