Section One: Compassion Fatigue, Vicarious Trauma, Secondary Trauma, Burnout, Lions, Tigers, and Bears (Oh My)

Compassion is an extraordinary gift. Some people welcome it and wear it gracefully with their loved ones, neighbors, even their favorite TV characters. Some run from it as if it’s ticking loudly, remembering hurts whose scars still sting as much as the pain they replaced. And some people rip through the wrapping. It fits like a glove, and they never take it off, not even when they sleep.

You might be a counselor, might be a cop, might be a sponsor, a coach, a doctor, a nurse, a cleric, or a service member. You might be a friend whose friend is in trouble, a parent who aches when the world is cruel, a caregiver watching life and dignity wither with age or disease.

Something made you open this book.

Definitions?

For the purpose of this exploration, please don’t worry too much about what the word “compassion” means.

• If you Google it, you’ll find things like “sympathy,” “empathy,” “sorrow,” “suffering with,” “suffering together,” “empathy that inspires a desire to help,” and a number of variations on those themes.
• Some experts emphasize the difference between “sympathy” on one hand and empathy (or “suffering with”) on the other, because the latter includes a sense of identification.
• Others place compassion one step beyond empathy, in that it leads to positive action.

And if you look up “compassion fatigue”:

• You’ll see that it’s often called “secondary trauma,” which some sources equate with and some clearly distinguish from “vicarious trauma” (which is an actual disorder).
• Some describe compassion fatigue as an excess of compassion and others as depletion of compassion (or a depletion of physical, emotional, or spiritual strength).
• Apparently compassion fatigue is either synonymous with burnout or a precursor to burnout. Perhaps it’s the renegade flame that leaves us burned out when it—well— burns out.

So beware the term “compassion fatigue.” Not only is it wobbly, but it’s also a catch-all term. There are several conditions whose signs or symptoms overlap with those attributed to compassion fatigue. These are conditions that people might own and address much sooner if they didn’t pounce on “compassion fatigue” as the explanation.

What if You Have it?

If you’re “diagnosed” with compassion fatigue—or if you just want to avoid it—most of the advice you’ll get will be generic, positive, helpful: Take some time off, build a support network, join a gym, take a bubble bath. But that advice may also be a bit of a tease, especially if you’re carrying a bottomless caseload, pulling down double shifts, or topping off a full-time job with all-night caregiving.

Who has time for a bubble bath?

But what if there’s something else going on, but instead of searching your experience for a deeper understanding, you stop digging at “compassion fatigue”? With that catch-all term as your explanation, you might limit your efforts to standard stress-management techniques.

Those techniques may be positive, even important, but they won’t address many of the conditions that might be behind your current challenges.

In the “Thought/Discussion Questions” pages that follow is a quick inventory, a few questions about your life these days.

Let’s see why you opened this book.

Section Two: Thoughts on Compassion

This book is unashamedly pro-compassion. Compassion is:

• One of our most significant strengths and one of our greatest joys,
• An important tool of the survival instinct,
• An essential building block for morality, and
• An unmistakable call to action.

Without it we would be empty, selfish, rudderless, and probably bored.

Compassion and Survival

The survival instinct is not just about the survival of the individual. It can’t be. Our bodies are wired, not just to keep us alive, but also to keep the species going. Think about it: Why else would sex be such an incredible draw, with such essentially silly acts feeling so good sometimes, and some people willing to kill or die for their desires?

And why would people dedicate and even sacrifice their lives to save the lives of other people, in many cases people they’ve never met? It makes sense that things like compassion and protectiveness would be hard-wired into the species, because strict adherence to “every man for himself” would eventually whittle us down to a few strong but very exhausted men.

Even some of the developmental psychologists will tell you: our own experience of pain is often the first step toward perceiving and identifying—and identifying with—the pain of others. Many of us start noticing when we’re adding to the pain of others and finding it a little uncomfortable. That makes it possible to evaluate our actions and their consequences, experiment with moral codes, and embrace some of the codes that are offered us.

