journal
The Art of Surviving Compassion Fatigue: A Multidimensional Approach
May 22, 2008
We are living in perilous times in which at every turn, we are faced with unrelenting human suffering: natural disasters are increasing with alarming frequency, wars waged on every continent, and terrorism a constant concern. What is more, even if we live in relatively peaceful conditions in our immediate family, communities or even nations, all we have to do is turn on the television or open the newspaper to be confronted with a collective dream filled with images of torture, abandonment, abuse, murder, dismemberment, poverty, guns, bombs, and various forms of physical and emotional abuse. With the rise of global technologies and globalism, no one is immune.
Many of us may have jobs in which we are confronted with these realities on a daily basis. Or we may be dealing with aging parents, with the challenges of illness in ourselves and others, or with the death of loved ones. It is so true, as Gautama Buddha said 2,500 years ago that suffering is common to all. And perhaps more than ever, we are asked to be a witness to it.
In the face of this much suffering, we may find ourselves feeling burned out, depressed, angry, frustrated, and helpless. Particularly if we are in the role of a helper, friend or family member of those who have been traumatized in the past or are currently dealing with such situations, we may be particularly susceptible to developing a deep feeling of compassion fatigue. Compassion fatigue is a term coined by Charles R. Figley, a psychiatrist who has specialized in the naming, diagnosis and cure of Secondary Traumatic Stress (STS). He has defined it as follows:
“We can define STS as the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other–the stress resulting from helping or wanting to help a traumatized or suffering person” (Figley, 1993).
One way of describing compassion fatigue that has been used is that we are “traumatized by concern”. As B. Hudnall Stamm, a psychologist who specializes in the identification and treatment of STS, writes: “The capacity for compassion and empathy seems to be at the core of our ability to do the work and at the core of our ability to be wounded with the work” (Stamm, 1999). Our ability to care can render us vulnerable to the emotional impact of what we witness.
In the face of the inevitable impact of being in the presence of others’ pain, whether in our work, families, or simply through viewing television, what can we do to remain open and present to so much suffering without becoming overwhelmed and paralyzed? What causes trauma, and particularly compassion fatigue? And if we do develop symptoms of compassion fatigue, how do we recover our equanimity and vitality? How do we maintain a sense of meaning in the face of so much pain? Many of us wish to be able to work in the most challenging of circumstances out of a commitment to helping others. Yet it can be a daily challenge on many levels.
I believe the answer comes from combining the best of current Western scientific understandings about trauma and STS and from many spiritual and healing sources outside the mainstream. While the Western sciences tend to look at symptomology related to past traumatic events. many spiritual and healing traditions talk about the “multigenerational legacy” of trauma. As psychologist Yael Danieli, who has worked extensively with survivors of the Holocaust and their children, “Multigenerational transmission of trauma is an integral part of human history. Transmitted in word, writing, body language, and even in silence, it is as old as humankind. It has been thought of, alluded to, written about, and examined in both oral and written histories in all societies, cultures, and religions” (Danieli, 1998, 2).
I would also argue that PTSD and its correlate, STS is a multidimensional phenomenon that engages and captures us on many levels: individually, in and through our families of origin and our ancestral lines, and collectively through our communities, ethnic, racial, and religious groups, and our nations. Reflecting the perspective provided by Carl Jung about the collective unconscious, the impact of the shadows of violence held in our pan-human consciousness means that we are also impacted, albeit usually unconsciously, by the experience of violence throughout time and history. Given how ubiquitous images of violence in the media are in present time, we are also perhaps more than ever tied into this collective experience of violence and trauma. This means that all of us are at risk and that approaches emphasizing more widespread knowledge of the causes, effects, and ways of addressing PTSD and STS are critical on a society-wide level. It also means that with greater understanding, we can rise above it and be better off.
Defining Secondary Traumatic Stress
Since the events of 9/11 and because of the ongoing war in Iraq, there has been increasing public awareness of the impact of violence on individuals and groups. Post Traumatic Stress Disorder (PTSD) as defined in the Diagnostic and Statistical Manual IV (DSM IV) of the American Psychiatric Association occurs when a “person [has] experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” Further, symptoms of PTSD can set in when “the person’s response involved intense fear, helplessness, or horror.” The events that can trigger PTSD “include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarcertaion as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with life-threatening illness” (DSM IV, 1994).
