Living with compassion fatigue

Introduction

As veterinarians, we do not always realize that – because of the complexity of our work – we are at high risk for compassion fatigue¹. The constant rollercoaster of emotions that comes from euthanizing a long-time patient, then celebrating with a family and their new puppy, followed by treating an animal cruelty case or complex medical issue, creates extremely emotional highs and lows from hour to hour throughout the day (Figure 1). One study has found that 57% of veterinarians face one or two ethical dilemmas each week during their work 1, and another study estimated that 40% of veterinarians are either suffering from, or are bordering on, depression 2. Because of this, there continues to be research into the causes of burnout, compassion fatigue, and the higher-than- average rates of mental health concerns in veterinary medicine 1.

¹ Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring (Wikipedia).

A study conducted by the Centers for Disease Control and Prevention² (CDC) revealed approximately 1 in 3 veterinarians has anxiety, and 1 in 6 has considered suicide, with a suicide death rate at least three times higher than the general population (Figure 2) 2. These findings are startling – and mean that it is very likely you work with someone who is struggling and/or are suffering yourself. Even though these statistics support the fact that mental health concerns are both serious and common in our profession, most veterinarians feel they will be stigmatized and that their career will be damaged if they reach out for help (Figure 3) 1.

² https://www.cdc.gov

In writing this article, we hope to help bring this conversation to light by sharing our stories, learnings, and some useful tools to help break down the barriers to getting assistance. We both know what it feels like to be struggling, and we would not have made it without the support of others. In sharing what we have learned, we hope to help others in their desire to remain part of, and enjoy, a profession many have dreamed of being involved with since they were youngsters.

Defining and recognizing the problem is the first step. As defined by Dr. Charles Figley, Professor of mental health at Tulane University, Louisiana, compassion fatigue is “an extreme state of tension and preoccupation with the suffering of those being helped, to the degree that it can create a secondary traumatic stress for the helper.” Dr. Elizabeth Strand, Director of Veterinary Social Work at the University of Tennessee, puts it another way; “it’s the result of caring very much and working very hard… and not recognizing and taking care of your own needs.”

Compassion fatigue

Compassion fatigue can manifest itself in many ways. Burn out, or the detachment from work and other meaningful relationships, along with trouble sleeping, increased alcohol intake, intense contemplation or rumination, depression, and psychosomatic complaints can all be indicators of compassion fatigue (Figure 4). Does any of that sound familiar? The chances are that at least one of those indicators rings true to you, and we have a few processes to share that can help with these symptoms.

In addition to caring for yourself, it is also important to initiate conversations with your peers when you recognize it in them. They may not yet have the tools to deal with this, and we owe it to each other to help. As a community we need to get better at recognizing, destigmatizing and seeking assistance around this important topic – it could literally save a life. The more we normalize these conversations, and participate in these conversations, the healthier we will become as a profession.

It is also important to realize that the risk of compassion fatigue is not something that we can remove from our lives altogether, given it is a by-product of the work we do. As doctors, we look to treat and cure, but we cannot cure compassion fatigue; however we can manage it. So we need to learn how to do our work and take care of ourselves at the same time. This takes planning and practice.

Recognizing emotional distress

When defined in black and white, we start to see how the statistics given above are so relevant for our profession. So how do we recognize emotional distress in ourselves and others?

Dana’s story:

I was two years out of veterinary school, working as a lead doctor in a busy four-doctor small animal practice. As a leader, I felt it was my responsibility to not only take good care of my patients and clients, but also my team. What I didn’t see was that I was trying to protect my team from negative emotions by taking them all on myself.

I often found my days loaded with multiple euthanasia appointments, hearing my team say things like: “Put it on Novara’s schedule, she doesn’t mind them.” Eventually, the team started calling me “Dr. Death.” I told myself this was a compliment that my team appreciated that I could handle this for them, and that maybe it didn’t affect me in the same way it did them. Unfortunately, I learned the hard way that I was not being honest with myself. One day, I found myself with five euthanasias scheduled. The last of the day was a dear, long-term patient of mine. Not only was this hard to get through, but it also kept me late at work and prevented me from getting home to a gathering with friends. I walked out of the consult room and told myself, “don’t let them see you cry.”