And—at some point—we start to make moral decisions influenced by the absence or presence of compassion. We decide to cause pain or not to cause pain, to let people suffer alone or to do whatever we can to help, even if it’s just to bear witness and care what happens to them— which, ironically, is often the most powerful act of healing we can offer.

Compassion and Reward

Like sexuality, hunger, creativity, and other tools of the human survival instinct, compassion hooks into our natural reward system. The many neurochemical processes in that system influence our decisions by rewarding certain choices through pleasure, joy, a sense of satisfaction or fulfillment, etc. And acts of compassion—particularly when they produce positive results—can be enormously satisfying for the people who perform them.

In spite of all the pain they see and the sacrifices they’re making:

• Many people stay in helping or healing roles all or most of their lives.
• Their capacity for compassion becomes an essential skill, often their favorite part of their identity as human beings.
• When something they do proves useful, comforting, or empowering, it brings them joy.
• With time, their compassion grows deeper, as their love of each person resonates with their love of every other person who has entered their lives.

Compassion and Joy

This is pure speculation, but consider the possibility that compassion and joy have the same root in the human mind and spirit.

• Compassion brings us, not only pain at others’ pain, but also joy at others’ joy, and at the connection that compassion forges among us.
• Both compassion and joy—and whatever their combined power might be—are meant to flow right through us, uninterrupted. Unfortunately, we have many ways of stopping them, trapping them, analyzing them, justifying, denying, minimizing, exaggerating, distracting ourselves from them, and losing ourselves in them.
• Compassion gets caught on our fears, angers, anxieties, resentments, guilt, jealousy, obsessions, compulsions, and preoccupations. After all, we’re busy people.
• We can easily short-circuit compassion through our belief that we’re supposed to be able to “fix” people or take away their pain.

But what if we learned how to “un-trap” compassion and let it—and all the joy and pain it carries—flow freely through us? Would it make us tired? Or would it renew us every second?

• We get tired,
• We get jumpy,
• We get numb,
• We get scared,
• We get angry,
• We get sad,
• We get distant,
• We get obnoxious,
• We get compulsive,
• We get guilty,
• We get hopeless, and/or
• We get spooked.

And definitely, definitely, there are things you can do to restore your strength and use what you’ve learned to help you follow whatever purpose draws you through this world.

Issues of self-knowledge and self-care are moral and ethical issues. Always. Trust is sacred, easily shattered, and sometimes lost forever.

The forces that distract the helper from vigilance can be powerful and persuasive, but we have choices. If we sort through what’s happening, name it, and speak honestly about it, those choices can become very clear.

And decisions made in clarity can carry a sort of peace, no matter what chaos surrounds us.

Section Five: Deconstructing “Compassion Fatigue”

At a training on “Compassion Fatigue,” you can watch the participants’ faces and see the wheels turning.

• Yes! They’re overworked, overwhelmed, underpaid, and exhausted.
• Yes! They’re proud of their compassion and commitment.
• Yes! It’s a significant strength.
• No! They don’t want to crash and burn out.

Where, oh where is that magic spigot they can turn up or down until their blood runs just the right amount of compassion?

Never mind! Don’t worry! You don’t need a magic spigot. It’s not about too much or too little compassion. It’s not even compassion that’s the problem. You may already know what the problem is, in which case you can stop reading and go take a bubble bath.

But if you’re curious, the next section—“What Does Make You Tired?”—takes you through a “divide-and-conquer” process, to get you started toward some relief. It won’t solve any of these problems, you understand, but it might help you adjust your compass.

The word “deconstructing” is very useful. It comes from a French concept, and it usually means a lot of complex, impressive, philosophical things. But here it just means breaking down and looking objectively at the phenomenon known as compassion fatigue, noticing the differences among the many challenges that might be at work, and reaching a more accurate understanding.

So the rest of this book will look at some of the things that might really be happening when people show signs of “compassion fatigue.”

If the problem isn’t compassion, what is it? The challenges we’ll take a closer look at in the next section are by no means the only possible answers, but they are fairly common ones.

Challenges that Might Masquerade as “Compassion Fatigue”

• A Troubled WorldWith bad news and conflict as a frequent backdrop for our efforts, it can be hard to keep a resilient spirit. But hope is not impossible, and the very compassion that leads us into helping and healing roles can have transformative effects when it plays out on a larger scale. We can have the courage to love and be forces for healing in the world.
• Focus on Problems and DeficitsA focus on problems and deficits has been a large part of many cultures for a long time. Even large systems of education, health, and human services seem to be organized around recognizing and dealing with problems. This makes it hard to have strength and energy. But if we have enough courage, we can help shape our cultures into places where strength- based approaches can flourish and we can conjure up a little more hope and joy.
• Neglected Self-CareSometimes what seems to be compassion fatigue is really regular old fatigue, the product of neglecting important aspects of our own self-care. In helping roles, it’s easy to gloss over self-care, because we’re busy responding to so many needs and pressures. But our well being, and that of the people we’d like to help, depend on our health and energy levels. We can use some elements of change theory to help us set up healthier patterns of self-care.
• Our Own Unhealed WoundsOften the experiences that teach us compassion also leave deep wounds that follow us through life and make us more vulnerable to stress and loss of resilience. When we’re exposed to others’ pain, those wounds can awaken our own pain, and we can react in ways that make us less effective as helpers and healers, and possibly dangerous to others or ourselves. Each of us is responsible for knowing our vulnerabilities and staying active in our own healing processes.
• Identification—Too Much or Too LittleThe ability to identify with others is an important skill that contributes to many areas of life and functioning, including compassion. Especially in a helping or healing role, identifying with others too much or too little can cause problems. If we identify too much, then our resilience can get lost in their pain, or we can end up focusing most of our attention on our emotional reactions to their pain, so we can get distracted and fail to meet their needs OR take care of ourselves. If we identify too little, we can feel alienated and lose our compassion, which makes us much less effective and puts the people we serve at risk.
• Distorted Roles/RelationshipsA helping or healing role can be challenging enough without the common human tendency toward flawed thinking or perception of other people and of our roles and relationships with them. This might take many forms, but these kinds of situations can put us under heavy stress—and heavy stress can make us more vulnerable to these kinds of situations.
• Frustrating Survival SkillsPeople who are facing physical and/or emotional challenges might act in several ways that we think of as troublesome psychological “symptoms,” but it might give us more useful information if we think of them as survival skills, even if they make our helping roles more difficult. It’s important to listen beyond the “symptoms” and foster healthier skills.
• Exposure to Others’ Pain and TraumaIn some cases, too much exposure to the stories and effects of others’ trauma can lead to a disorder called “vicarious trauma,” which can interfere with our sense of hope, meaning, or spiritual connection. If you’re assessed for and diagnosed with this disorder, it’s important to have peer support and professional help that’s appropriate to your stage of recovery from this condition—and the first stage is just the process of getting safe and stable.
• Commitment to Difficult SituationsSometimes helping or healing situations we’re deeply committed to—or can’t leave for important survival-related reasons—can be difficult in many ways. It’s important to seek support from people who won’t judge us or give us simplistic advice, but will help us clarify our thinking and see any options or resources we might not have thought of under our current levels of stress.
• Working in Toxic SystemsMany organizations dedicated to helping people are run by people who have some significant unaddressed issues. These issues can affect the way the organizations are run, the way staff are treated, and the amount of support staff receive. If these kinds of factors might be adding to your stress, it’s important to find out how healthy your organization is, how its functioning is affecting you, and what courses of action would be healthy for you.
• Doing it All By YourselfWe need other people, particularly when we’re working in helping or healing roles, or when we’re in caregiving roles. We need good “sounding boards,” people who can listen, reflect back, and help us find strength, confidence, and hope. We don’t need to confide in people who will criticize us, make simplistic suggestions, or play up the drama in the situation. We can find sources of mutual support online or in our communities.