While the definition provided by the DSM IV tends to focus on extreme events, PTSD can also occur in situations that may seem to an outside observer to be much more mild. For instance, ongoing verbal abuse and manipulation can be traumatizing, particularly of a child by a parent or other caregiver. We can even find ourselves in a given moment suddenly frozen in the face of reports or images of violence on the television, such as seeing the picture of a terrorist holding a gun to the head of a hostage. Such an image might last for weeks after seeing it and cause much anxiety and distress. This is a level of collective trauma experienced by all of us in our media-saturated world that is not often discussed. Yet, in my years teaching courses on the problems of violence at the University of Virginia, the testimony of hundreds of students proved to me beyond a doubt that the degree to which we are exposed to violence in the media on a daily basis can alone lead to symptoms normally associated with PTSD. And given the fact that we were able to watch the debacle at Columbine and 9/11 as they unfolded on television, the impact of those events went well beyond the communities and cities in which they gook place.
In both Western psychology and indigenous healing traditions, researchers, therapists and other healers also know that what is considered traumatic to one person may not be to another. Much depends upon a person’s personal, familial and ancestral history and temperament. Much can depend on the timing of an event and on how much support that individual has overall in his or her own life both before, during and after it. One person may go through an event such as a kidnapping and come out of it without ongoing, long-term symptoms, while another may devolve into increasing levels of pain and suffering.
An individual can also suffer from acute symptoms immediately following an event that then quickly resolve. Currently, PTSD and STS are considered chronic when symptoms enter the clinical range and last more than 3-6 months. These can include the following, as described in the DSM IV: “Commonly the person has recurrent and intrusive recollections of the vent or recurrent distressing dreams during which the event is replayed. In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at the moment” (DSM IV, 1994). Other symptoms that may be less extreme than these include: “persistent symptoms of anxiety or increased arousal that were not present before the trauma. These symptoms may include difficulty falling or staying asleep…hypervigilance, and exaggerated startle response. Some individuals report irritability or outbursts of anger or difficulty concentrating or completing tasks” (DSM IV, 1994).
What do the criteria provided by the American Psychiatric Association tell us about Secondary Traumatic Stress? The following paragraph from the fourth edition gives us a glimpse:
“The essential feature of posttraumatic stress disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves threatened death, actual or threatened serious injury, or other threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death of injury experienced by a family member or other close associates” (DSM IV, 1994; emphasis mine). Further, Criterion A of the DSM IV definition of PTSD as relates to STS gives us some clues: “Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one’s child has a life-threatening disease.”
Lenore Terr, a psychiatrist who has extensively studied individual and group trauma, has noted that whole communities are affected in the aftermath of overwhelming events, even if many were not the actual victims. She undertook one longitudinal, community-wide study of Chowchilla where in 1976, a bus filled with schoolchildren was hijacked and buried with everyone alive. The children and the busdriver managed to escape, but the impact of the event reverberated throughout this sleep community for years to come (Terr, 1990). Similarly, research has shown definitively that traumas experiences by previous generations does get passed down the subsequent generations. In this way, we often see patterns within families of hypervigilance and hyperarousal or we see repeated patterns of accidents even on the same dates within one generation as within the last (Schutzenberger, 1998). Danieli notes that the complexity of multiple systems or spheres influences within an individual’s identity contributes to this process:
“Among these are biological and intrapsychic: the interpersonal–familial, social, and communal; the ethnic, cultural, ethnical, religious, spiritual, and natural; the educational/professional/occupational; the material/economic, legal, environmental, political, national, and international…..These systems dynamically coexist along the time dimension to create a continuous conception of life from past through present to the future. Ideally, the individual should simultaneously have free psychological access to, and movement within, all those identity dimensions” (Danieli, 1998, 7).
