Part 2 of a 7 Part Series
(The entire Matrix of Clinician Distress series is available in article and podcast format - see footnote for more explanation on how to find.)
Burnout, Compassion Fatigue, and Moral Injury
Burnout - The Parallel Epidemic Which Preceded Covid-19
I want you to know at the outset that I’m no stranger to burnout. I could’ve been its poster child. And that’s exactly why I went into physician coaching as I felt that if I could work my way through it (and I did, with a coach-informed therapist), I’d devote myself to help others understand and resolve it. I studied it intensely and, as a psychiatrist specializing in stress, developed a novel non-clinical understanding of it and a very pragmatic systematic approach to resolving it.
While many are so used to seeing dramatic attention-getting statistics that they gloss over them, this one ought to compel you to pause to reflect on its magnitude and its implications.
50% of Clinicians Suffering From Burnout
Numerous studies, some conducted annually over the last five years, indicate that upwards of 50% of physicians (and likely nurses, though the studies are less prominent) are currently grappling with burnout to some extent.
Defined according to criteria progressively established by Christina Maslach and Richard Leiter, the essence of the burnout syndrome is this: it’s an occupational stress syndrome characterized by fatigue, detachment, and a reduced sense of accomplishment which especially afflicts people who do “people work” of some kind.
What’s important to understand is that burnout is not like many other illnesses or injuries where you either have it or you don’t.
Rather, translating Maslach and Leiter’s three core criteria – exhaustion, detachment, and reduced accomplishment – into linear scales, I see it as a syndrome showing manifestations of varying intensity in three key domains: the energy domain, the active connection domain, and the professional efficacy domain.
Three Domains of Burnout Symptoms
Additionally, as we break it down into how stress reactions are known to cluster in four key types of manifestations, it helps to realize that each of these domains really ought to be considered as having subdomains of symptom manifestation. Presuming Maslach and Leiter are correct in proposing that these three domains are the main ones to be focused on in the burnout syndrome, my study over the years suggests that we can expand the symptom manifestation of each of these domains as follows:
Active Connection Domain
Professional Efficacy Domain
Actual work output considering both quantity or quality
One’s sense of their output, their accomplishment, their effectiveness, the value of their own effort.
As we have all experienced in our various work and life endeavors, depending on a mix of factors, you can have variable degrees of energy, connection and sense of your effectiveness.
So, think of each of these three domains with their subdomains as existing on a linear continuum. In this example, far left is the depletion, negative state; far right is the wellbeing, positive state.
Three Simple Zones – Don't Have It; Getting It; Got It.
So instead of thinking about burnout as an “on-off” phenomenon, I.e. you either have it or you don’t, I’ve found it helpful to think about it as existing on a continuum of severity with varying presentations in each of the domains.
It’s not a matter of either being “okay” with no burnout or “burned out.” There's an intermediate zone.
And so I initially divided it up into three admittedly very non-scientifically labeled phases:
I’m “Okay” - i.e. I am in functional, operational mode with no apparent burnout. This is the “Okayness” zone. Most of us, including most clinicians, operate in this Okayness zone.
I’m getting beaten up and feeling ragged and weary but still fully operational although at a cost to my energy. This is the “Weardown” zone.
I’m burned out, fried. This is the “Burnout” zone. But even here, I'm still sufficiently operational though the quality of my performance may be diminishing.
Five Zones Seems More Appropriate
But this felt incomplete as I also realized that there was a zone above “Okayness” and a zone below “Burnout.” I termed these “Engagement” and “Meltdown.”
Engagement is that state of being “in flow.” It doesn’t mean that work is not challenging but rather that it’s fulfilling and energizing and doesn't deplete you. It’s in sync with your vision and objectives.
At the other end of the scale, Meltdown is severe burnout where you see demonstrable effect on one’s performance. You're not performing sufficiently and may be prone to error which in healthcare can have drastic consequences.
So the five-zone continuum looks like this:
Most of us reside in a state of “Okayness." “Okay” is not necessarily healthy; it’s just okay, the absence of overt illness.
A couch potato may not be sick, but they’re not top-notch “well” in the sense of energized and engaged. In a way, they’re in a pre-illness state; they’re an illness waiting to happen. Realize then that we start our descent into Weardown and then Burnout not from a state of optimal engagement and top-notch wellness but one that is already pre-illness-based.
The next lower zone, Weardown, is like the couch potato now having chest pain which turns out to be angina. Angina is not a disease per se. It’s a symptom complex indicating you’ve got heart disease caused by blockage of your heart’s blood supply.
Yes, as your heart is just like the other muscles you’re more familiar with like your biceps, it needs a blood supply to keep it going. As a specialized muscle, the heart has its own blood supply, the coronary arteries. When the heart uses up too much energy as through extreme exertion, or when the coronary arteries can’t deliver enough blood flow to the heart even at its resting stage because they’re all gunked up with sludge, it causes pain. That’s angina. Weardown is just like angina.
When the blocked arteries actually cause the heart muscle injury and part of that muscle dies (i.e. “infarcts”), that’s a myocardial infarction or “heart attack.”