Section Six: A Troubled World

There’s an old Chinese curse: “May you live in interesting times.” We live in interesting times.

If we took a map of the world and started to shade in red all the places where pain, shame, poverty, deprivation, illness, corruption, injustice, persecution, fear, grief, guilt, retribution, and rage are staples of everyday life, we’d soon be looking at a bright red map of the world.

Underneath each of those red splotches lie the seeds of more pain, in the next generation and in many generations to come—and the momentum of history seems bent on making it worse.

More and more people speak of the struggle to keep their spirits alive in the face of these overwhelming realities. The sheer volume and complexity of challenge in the world leaves each of us powerless against it. For the loving, responsible soul, even a small chunk of the world can seem unsteady and unsettling against this backdrop.

• What does all this uncertainty mean for the work we’re trying to accomplish?
• With everything falling apart, what do our small efforts mean?
• If love is the answer, why does caring sometimes make us hurt more?

Broken Bones

In New Seeds of Contemplation, the American poet, monk, and mystic Thomas Merton wrote that “As long as we are on earth, the love that unites us will bring us suffering by our very contact with one another, because this love is the resetting of a Body of broken bones.” Doesn’t it feel like that sometimes? A Body of broken bones.

The illusion that each of us is fundamentally separate—that the world is, should be, and must be “dog eat dog,” “cat eat mouse,” “nation against nation,” etc.—keeps those dogs eating dogs, cats eating mice, and human beings stretching our concept of inhumanity. Every day, people suffer and die for an illusion.

Choices

Merton saw two choices in response to the pain of disunion: to hate—which only brings us more of the same—or to love. And love, “by its acceptance of the pain of reunion, begins to heal all wounds.” In the overwhelming barrage of scary news stories, it’s easy to forget the equally overwhelming (but significantly under-reported) passage of love back and forth among our little lives, every day, in every nation.

At any moment—this moment, for example:

• There are billions of people doing things that are selfish, cruel, and cowardly, and billions of people facing pain, loss, indignity, and death.

—but—

• There are also billions of people doing things that are kind, loving, generous, and brave, and billions feeling relief, gratitude, wonder, and joy.

Is there hope? Who knows? We’re powerless over much of the world’s fate, and for those of us in helping or caregiving roles, this sense of global helplessness may resonate with our powerlessness over so many aspects of the well being of the people we serve. In these roles, it’s helpful to remember that, even if we can’t do much about the big things, there’s a lot we can do about many of the small things. It’s the same with the world.

You’ve probably seen the love of a few people transform the lives of individuals, families, possibly whole communities. What might the love of many—even most—people do? We may be powerless against the volume and complexity of challenge in the world, but:

• We’re not powerless over our own everyday choices.
• We’re not alone.
• In our own little lives, we can learn to reach out in courage, to accept the pain of reunion, the resetting of this “body of broken bones.”

Of course, this won’t work if we think we’re supposed to fix the world, or get all bitter and sulky because it is what it is. With all the clever ways we have of trying to block out the pain of living, we just end up locking ourselves in with the pain.

We’ve chosen to care. It’s in our nature to care. If we keep the pipes clear:

• We can handle whatever they carry.
• We’ll be loved as much as we love—perhaps even more
• The large or small part we can play will be just the right part for this moment.
• The next moment will take care of itself.

We will be conduits of healing. And whenever even some small drop of healing passes through us, it heals us, too.

Section Seven: Focus on Problems and Deficits

If we never noticed problems and dangers, we’d be a very happy but short-lived species. A number of structures and circuits in our brains are organized to:

• Catalogue signs of pain and danger,
• Spot them a mile away,
• Imagine all the potential consequences, and
• Think of ways of fixing them.

These functions have evolved incredibly far, just not far enough to notice that they’re not our only—or even our most useful—functions. When they get too frisky, we have things like anxiety, depression, and posttraumatic stress disorder. The rest of the time, they just try to boss us around.