She goes on to define how “trauma causes a rupture…and a state of being ’stuck’ in this free flow” called “fixity.” As she notes, “This fixity may render the individual vulnerable, particularly to further trauma/ruptures, throughout the life cycle” (Danieli, 1998, 7). To address these ruptures and the lack of movement within an individual and the wider systems in which s/he operates, it is necessary to approach it multidimensionally. In the system designed by Danieli, she largely sees this in the framework of western understandings of how physical reality works.
This framework can be considerably extended when we apply Jung’s concept of the collective unconscious and working with the individual and collective shadow with concepts from indigenous and Asian belief systems of the energetic web that connects all of us. In this framework, we must also work on the level of dreams and within the energy body that surrounds each of us individually. Indigenous healing traditions have long worked with this energetic matrix and understood that within it is contained all the material related to birth, family of origin, clan, tribe, and ancestry. While in the West we might describe this in genetic terms, in indigenous traditions, it is often described more in terms of energies and sometimes in the presence of spirits or entities. Unlike indigenous systems, the Western sciences often do not recognize the existence of transgenerational influences if they cannot be isolated out of the genetic makeup of an individual. Yet we also know that the realization that there is a gene influencing patterns of alcoholism or diabetes in families–two illnesses that were long considered related to more external factors, such as psychology and diet or to individual genetic make-up–it stands to reason that perhaps at some time in the future, we will discover a genetic matrix that allows us to see how traumas may influence genetics through generations.
For many decades, Native American and other indigenous scholars, activists, practitioners, teachers, and healers around the world have been working to rectify the imbalances within their communities and in political and social relationships with the dominant cultures to which their peoples have been subsumed and by whom they have long been oppressed. Many have published and taught worldwide. Many are themselves academics and/or practitioners trained in western and indigenous disciplines, systems of knowledge, and ways of knowing (Churchill 2004; deLoria 2006; Nordstrom 1997, Prechtel 1999 and 2004; Tedlock 2005). They have long known that violence in one generation has a long arm and can affect many generations afterwards if healing does not take place. They also know that ritual and non-cognitive ways of accessing knowledge and understanding can be more effective than simple intellectual understanding.
For instance, in the early 1990s, the Lakota undertook a ritual of commemoration of the ancestors who had been killed in the Wounded Knee massacre at the end of the 19th century. The ritual involved a 10-day ride along the same route the tribe had fled with the American military at their heels in the dead of winter. This ride was done for four years consecutively in the middle of winter to remember the hardships their ancestors had undergone. It was also done to honor the dead and to finally put them to rest. As one of the leaders of the ride stated, “The ancestors have never gone thorugh the process, the ritual that is usually accorded to the individual or the family that has lost a loved one. In that time, they are in a period of mourning. My brothers and I…decided that we need to do this spiritual ceremony for wiping the tears…Our nation could not pull itself out of that state they were in after that tragic event. So we will go through that process of wiping the tears of our people….We will rewrite history the way we have been told orally by our grandparents. The ceremony after it is concluded will be like turning a page in history” (Wiping the Tears of Seven Generations, Moreno and Rhine, 1992).
Such approaches to violent experience, contrary to Western approaches rooted in medical and psychological or political models, address the transcendent, or spiritual experience of violence and offer palliative responses that are often carried in the cultural and spiritual practices and traditions of the wounded – and wounding – cultures. Without this type of reconfiguration of experience within a community or an individual, the distortion of perception and experience can continue unabated. Attempting to change these patterns simply through intellectual understandings, behavioral methods, and other methods often do not work due to the level of collective trauma, both primary and secondary, that has been experienced.
This is due, in part, to the fact that mass forms of violence and their attendant problems can significantly alter cultural symbolism and meaning systems and set in motion certain forms of social action that may lead to further violence (Isaenko and Petschauer 1994; Menon and Fuller 2000; Volkan 2004; Volkan and Itzkowitz 1994). For instance, we know that the genocide of one group by another often results in the desire for revenge by the surviving victims. Or the belief in an all-loving God can shift to believing God wishes for revenge for the loss of innocents. The experience of overwhelming loss and trauma shifts perception towards creating pain in return for pain or it can be internalized into a culture that does not thrive. This has been the situation in Belaev, Russia, where terrorists took control of an elementary school in which dozens of men, women and children were killed when the captors set off a suicide bomb. Almost a decade later, researchers have noted that Belaev, once a small and thriving town, has become like a husk, with many of the young people leaving never to return. Anyone who has gone through a major life trauma that often there is a feeling of being “off” in more than emotional ways; it may feel like one is leaning outside of the body or existing in an altered dimension much as one might feel when in a deep state of meditation or relaxation when the lens of awareness shifts.
So it is that compassion fatigue may actually be a concrete form of “emotional contagion” in which we are affected on multiple levels: physically, emotionally, mentally, and energetically. Our entire body/mind is dramatically altered. All we have to do is go to a violent or frightening film to know that we can, along with a group of others sharing in the same experience, even vicariously, can be strongly affected during and after the event. The degree to which we are resilient in the face of such effects are determined by the complexity of spheres discussed by Danieli and by the ways in which we may be interconnected on these multiple levels. As she puts it, “Integration of the trauma must take place in all of life’s relevant dimensions or systems and cannot be accomplished by the individual alone” (Danieli, 1998, 7). Fixity must be shifted to flow.
Accessing Multiple Dimensions of Knowledge and Experience to Resolve and Ameliorate STS
How do we return to flow when we feel trapped in situations where “action is of no avail” (Herman, 1992, 32)? The children and adults most affected by the Chowchilla kidnapping were those who froze in the face of overwhelming terror. Those who went into action and thus affected the rescuing of the group have been shown to be more resilient, as have been their families (Terr, 1990).
It is the freezing up that occurs in the face of hearing about or experiencing an overwhelming experience that renders us vulnerable to PTSD and/or STS. Certainly when we are helpers or caregivers of individuals or groups whose situation is intractable, we may find ourselves feeling overwhelmed and–frozen. Helplessness is a key element in developing symptoms of STS. We feel as if there is nothing to do even while we are bombarded daily with the unrelenting pain of others.
Peter Levine, author of Waking the Tiger, discovered in his psychotherapy practice that the experience of freezing and the concomitant fixation in the psyche on the traumatizing event is what must be addressed. Strictly intellectual understandings of an event cannot generally access this state. In an example he gave of a client who had been in a car accident many years previously and had since been suffering from intractable anxiety, he described how a sudden shift as they were talking into her becoming aware of an image of very large tiger in the room made him curious. She was suddenly quite inexplicably afraid of this imaginary being and wanted to stop thinking about this large. powerful animal who, she said, was about to jump on her. He told her to stay in her mind with the tiger, rather than shutting it out. With Levine’s support, she continued with the use of the image that had been started and, using a method known as “active imagination”, Levine encouraged her to face the tiger, rather than fleeing. She did as he instructed and in her mind, the tiger stopped in its tracks and then ran the other way. This single moment cured her symptoms permanently. It seemed like a miracle (Levine, 1997).
Yet, Levine followed this thread and began to understand that neurobiologically, we need to be able to respond to trauma or process it later by finding a way to move through it, whether in actual physical action or in some ensuing process. Such processes can involve any combination of meditation, ritual, art, and play. These are methods that indigenous systems of healing have used for thousands of years and that have in many ways been lost in the Western fascination with the rational mind, machines, and scientific methods for measuring and treating distress. All of them enable us to drop into levels of perception much like trance. Within trance states, a source of healing can be found. Professor of religion Lawrence Sullivan notes: “The goal of many healing rituals is to help the sufferer experience wholeness….[These are] primarily images of a time which is no longer available, which can only be described in mythic terms, or can only be enacted symbolically through performances and ritual” (Sullivan, 1993).
Meditation can help us shift perception and help us work with states of hyperarousal and dissocation and to access a state of wholeness. Art and ritual can provide us with ways to return to the state of trauma or the freezing that we felt and find creative and non-cognitive ways to move through them. We reaccess our innate wholeness which is never truly lost. This process is very much like having a dream when asleep where situations may resolve in ways that seem magical, yet their impact may be no less important than if they had happened in a waking state on more concrete levels. Just as Levine’s client found relief through an intrusive image that led to movement out of a state of feeling trapped, or just as the Lakota engaged a rigourous 4-year ritual to help their community put to rest the unquiet dead that had haunted them in the form of depression, alcoholism, a loss of meaning and community, so we can do the same.
All of this and more can also become play. When we are playing, we are in a spontaenous state. We are able to flow and to access new levels of self-awareness. On the other hand, when we are feeling paralyzed from our own or another’s trauma, we often lose our spontaneity and our capacity to play. In order to feel safe, we can slip into a state of hypervigilance. Play and spontaneity cannot exist when we are hyperaroused. We literally have no time nor space to let our alertness to a real or imagined potential threat drop.
All of these methods ultimately help us access trance states. It has been argued that an experience of violence puts us into a state of altered awareness (Mann and Culbertson, 2006). When we are in a car accident, we may have a sensation that time is slowing down and many minutes go by, only to be told afterwards that it was merely seconds. Overwhelming experiences repress experience of the body in order to numb physical or emotional pain as is required to continue bodily functions like running or fighting. This is a common response to overwhelming experiences called “dissociation” in western psychiatry and psychology. We enter into a mind-body space which overrides—takes over—our normal, day-to-day perceptual reality in radical ways. So, in the midst of snipers and bombs families attend to day-to-day tasks, as Nordstrom and Robben (1995) note is a normal condition of human beings attempting to survive in war.
Within this realm of experience, as the body functions and does what it needs to do, other experiences and states of being may also be operating, as is graphically shown by Christopher Hedges, a former New York Times war correspondent:
When we ingest the anodyne of war we feel what those we strive to destroy feel….It is the same narcotic. I partook of it for many years. And like every recovering addict there is a part of me that remains nostalgic for war’s simplicity and high, even as I cope with the scars it has left behind, mourn the deaths of those I worked with, and struggle with the bestiality I would have been better off not witnessing. There is a part of me—maybe it is a part of many of us—that decided at certain moments I would rather die like this than go back to the routine of life. The chance to exist for an intense and overpowering moment, even if it meant certain oblivion, seemed worth it in the midst of war—and very stupid once the war ended (Hedges, 2002, 5).
When Hedges speaks of “this part of me”—he is working around the edges of something that is more than simply emotion, ego, or drive. He shows graphically how one is pulled by something out of control—he speaks of something that is like a siren, luring him into a kind of irrational madness. Why is this? This state of disembodied embodiment after experiencing violence is critical.
We all know that fear can temporarily paralyze us and alter our frame of mind. Certainly when we are witness to someone else’s pain from a current or past even and we have no power to control or change the situation, we feel literally frozen. In actuality, we are often in a state of trance–a trauma trance. We are thrown out of ordinary reality and into something extraordinary, albeit difficult.
Yet the very nature of the human body and mind is movement. Within trance, time moves differently and space is perceived in new ways. Whether time and space are dislocated from violence or in the face of difficulty or whether such shifts are evoked from positive causes, the experience is fundamentally the same. Therefore, facilitating movement is a way to reaccess and continue to develop a state of wholeness. As Lawrence Sullivan puts it, “Part of overcoming illness and restoring health is to regraph the person in his or her own space” (Sullivan, 1993). This is an explicit goal of the use of meditation, art, ritual and play.
We can see this in meditation when we attempt to observe the breath and find out that our mind continues nonetheless to chatter without ceasing and our physical sensations can dramatically shift and change from moment to moment. We can also suddenly feel as if we are out of our body or that time stops. On the other hand, we also can experience in meditation being hung up in an emotional state such as anger. It may seem we cannot stop feeling this way. This kind of emotional fixation is in and of itself a trance state. From a neurobiological perspective, this is actually true. Particularly if we are habituated into certain emotional and mental patterns, our brain is literally hardwired to fire the exact same neurons down the exact same pathway over and over again. This is literally a kind of biological fixity. This physical pattern then effects our emotional patterns and visa versa. Within the realm of energy, it is as if our energy field is distorted in a particular way and thus even while we may understand intellectually that we can change our state, we may not be able to shift.
Therefore, any activity that promotes movement, connection, and flow are helpful. These can take place on intellectual levels. Certainly having knowledge of what Secondary Traumatic Stress is can help us identify what is happening. Without this knowledge, we may think we are crazy and even be ashamed that we are not coping well enough. Knowledge promotes flow. The more we know, the more we can exit from erroneous self-concepts.
We can also work with emotions. One of the main things lost in the wake of trauma, whether primary or secondary, is a sense of strength, safety and trust. These feelings can be replaced by fear, anger, frustration, and even numbness–a lack of feeling. Numbness is the very extreme end of lack of flow: when we are numb, we are frozen. The doors are shut. Developing ways to continually reaccess and build upon our innate strengths, however we may define them, is critical. This is particularly true when we may experience that our capacity for empathy, a condition of emotional sensitivity to others’ pain, seems to cause our distress. Various forms of meditation can help us begin to understand the constantly moving nature of emotional states and how to use states of trance to shift or unwind. Like our mind, emotions are constantly shifting and are multidimensional: we may be feeling angry, sad, and even happy all at the same time. The key is to develop more and more subtle levels of awareness of ourselves so that we are not just listening to the dominant feeling.
On the other hand, we may truly be stuck in anger, for instance. Often the quality of emotional “stuckness” is a result of our judgment about feeling something. Or we may be afraid that if we allow ourselves to feel fear or anger fully, it will cause us to behave badly or we may even destroy our relationships. Therefore, reinstating flow means honoring and allowing the free movement of an emotion through our body/mind. Trance states provide us with this tool. This might involve actually using physical movement or simply dropping into feeling the sensations stimulated by the emotion and staying with them, whether we shake, start to cry, or need to fall to the ground. Brad Keeney talks about this as “shaking medicine” indigenous to the Bushmen of Australia: “The complement to relaxation is arousal….heightened arousal, whether through wild dancing, spontaneous jumping up and down, or body shaking, is as valuable a healing and transformational practice as sitting quietly in the lotus position” (Keeney, 2007, 5). Among the Bushmen, the practice of shaking into a state of deep trance is honed to a fine tool in which the whole group can feel the presence of God and Spirit entering into the circle. This energy they then use to heal imbalances in the mind and body of individuals in the group or of the whole.
Because the emotions and the energy body which surrounds and interpenetrates us are intricately connected, any process that stimulates emotional flow or its inverse, energetic flow, will release what is blocked. Ritual and art enable us to access motion and flow. Like a dream experienced when asleep, these non-cognitive modes of perception access deeper levels of the unconscious and enable us to move to a different place in ourselves.
Conclusion
Within the framework of the multidimensionality of trauma, whether experienced directly as PTSD or STD, it is critical to understand the trance-like nature of trauma. We get pulled into a state in which we are fixed or frozen and in which we feel overwhelming helplessness. Whether we are a victim or a witness in some way, the experience is fundamentally the same. Particularly given the fact that we live in a society in which multigenerational legacies of trauma cannot be avoided–whether through our ancestral history or by witnessing events in the media–we are all in some way entrained into a state of trance. Within this larger framework given to us by both Western science and indigenous healing traditions, we can find useful tools to keep us moving, to keep us fresh. We can regraph our bodies and minds in time so that we continually access states of wholeness. As Sullivan puts it: “In many ways disease and episodes of sickness remind people that meaning is an achievement. The notion that human beings live meaningful lives is both a problem and a promise. In the face of disease and other challenges that becloud meaning or disclose it in painful glimpses, you are impelled to try to discover, clarify, or achieve meaning through creative expression. Similarly, researchers of STS note the very human side of learning to care:
“But engaging [the power of trauma] can bring us to the edge of the human condition and offer us opportunities to move beyond the common distractions of life, which frees us to deal with the unspeakable which is happening in our very experience” (Stamm, 1999).
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