I was so emotional on the way home that I almost drove off the road; I rang my husband and yelled at him, and heard myself tell him “I wish I had just driven off the road.” To this day, I don’t believe I really meant that, but I shouldn’t have let myself hit the bottom before stopping to listen to myself. Through the love and support of my husband, I was able to see that my mind was trying to tell me that I was not OK and things needed to change. Together, we came up with a plan for talking to my team and setting boundaries at work. 

Compassion fatigue can take many forms and appear in different ways, depending on the person and the situation, as told in Kimberly’s story:

Kimberly’s story:

As a “type A” perfectionist (someone who is a perfectionist, highly motivated and self-critical), working full time through vet school and then landing a dream job in a very busy private practice, I never knew anything other than working long days and constantly challenging myself to learn and do more. Over time, work became my everything. When I wasn’t at the clinic, I was filling in at another job so others could take a vacation or a sick day. It got to a point where there was no more happiness or joy in my life because work consumed every minute of every day.

In full transparency, I was completely unaware until, one day, my husband helped me see how out of balance my life had become. The more I worked, the more I needed to work to prove to myself that I was “good enough,” and it was costing both my physical and mental health as well as my relationships. I came to realize that internally I suffered from self-doubt – frequently referred to as “impostor syndrome” – and it was rapidly turning into compassion fatigue in the form of burnout. If I continued to do what I was doing, it became clear to me that I would not survive in this profession.

So I made decisions that would allow me to find a balance once more, and distinctly defined the triggers that could cause me to fall back into old ways. I became very clear with my goals and intent, and to this day continue to check in with myself to ensure I am feeling balanced. I now know the signs and openly discuss them with those around me, so they can help me be on the lookout for them too.

Creating a care plan

To help prevent emotional distress, consider creating a care plan with the goal of taking care of your whole self to ensure better resilience under tough circumstances. A successful care plan enables us to release blocked emotions that we carry with us during the day. This plan should be multi-faceted and ever-changing and evolving as part of our life’s work.

With that in mind, we start by identifying that our overall wellbeing is heavily influenced by the five key elements of health and wellbeing: healthy body, healthy mind, healthy career, healthy community and healthy finances. When we deconstruct each of these categories and take time to think about the importance of each, we will end up with a care plan that can help us sustain in the face of compassion fatigue (Figure 5).

Thinking about Healthy Body is more than just exercise. This also includes enough quantity and quality of sleep, healthy nutritional habits, and access to healthcare for prevention and intervention. This ties in closely with Healthy Mind – having awareness and acceptance of your feelings is a critical piece of managing your health. Creating routines around exercise, eating and sleeping are important to your body physically, but how do you create routines for your mind? That’s where mindfulness comes in. As a concept this is much like teaching yourself to become the director of your own thoughts; in other words, train your brain to attend to the present, in your mind, body and environment moment-to-moment, rather than what most of us typically do, which is mentally wander through thoughts that focus on worries, negative or critical messages, “what ifs” and past failures. Just like physical exercise, training your brain for a shift to mindfulness takes practice.

When it comes to Healthy Career, we are fortunate to be in a profession that is primarily driven by passion and purpose, which in most cases means that we do work that matters to us. It is just as important to do work that is sustainable, so spend time mapping out what you want your career to look like and what matters most to you at work.

It is equally important to have connection to people outside of work that provide support, compassion and communal engagement. Who is your family, tribe or group? Developing and maintaining a Healthy Community is imperative because our purpose-driven work cannot be sustained without support. Feeling connected through social networks, volunteer projects or hobbies outside of work can enable you to direct your thoughts towards something positive, and helps create relationships with others that can support you during the tough times. 

The last piece in taking care of your whole self includes your Healthy Finances. Financial obligations for family, housing, healthcare, and (in many cases) large amounts of student debt weigh on us every day. The first step to financial wellbeing is knowing where you are, so you can come up with a plan based on your goals. Creating realistic targets and sticking to a plan make it much more likely you will meet specific financial goals and help give you a stable foundation to continue in the right direction. You must know and be honest with where you are now to formulate the right long-term plan for your financial wellbeing. Seeking guidance and support from a financial advisor is a useful way to get started on the right track.