And so we’ve been steeped in the traditional focus on what everybody’s doing wrong and how we can make them (or ourselves) better—better children, parents, partners, pets, students, clients, patients, neighbors, warriors, workers, whatever. Whole systems have been organized around:

• Identifying and assessing problems, bad behaviors, questionable character traits, areas of ignorance, and substandard skills;
• Planning and providing services designed to address these problems, bad behaviors, etc.;
• Evaluating and rewarding people’s progress (or punishing their lack of progress), based on how much their problems have grown or shrunk; and
• Funding/reimbursing services based on how many problems systems have addressed.

If you grew up in the world, you’ve probably noticed this. If you work in one of the many health, education, human service, public safety, criminal justice, or military fields, you might be drowning in it. Many people take this negative, problem focus for granted. But the fact that we’re used to something won’t stop it from eating away at our strength, our compassion, our happiness, our initiative, or our capacity for hope. We might just carry it deeper.

Swimming Upstream

Many fields have been trying to move toward a focus on strengths, skills, resilience, health, well-being, and recovery, because we’ve seen the underside of our traditional negative focus. We’ve seen:

• The illogic of trying to make people stronger by directing attention to their weaknesses;
• The shattering damage that our problem focus can have on people who carry heavy loads of vulnerability;
• The reactive stance that our systems are locked into, if we have to wait until problems get bad enough before we can address them;
• The vast amount of time and resources it takes to address all the full-blown problems, compared to the reasonable amount it would have taken to prevent those problems; and
• The weight of all this on the people who work in those systems.

Each of these attempted shifts in focus is a major cultural change, like turning the Titanic before we hit the iceberg. To change policies, practices, and funding structures, we first have to get through all those brain parts that keep patiently pointing out problems—multiplied by the thousands of people whose feelings of effectiveness have always depended on doing things the way they’ve always been done.

Change Agents Have More Fun

If you feel powerless, weighed down by the negative momentum in your field, situation, etc., why not do something powerful? Change agents are needed at all levels, including:

• The strong leaders who envision strength- and health-based approaches and have the courage to move their systems through a process that ultimately transforms them;
• The practical visionaries who figure out ways of making this happen in the real, human world;
• The early adopters, opinion leaders, and champions who “sell” these approaches to their neighbors, colleagues, or fellow employees (and the occasional boss); and
• The courageous souls who are willing to let go of the way they’ve always done things, try something new, point out how the model might be improved, and join the process of trying to make it work—and work more effectively.

Whatever your skills might be—thinking, doing, analyzing, synthesizing, talking, writing, listening, connecting, reflecting, or getting other people to do all that stuff—your skills are needed, and they will be appreciated. Your efforts will be energized, and who knows? You and your fellow change agents might just be successful.

It might take a long time, but at some point even those bossy old brain parts will have to realize the old way just costs too much and hurts too much, and then they’ll start to turn the wheel— maybe even in time to avoid the iceberg.

Section Eight: Neglected Self-Care

In words attributed to the renowned Swiss psychiatrist and psychotherapist Carl Jung, “Sometimes, Mr. Freud, a cigar is just a cigar.” Sometimes “compassion fatigue” is just fatigue, fallout from a lack of self-care.

Startling new research indicates that:

• Even people driven by a strong sense of purpose need sleep!
• Doctors and nurses can get sick!
• Counselors and coaches can give themselves bad advice!
• There is no minimum daily requirement for caffeine!
• Other people’s well-being is not necessarily more important than your own!
• Putting off going to the doctor doesn’t make your symptoms go away!
• A job that requires superhuman stamina and doesn’t allow for basic self-care may not actually be a good job!
• The work we do at the last minute under intense pressure actually isn’t more effective or impressive than the work we start earlier and do at a more comfortable pace!
• Skipping breakfast and lunch and having a big dinner at 10 p.m. doesn’t make you lose weight!
• People who work themselves into an early grave actually end up helping fewer people, rather than more people!