Burnout is like a heart attack. The heart’s arteries are blocked and they’re not delivering the blood flow the heart needs. When the heart doesn’t get the blood it needs, it sends signals, pain for one. That’s the crushing pain of a heart attack.
Sometimes, the heart’s blockage can be so severe that it can cause the heart to go into dangerous rhythms, or make it so weak that it can’t pump enough blood to the brain, the lungs, or the other organs in the body. That’s when you call the emergency cardiac team for drastic measures to keep the heart and the rest of the body going. We call it a “code blue.” That’s a life-threatening cardiac emergency.
Severe burnout, i.e. Meltdown, is such a life-threatening emergency. It is the “code blue” stage of burnout and is truly an occupational emergency.
It bears repeating that studies over the past several years consistently show that more than 50% of physicians currently are experiencing some degree of burnout. Reflect on that for a moment.
That's like saying more than half of your workforce either has severe angina or is having a heart attack and worse, there's a stream of Code Blues lining up.
What’s the Impact of Burnout?
Greatly diminished quality of life.
Diminished investment in work which is comprised of patient care.
Increased risk of healthcare error.
Increased attrition from the current clinical staff position and thus disruption of the workflow of the care team.
Increased career transition out of clinical practice altogether.
Increased risk of substance misuse and abuse.
Increased risk of depression and suicide.
Have you ever been so emotionally spent that you felt like you had nothing left to offer? When you’re too used up, there’s nothing left to go around. The well of caring has dried up.
In short, that’s compassion fatigue.
Sometimes, what looks like compassion fatigue is actually a strategic emotional ecology decision that might better be termed “compassion restriction.” But it’s not a decision in the conscious sense. Rather, it’s an unconscious restriction of the emotional flow from the well.
You may not know that the body has a variety of these sorts of self preservation “failsafes” built in. For example, when you’re out in the freezing cold and you’re losing critically needed body temperature, there’s a pre-programmed failsafe that orders the peripheral and superficial circulatory system - the tiny arteries near the surface of the skin - to close up so as to shut down any further warm blood flow to the surface and thus prevent further heat loss and preserve critically important body temperature. All in the service of preventing any more loss of body heat through the skin. Of course, that emergency bypass mechanism serves a beneficial purpose for only a limited time. Then, because of lack of necessary blood flow, frostbite kicks in.
But it's important to stress that while compensatory failsafe mechanisms exist, they are designed only as emergency fall backs and thus are short-lived in their duration of effectiveness. We ought to think about the “elective emotional ecology” of compassion fatigue as such a failsafe mechanism.
How Does Compassion Fatigue Fit With Our Understanding Of Stress?
Most people show an array of symptoms when they experience stress, especially chronic stress. Stress activates a stress response which consists of a variety of emotional and physiological cascades that take a toll on the body. If there’s such a thing as a “good emotion” bank account, stress uses it up. Quickly. Stress causes a major draw on the emotion bank account; it’s an emotion-depletion machine. And chronically, it can dry up the emotional bank account. Like your bank account, that well needs to be replenished on a regular basis. Unremitting stress prevents that replenishment from happening. Chronic stress is like continuous war.
What do we look like when we’re stressed?
We’ve all been there. Stressed. Some to the max, some on an ongoing basis.
While there are a host of physiological and psychological responses to stress, I think two processes pertaining to our emotional regulation really deserve highlighting: affect constriction (recall above emotional ecology); and affective rawness.
This is like how you feel when you’re trying to pay attention and express concern but when you’re war weary or so sleep-deprived, you’re like a zombie. You have a diminished affective range ("blunted affect"), sometimes approaching emotional flatness, the equivalent of an empty gas tank.
Think of someone who used to talk with normal voice volume and modulation and who now talks in diminished monotone. Not that they want to. It’s just that’s how it comes out.
This is the loss of the ability to hold one’s emotions in check, predominantly the unpleasant or “negative” emotions: anger, anxiety, sadness, shame, hurt.
Irritability seems to be the prominent manifestation. Easy tearfulness another. The negative emotions now easily flood the system.
Like pulling off a scab causing the underlying wound to seep, the same loss of protection happens with affect dysregulation. It’s probably wired in as a core instinct; when we’re hungry, thirsty, tired … irritability surfaces. And, it can get nasty because it's disinhibited; there's no protection against it. It's reactive, impulsive in quality.
Emotional fragility is another manifestation of affective rawness. It’s sometimes mis-termed emotional lability. But emotional lability is more indicative of dysregulated affect as a whole, both the negative and positive emotions. So in emotional lability just as you might see disproportionate reactive anger, you’ll also see inappropriate reactive happiness, sometimes bordering on mania.
With Emotional Fragility, there’s easy breakthrough of sadness and tearfulness; and an intensification and outward expression, often flooding, of mostly negative emotions.
Where Compassion Fatigue Fits In The Clinician Distress Matrix
First realize that though it frequently accompanies it, compassion fatigue can exist independently of burnout.
But when considering it as part of the phenomenology of burnout, it's a manifestation of emotional exhaustion on the Energy continuum. Emotional exhaustion is perhaps the most prominent symptom seen in burnout.
Realize, it’s not that I don’t care; it’s that I can’t care. I feel like I have nothing else to give. