Compassion Fatigue
Colonel Lenore Enzel , US Army
November 11, 2005

Thank you so much for the honor of speaking with you today.  I’d like to start by saying what I am and what I am not.  What I am is the Chief Nurse at an Army Hospital that has deployed hundreds of personnel on a Post that has deployed thousands of personnel to Iraq and Afghanistan.  What I am not is a Psych Nurse or any sort of expert on PTSD, Compassion Fatigue, or Burnout.  I cannot enter the debate as to whether or not Compassion fatigue is part of PTSD, part of burnout, or even whether or not there is such a condition.  So what I will tell you about today is the result of what I’ve seen in my redeploying staff members, what they’ve told me,  and what  I’ve read.

Compassion Fatigue has been called “the cost of caring” day after day about and for others in emotional pain.  It is also called Secondary Traumatic Stress or Vicarious Traumatization and is part of the Field of Traumatology.  It has been described as a state of emotional, physical, and mental exhaustion where one feels depleted, chronically tired, helpless, hopeless, and cynical about oneself, work, life, and the state of the world.  It is marked by a gradual disengagement, where emotions are blunted, and exhaustion affects motivation and drive.  People suffering from Compassion Fatigue may feel that life is no longer worth living.  Helping professionals who listen to the stories of fear, pain, and suffering of others may feel similar fear, pain, and suffering because they care.  And if they have personally suffered significant past traumas (rape, combat, natural disaster) they are more vulnerable to become a victim of compassion fatigue.  LTC Sally Harvey, an Army Psychologist at Landstuhl Regional Medical center in Germany, said “Our staff experiences many of those same emotions that our patients do.  People feel depressed.  Some people feel overwhelmed.  It’s very much akin to what we call battle fatigue for those out there on the front lines."

An article in the journal, Nursing Spectrum, written by an Army Reserve Nurse described the ICU at Landstuhl Regional Medical Center (the site to which most injured soldiers are evacuated) as an eerie scene from the movie, “Coma”.  Bed after bed is filled with the youthful well muscled bodies; men and women in otherwise peak physical condition connected to ventilators, and other life sustaining catheters, wires, and drains.  One of the nurses, MAJ Kendra Whyatt, said that as an intermediate care point between Iraq and a hospital back in the US, “we don’t do a lot of discharge planning”.  She tells the nurses she supervises, “You’re going to have them for 72 hours, so make it the best 72hrs you can”.

COL Bernie Roth who also works in the Landstuhl Intensive Care Unit said “you walk in and see young kids blown apart.  Sometimes half their brain is gone, arms gone, legs gone. It’s hard. It’s really hard”.

LTC Peter Matsuura, an Army Reserve physician who gave up his private practice in Hawaii for 3 months to help out in Landstuhl said “it’s hard to see these kids come in.  It tears your heart out”.

And living with this means there is a price to pay for those who care for the wounded.  Yet many doctors and nurses who suffer from compassion fatigue do not seek formal treatment.  Some fear that a record of psychological stress could hurt their chances for promotion.  Most seem to feel they can’t take time off from their patients.  And so there are a lot of healthcare workers suffering in silence.

I think LTC Harvey summed it up best when she said “None of us is going to leave here the people we were when we came here.  There is a tremendous cost to caring”.  This has all sorts of implications for family and friends when their soldier redeploys.  The emotional distancing that protects them and allows them to do their jobs during periods of high stress may not be easy to turn around when they go home to their significant others.  Families may feel shut out and substance abuse is a constant threat.  Sometimes their traumatization is demonstrated simply by going into a restaurant and having to sit with your back to the wall, facing the door.  Complicating their experiences, the enemy is constantly and deliberately attacking our hospitals.  The Red Cross means nothing and there are genuine fears for personal safety.

Compassion Fatigue can also be called secondary Post Traumatic Stress Disorder (PTSD).  Its victims have many of the same symptoms – avoidance, numbness, and persistent arousal.  There are human costs to Compassion fatigue.  It is a physical, emotional, and spiritual fatigue or exhaustion that takes over a person and causes a decline in his or her ability to experience joy or to feel and care for others.  Compassion Fatigue develops over time, taking weeks, sometimes years to develop.  Over time, the ability to care for others becomes eroded; they are emotionally drained from hearing about and being exposed to the pain and trauma of the people they are helping.  They are disconnected from their ‘community’ and as their symptoms get worse, they pull back more and more until they are completely isolated.  One of my friends who recently returned from Iraq described nursing staff that were totally detached from the patient; very competent and providing outstanding care – but devoid of feelings.  And she said the patients could pick up on that.  Another nurse told me “Every time someone dies, you pull back more; get more distant – lose more humanity”.  He told me that when he first got to Iraq, when a soldier died, he would open their wallets and look at their pictures and the wallet contents and try to humanize the person.  One day, he opened a wallet and saw the very recently deceased soldier in a photo with his family.  The soldier was smiling and surrounded by a wife and several small children.  Something happened that day when he looked at that picture and he never opened another dead soldier’s wallet again.

In order to begin the journey to recovery from Compassion Fatigue, the caregiver must first recognize and accept that they are having these symptoms and make a decision to address and resolve them.  Often, they will attempt to ignore their distress until it becomes impossible to do so. 

The best way to avoid/treat Compassion Fatigue is to develop an on-going support system where one can discuss their feelings and concerns in a trusting environment.  It is important to educate healthcare workers about Compassion Fatigue and to remind them that like PTSD, they are having normal reactions to abnormal events.  It is important that each day each person has one focused, connected, meaningful conversation.  One friend told me about evening walks around the compound with someone in whom she could confide.