Whatever time or effort we invest in self-care is time or effort well invested, but for many people, it’s a difficult investment. We know we’re strong, we’ll be okay, we have a purpose to fulfill, people are counting on us, and all the other very reasonable excuses for not fulfilling this basic responsibility to ourselves and the people we serve. Being of service to our fellow human beings can be a dramatic calling. Self-care is much less dramatic—until the lack of self-care tips us over into illness, injury, family trouble, job trouble, or hurting someone.

Choosing Self-Care

If it’s someone else who’s neglecting self-care, it’s simple:

• Whatever they’re not doing enough of, they should do more. Whatever they’re doing too much of, they should do less—or none at all, if less doesn’t work for them.
• Whoever they need to connect with, or get help or support from, they should connect with them. Whoever they need to stay away from, they should stay away from them.

If it’s you, of course, it’s much more complicated. When you address these complications, you might try thinking about Prochaska’s and DiClemente’s five stages of change. [1] A few examples:

When an individual or human service organization engages in healthy self-care, that sends a message that you mean what you say and shows the people you serve that being healthy can work. And if the only way to stay healthy is to say “no” to an opportunity to make a real difference, just know that another opportunity to make a real difference will come along.

If this is really part of what you were put on earth to do, it will happen.

Section Nine: Our Own Unhealed Wounds

Whether it’s Ernest Hemingway quoting Friedrich Nietzsche or a little girl quoting Kelly Clarkson, “What doesn’t kill you makes you stronger” is always a little bit of a stretch. There are plenty of things that don’t kill us—toothpaste, for example—but don’t make us stronger.

Many challenges that feel like the overflow of other people’s pain are really the resonance of that pain against our own unhealed experience. We may be “strong at the broken places,” (Hemingway this time), but we’re also more vulnerable. And how much of the healing process we’ve completed seems to be less important than how well aware we are of our vulnerability— and how willing we are to address it.

Desensitization vs. Accumulation

Many patterns of our own physical nature lead us to think that unpleasant experiences—pain, danger, loss, betrayal, disrespect, discrimination, humiliation—should get easier with repeated application. After all:

• Muscles build with repeated stress, each time a little stronger, each time overcoming a little more resistance.
• Immunity comes from exposure, so people who’ve had chicken pox won’t get it a second time, and we make vaccines from proteins grown in bodies that have learned how to fight the disease.

After a while, we just get used to things, right? Not necessarily. Our bodies sometimes take the opposite direction:

• Many people have allergic reactions, with the body reacting badly—sometimes violently or even fatally—to an otherwise innocuous substance.
• In many cases the body reacts more severely with each exposure. For example, people who are exposed to toxic mold may not be strongly allergic at first, but prolonged mold exposure might intensify their reactions.
• Sometimes the body develops autoimmune disorders, with immune functions going haywire and the body attacking itself.

In other words, sometimes we don’t get used to things. When we look at the human stress system (mentioned in Section 3, “Thoughts on Fatigue,”), we notice that it’s mild or moderate, brief, and intermittent stress that builds strength, resilience, and resistance to fatigue. Stress that’s extreme or relentless often has the opposite effect. For example:

• Many people who experience multiple losses find fresh remnants of past losses in their present grieving processes, and trauma often builds on and magnifies past trauma.
• Overwhelming experiences like the loss of a loved one, surviving a disaster, living in an abusive household, or growing up with poverty and racism might make us more vulnerable to future pain, and more likely to have our ghosts awakened by the pain we see around us.
• In their desire to protect us, ancient brain structures record, catalogue, and later recognize the sights and sounds of pain and danger. It makes sense that these primitive protectors would react strongly to the signs of pain and danger in other people’s lives.

So if our own early experience of pain is part of the developmental process that first “grows” our capacity for compassion for the pain of others, it may also make us more vulnerable to being triggered through exposure to that pain. The result might be troublesome emotions that we’re told to interpret as “compassion fatigue,” but it might also include a tendency to distort our identification with, perceptions of, or relationships with, the people we’re committed to serving, the subject of the next two sections.