LASTing in the veterinary profession

The care plan can be a great long-term tool to help maintain your health and wellbeing. But given we cannot take the risk of compassion fatigue out of the work we do every day, it is also important that we have tools and resources to help us in moments of need (Figure 6). One such tool, developed in-house by Banfied, employs the acronym L.A.S.T., which stands for Listen, Accept, Seek, Test. Remember it by thinking, “If I want to last in this profession, I need to LAST.” Running through the steps outlined below can help unblock your emotions in the moment.

As you leave an exam room after an emotional case, angry client or euthanasia, your first instinct may be to compartmentalize your emotions to get through the day. Whereas our profession requires a certain level of skill around compartmentalization, this does not mean you should not expect it to take a toll on your wellbeing. Next time this happens, try taking a micro break, and Listen to your body. Maybe your back is hurting, or you are hungry, or sad, or frustrated. All these things are real and need to be addressed.

After listening, it is time to Accept. This may seem abstract; however, we often judge ourselves harshly by telling ourselves things like: “I’m the doctor, I shouldn’t cry” or “I have too much to do to stop for lunch” or “my back hurts, but I can tough it out.” It is often hard in our busy days to allow ourselves to accept how we are really doing, but it is critical to practice accepting without judgment.

From there, Seek a plan. Instead of judging yourself for how you feel, think about a possible solution. Maybe you need to go somewhere to cry, or seek support from a colleague, or take a longer break to eat some food, or take five minutes to meditate or stretch. The important thing is not that you fix how you feel immediately, but that you are trying something. Whatever it is that you are feeling, whether you judge yourself or not, is real. When you ignore that fact and do nothing, your emotions and physical injuries can start to accumulate.

Next, seek a solution and Test it out. If what you tried did not seem to help, try something different next time. Compassion fatigue is not a static condition, so the solution will not be static either. A real scenario as an example of how to use LAST in the moment can help illustrate this:

I just completed my fourth euthanasia of the day, and it’s Christmas Eve. I get in my car to drive home, two hours later than planned. I’m feeling heavy, and it’s hard to concentrate on driving. I decide that it would be best for me to safely pull over and try LAST.

Listen: I notice I’ve been holding my breath, and I feel a heavy weight on my chest when I breathe. My vision is slightly blurry, and I have pain in my jaw from clenching. I have a deep sadness that I can’t shake but know I am late for a holiday celebration, which makes me also feel guilty and alone. 

Accept: I have the realization that even though I am known for “handling” euthanasias well, I have been just storing the sadness I felt every time. I’m feeling overwhelmed, sad and guilty. I have the urge to scream, cry – or both.

Seek: Since I feel like I want to scream or cry, maybe that’s the best way forward. I start by trying a scream because that’s easier. It was awkward at first, but alone in my car, trying to withhold judgment on myself, I screamed louder and louder and then cried. I start to feel better and then I can stop crying.

Test: After allowing myself to scream and cry in the car for a few minutes, I feel like I can breathe easily again. I’m feeling less overwhelmed now that I have expressed some emotion that felt equal to the scale of my day. I think the next step is to dry my eyes and start home, where I can talk to my partner about my day, so I don’t feel so alone.

This scenario hopefully helps to highlight how this method may be used in the moment to help you unload your blocked emotions. However it is important to remember that LAST isn’t just needed in extreme circumstances; small moments and emotions build up over time, and the better you get at practicing mindfulness and unblocking smaller-scale emotions as they arise, the better your chances at lasting in this wonderful profession. Some resources which may help, including books, websites and apps, are listed at the end of this article.

Additional resources

Websites

• CompassionFatigue.org – contains resources for managing compassion fatigue
• Self-compassion.org – addresses the skills needed to develop compassion for yourself

Apps

• CALM – Mindful meditations and help falling asleep
• Headspace – Mindful meditation
• SAM – Self-help anxiety management
• Happify – Evidence based activities and games to reduce stress and negative emotions

As we continue to research and understand compassion fatigue within the veterinary profession, we also need to start addressing what we can do to cope with it. Defining compassion fatigue and learning how to recognize it in ourselves and in others is the first step. Try to discuss with colleagues when you notice the symptoms – even if you anticipate it to be a difficult conversation. Create a sustainable care plan to take care of your whole self and help prevent the compounding effects of compassion fatigue over time. In addition, and importantly, be sure to act in the moment when you are most stressed by using the LAST acronym. We help animals and families for a living, but we cannot continue to help others without first helping ourselves. Those called to this profession should not only be able to survive, but also thrive.