It’s also important to remind them that there is no ideal way to handle the traumas that they have seen.  One year later, many of my nurses continue to believe they did not do all they could, that had they just done something differently an injured soldier or Iraqi child might have lived.  They felt like they were failures when patients died.  Likewise, they ruminate about those they saved; the amputees, the blind, the quadriplegics and paraplegics.  They often wonder about them and what kind of life they are having.  Should they have saved them?  This negative self judgment can be very harmful.  We must help them develop realistic expectations about their limitations and help them set healthy boundaries.  There is so much to do and they work so hard – trying to keep doing more and more.  But there is so much to do; it will all never be done no matter how hard they work.

The basics are also important – healthy eating, exercise, rest, prayer, meditation, relaxation techniques, hobbies, journaling, sharing with friends, turning off CNN and FOX News, and using humor are all important.  Also important is positive self talk to overcome self defeating thoughts.  It is essential to stay focused on one’s self-competence, resourcefulness, and training.

It is important for us to know our own triggers and vulnerabilities and learn to defuse them and to avoid them.  One of my nurses, who has a history of PTSD, keeps volunteering for jobs and missions that re-expose him to the situations that started his condition.  When I asked him about it he said, “That’s where I feel comfortable, that’s where my head is all the time”.  I think he’s addicted to the adrenaline rush.  He described it as particularly difficult for the nurses and doctors that had children the ages of those they were treating.  “This could be my son or daughter...”.

It is important that we allow healthcare workers to grieve when bad things happen to others.  We have started doing critical incident debriefings for combat units and must do more of them in our combat support hospitals, as well.   It teaches staff new skills, minimizes the chances that they’ll return home full of self doubt, and assures them that they are valuable members of the team.  We need to take good care of our caregivers so they can continue to take good care of our patients.  Landstuhl Regional Medical center in Germany has a volunteer massage therapist to help nurture the staff.

Along with the list of “do’s”, there is also a list of “don’ts”.   Until they have healed emotionally, physically, and spiritually from their experiences, they should not make any big decisions.  They should not have an affair, buy a luxury sports car, quit their job, get a divorce, get out of the Army, etc.  It’s better to wait until their stress is under control and self perceptions are more logical and less emotionally charged.

They should not blame others.  Being adversarial will only increase tension and isolation and prevent the deeper healing that must take place.  Likewise, it is wise to avoid complaining.  Misery loves company and it’s easy to fall into this pattern of complaining.  But it is not helpful and will only make you feel worse.

Most importantly, one should avoid the ‘quick fix’ of addictive behaviors and substance abuse.  Many helping professionals try to deal with compassion fatigue by working harder and longer.  Others self medicate with alcohol or prescription drugs.  Some use sex to relieve their personal pain.  These quick fixes will eventually cause whole different set of problems and will complicate an already overburdened life – accelerating the downward spiral to burnout and depression.

Compassion Fatigue is the normal and expected result of caring for and about the suffering of others.  The MHAT2 Study found as many as 1/3 of the mental health and primary care providers in Theater reported some concern about stress or burnout impacting their ability to provide services.

Compassion Fatigue and its painful symptoms are very real and carry the potential to disrupt, dissolve, and destroy careers, families, and even lives.  Often those who suffer from Compassion Fatigue most are those who are highly motivated to bring about change and healing in the lives of the suffering.  Its victims include doctors, nurses, medics, paramedics, firefighters, policemen, and mental health workers – anyone who is routinely exposed to situations that are outside the everyday experiences of the average person.  A study of trauma workers from the Oklahoma City Federal Building bombing showed that 65% exhibited some degree of severity of PTSD.

I’d like to conclude by reading from an article written by 8 Army RNs & LVNs assigned to the 31CSH, Baghdad.  It appeared in the May issue of Nursing 2005.

“We send our American patients home—sometimes on their feet, sometimes in wheelchairs or on crutches or stretchers. Some of our patients are badly disfigured, and some have horrendous scars that can't be seen. Others we send home in black body bags, after we lovingly wrap their bodies in woolen Army blankets. But send them home we do. We're the nurses of the 31st Combat Support Hospital in Baghdad, Iraq, and soldiers pass through our hands by the hundreds.

Besides American soldiers and marines, we care for coalition troops, Iraqi and foreign dignitaries, and ordinary civilians, including children and babies. We also take care of Iraqi soldiers, whether friend or foe. They all need our caring and our compassion, so we push ourselves to do more than we'd ever have thought possible.

War takes no holidays. We work at least 12 hours a day, 6 days a week, helping victims of mass casualties, mortar fire, car bombs, and military operations. Our job is endless: We provide nursing care through Easter and Independence Day, through Memorial Day and Thanksgiving, through Ramadan and the hajj. We work through our wedding anniversaries and our children's first steps, birthdays, and first days of school.

We console ourselves and our loved ones with long-distance phone calls. To get through it, we share prayers with chaplains and tears with friends.

When a soldier is dying, we hold his hand and promise not to let go first. We stay by his side and thank him for his sacrifices. Each death leaves us tearful and empty.

Our nights are broken by sounds of nearby mortars, the drone of medevac helicopters, and endless nightmares. Each new day brings us more patients who wrench our hearts. Then we get up and do it all over again.

We've become intimately familiar with the brutalities of war.”

Thank you very much for your attention and for caring about the outstanding men and women serving in our military medical department.

The Survivor Psalm
by Dr. Frank Ochberg
from ‘The Gift From Within’ organization, a wonderful source for
information on healing for trauma victims. 

I have been victimized.

I was in a fight that was not a fair fight.

I did not ask for the fight.

I lost.

There is no shame in losing such fights, only in winning.

I have reached the stage of survivor and am no longer a slave of victim status.

I look back with sadness, rather than hate.

I look forward with hope rather than despair.

I may never forget, but I need not constantly remember.

I was a victim.

I am a survivor

Colonel Lenore Enzel