The Healing Healer

There are written and unwritten rules about the therapist’s or the counselor’s need for therapy or counseling, the sponsor’s or peer mentor’s duty to work with a sponsor or mentor, the priest’s need to spend some time on the other side of the confessional window, etc. The reflection of our own past pain in the present can provide some rich opportunities for insight and growth in these processes.

But when we’re caught up in another person’s illness and/or healing, we may be tempted to use our sessions with our own healers as a sort of supervision, getting our therapist’s or mentor’s take on how we’re addressing the challenges we find in the people we serve. And if we’re skillful in how we manipulate the session, we can get some good advice on how to handle our work—and leave the session without having addressed what we most need to address.

With this or any of the challenges caught under the umbrella of “compassion fatigue,” it often comes down to the topic of Chapter 4, “The Morality of Compassion.” When we hold the well- being of another in our hands, we have a moral and ethical obligation to keep our hands as strong, as gentle, as clean, and as skillful as possible.

With that much at stake, we can’t afford to overlook any avoidable risk.

Section Ten: Identification—Too Much or Two Little

Caring and service toward others are very intimate things, and the quality of the relationship affects, not only the one receiving care, but also the one giving it. This and the next chapter look at some ways in which the thoughts and actions of the helper or caregiver can get distorted and make the relationship more challenging. The first of these has to do with our sense of identification with the people we serve.

Identification with others is an important building block in many areas of life. For example:

• The process of learning new skills uses some of the brain structures and circuits involved in the process of identifying with others. When we identify with people, we’re more likely to imitate their actions.
• The survival of the species depends on our identification with and willingness to cooperate with and care for others in our family, community, culture, country, or whatever other group we see as united with us.
• Depending on how we set the boundaries of what is united with us and what is “foreign,” we might develop a sense of belonging to (and in many cases being drawn to) one group and feeling separate from (and in some cases alienated from) another.
• Acceptance of others can be strongly influenced by whether or not we’re able to identify with them, which is influenced by learned beliefs and shared experiences, characteristics or connections, and by the way we look for and interpret those experiences (for example, identifying only with our own family or culture vs. identifying with people in general).
• Identification is important in the early development of empathy and compassion, which starts when our perception of others’ feelings reminds us of our own experience—and actually invokes some of those feelings—and we start to care and want them to be well.
• Caring for others doesn’t require that we identify with them in every way, but healthy identification—and the sense of belonging and comfort it carries, make caregiving and other helping roles easier, safer for everyone, more pleasant, and more effective.

In many ways, the ability to identify appropriately—not too much, not too little—is a skill, an important ingredient of compassion, and an essential quality in any formal or informal helping or healing relationship. Given the potential harm at each end of the scale, it is the absolute duty of every service provider to do whatever it takes to find the appropriate middle ground, or to hand the service relationship over to someone who can navigate it more safely and effectively.

Chapter Eleven: Distorted Roles or Relationships

Two words that have even more definitions and different sets of symptoms than “compassion fatigue” are “countertransference” and “codependence.” Sometimes a challenge that’s taken for compassion fatigue is really one of the many experiences most commonly lumped under one of those two terms. But rather than jump off one slippery rock just to land on two more, let’s call this chapter “Distorted Roles or Relationships.” It describes three varieties.

Seeing Ghosts

In the intimacy of a helping or healing relationship, when we look at someone we’re serving and see qualities of someone else in our lives—mom, dad, the ex-husband, that nasty teacher, etc.—it can trigger uncomfortable emotions and counterproductive actions. This is a natural and normal part of being a human being with a brain that wants to protect us from harm. But if we don’t notice these kinds of reactions, or if we lose sight of their origins, it might turn into what people most often refer to when they use the term “countertransference.” We might start:

• Believing our feelings are normal and even necessary responses to the person we’re serving
• Seeing in this person some motives or characteristics of others in our lives, even though he or she may not have those particular motives or characteristics
• Resenting the person we’re serving for actions or attitudes that really belong to others in our lives

People often remind us of other people, but if the experiences they remind us of were intense, and if we’re unaware of the power of this association and its effects, it can be uncomfortable and potentially harmful to both parties in the helping relationship. The fallout from a situation like this might be interpreted as compassion fatigue. But the rest-and-relaxation techniques suggested for compassion fatigue won’t be enough to solve these kinds of problems. Like some of the other challenges this book mentions, they’ll also require more work, including self- awareness, insightful people to provide reality checks, and professional help.

