CF is a relational issue, where the care giver responds to suffering, pain trauma and emotional stresses of others. CF is characterised by exhaustion, anger and irritability, negative coping behaviours including alcohol and drug abuse, reduced ability to feel sympathy and empathy, a diminished sense of enjoyment or satisfaction with work, increased absenteeism, and an impaired ability to make decisions and care for patients. It also negatively impacts relationships with colleagues and loved ones.

The neuroscience behind CF

Many people view healthcare professionals as heroes. This places an undue burden on them, and they may find it difficult to live up to these high expectations, whilst at the same time not wanting let people down. Many healthcare professionals view burnout and CF as a weakness. It is anything but, said Olwagen. First and foremost, you are human, and are faced daily with highly stressful and emotional events, which have an impact on your brain. When faced with trauma certain mirror neurons are activated in response.

Mirror neurons are aptly named for their ability to ‘mirror’ the brains of those around us. Particular areas in the prefrontal cortex have also been referred to as the ‘neuromoral’ network, which allows us to identify with the plights of others. When we hit a point of CF, these areas get over-stimulated and our brains do not mirror as effectively. It is then when we begin to lose empathy for the people around us as a protective mechanism for our own coping skills.

Are you at risk?

Typical trajectory of CF

Phase 1 (zealot): Full of enthusiasm, willing to go the extra mile for the patient, handholding, extra care, willingness to do anything.

Phase 2 (irritability): Begin to take shortcuts, avoid people and conversation about work, make mistakes.

Phase 3 (withdrawal): Patients become source of irritation, enthusiasm disappears, you start to avoid discussing your job, become less sociable.

Phase 4 (zombie): You go through the motions, find no humour in anything, don’t want to have fun, feel disconnected from your emotions, lose compassion and hope.

Compassion fatigue progression

The first stage is compassion discomfort: You may experience weariness, less enthusiasm, and a weakened attention span. This stage is temporary and may be resolved with rest and rejuvenation.

The second stage is compassion stress: Your stress levels increase, while the endurance level decreases. The resulting feelings are irritability, feeling weak, decreased performance and impaired concentration.

The third stage is CF: In this final stage, indifference and apathy are the primary emotions. You may display poor judgement, anger, diminished sense of enjoyment, lack of empathy, anxiety, difficulty separating professional life from personal life, or take part in reckless behaviour.

What can you do?

The good news is that you can ‘rewire’ your brain. Neuroplasticity is the ability of the brain to form new connections and pathways and change how its circuits are wired.

• Keeping your body and your health in good shape is essential. Get enough sleep, eat healthy and get some exercise. Know your limits and the impact of a lack of sleep and poor diet
• Mindfulness exercises, such as meditation, deep relaxation and guided imagery help to improve your emotional regulation, decreasing compassion fatigue and increasing compassion satisfaction
• Revisit your purpose and the meaning you originally found in becoming a care giver
• Watch your self-talk (your inner dialogue) and balance the negative with the positive.
• Optimism is a strong mediator of stress.

Apply the situation, interpretation, response, appraisal and expectation technique:

• Determine what the situation is that typically triggers your sense of compassion failure. Is there something particular, some specific kind of patient, certain types of pain/trauma that you respond to? Is there a trend in these situations?
• Clarify how you typically respond and interpret your current situation. We usually have unspoken rules that guide our behaviours such as: I must/should/am supposed to… or If I am not always on duty and available for my patients, they will suffer more etc. Usually the response and the trigger is something negative, such as: Because I’m not always available, I’m failing at being a good care giver or a negative self-perception: What’s wrong with me, I must be uncaring if I can’t empathise with this person’s suffering. Ask yourself what your triggers are and why they act as triggers.
• Understand your emotional response, for example self-doubt, anxiety, depression, sense of failure, etc. Be clear that the emotional response is usually related to some unspoken rule you have about how one should be and act or is the effect of the underlying negative self-talk
• Appraise the situation, your interpretation and emotional response. More often than not, you have lost perspective and have started generalising one situation to others, exaggerating the failure, using absolute terms such as: I must always be caring, compassionate and considerate.

When you re-appraise the situation, you start looking at what is more realistic or a more optimistic view, such as: Yes, I have been exposed to so much pain and it can be overwhelming. Perhaps I don’t need to put extra pressure on myself, placing unrealistic demands on myself as well or I am having an off day, because I have been on duty constantly, with few breaks, a little sleep and I am just so tired, not because I’m useless, but we all get fatigued or with all the pain and suffering I’ve seen and worked with during the Covid-19 pandemic, my coping cup is full, I need time out

In the past you have coped with crises in your life. Expect of yourself to bounce back, once you have taken some time out to reappraise the situation and are able to see it in context again

Try to find balance in your life by taking some time off work or embracing enhancing selfcare techniques. A balanced life means applying FORMAT: How much time am I spending on recharging my coping batteries and who/what can help me? Find a balance between spending time in these different arenas:

• Family time and displaying some gratitude to others
• Original activity, some hobby or creative skill
• Rest and rejuvenation, doing things that you know will reignite something pleasurable and let the dopamine kick in again
• Mastery by developing knowledge and skills
• Affirmation of your intent, willingness
• Technology and television: Do something that is just ‘brain dead’

Another essential factor to prevent and treat CF is to have some good relationships with colleagues, a supervisor, or a therapist that you can safely and confidentially discuss the distresses you are experiencing. Isolation is a symptom of compassion fatigue and is ultimately dangerous. To be resilient you need to have good support and connections with others.

• Allow others to also give you feedback on the things they appreciate about you
• Do not self-medicate with drugs or alcohol as that will just numb you temporarily
• Seek professional help. This is not a sign of weakness. We all get stuck in one perspective. Another professional might help you see things more clearly and help you to see this in context.