Romantic or Sexual Relationships

The line between appreciating someone’s attractiveness and considering the possibility of romantic or sexual involvement is absolutely important—and even more important when it comes to the people we serve in helping or healing roles. It seems that, like many lines between right and wrong, this one is harder to see as we get closer to it. Stress, fatigue, lack of self-care, lack of effective supervision, unhealed wounds, or any of the other challenges described in this book can make people more vulnerable to falling into this particular trap. And it is a trap:

• Elements of intense intimacy in healing roles and relationships can be compelling.
• People might start with flirtation and approach the line in subtle and gradual ways.
• The helper might be attracted to someone who would otherwise make a good partner— or to someone too vulnerable or volatile for safe involvement under any circumstances.

Unfortunately, no matter how healthy or admirable they are, this is a relationship of unequal power, and the inequality can last for years after the formal relationship is over. The potential for manipulation, coercion, abuse of power, betrayal of trust, and triggering of psychological vulnerability is enormous, even if the helper would never do any of those things on purpose.

Taking Responsibility for Others’ Choices

For many people, an important division between joyful, effective service and exhausting, ineffective, and possibly harmful service is our ability to keep sight of the differences between others’ responsibilities and our own. This one walks many thin lines. When we’re in formal helping roles, we’re responsible for doing everything we can morally, legally, ethically, reasonably, and humanely do to promote safety and well being. We’re responsible for:

• Our words and actions, and for anticipating their possible consequences;
• Knowing our limitations and doing whatever is necessary to compensate; and
• Noticing signs of danger and taking all appropriate precautions.

Beyond that, when people make self-destructive choices in spite of our best efforts, we’re not responsible for those decisions, or for their consequences. But we can feel like we’re responsible, and this can lead to one of the conditions that people in the substance use disorder field used to (and some still do) refer to as “codependence” (a catch-all term that’s interpreted in a few ways and applied to a number of different experiences). Whatever we call it, if we— consciously or unconsciously—feel responsible for other people’s choices, we might:

Finding the right label to identify a challenge is often less helpful than looking at exactly what’s going on in this particular situation, why it’s happening, what resources (internal and external) there are to address it, and how we might stabilize the situation and change course before things get really sticky. When helpers and healers apply our knowledge, skills, and resources to our own wounds and misconceptions, amazing things can happen. What we learn can help us right now, and once we’ve come to understand it at depth, it can help everyone in our care.

Section Twelve: Frustrating Survival Skills

When we take on human service roles, we’re often driven by compassion for people whose wounds, illnesses, age, disabilities, and/or other circumstances have caused them pain and left them more vulnerable than people should have to be.

And what we often discover is that most people have plenty of cognitive, emotional, and behavioral strategies for comforting their own pain, keeping a sense of control, and staying psychologically safe. Some of these strategies are called healthy coping skills. Others are often called symptoms, but they make more sense if we think of them as survival skills.

In the helping professions, sometimes what’s causing our challenges is not a lack of sleep, an excess of compassion, or a deep and unhealed wound. Sometimes it’s just that people are doing really troublesome things that frustrate us, and our frustration is exhausting. We know that:

• Their symptoms are normal and expected facets of their illnesses.
• Some of their symptoms might be manipulative and hard to manage or tolerate.
• Some of their symptoms might lead the powers-that-be to deny them services.
• We’re responsible for doing all we can to keep them safe and help them heal.

Three strategies for coping with other people’s survival strategies might be to: 1) choose to serve a population whose challenges you can handle, 2) understand these challenges in terms of the survival instinct, and 3) become a collector and teacher of healthy survival skills.

1. Choose the Right Challenges

This work resides in the public domain, unless otherwise indicated.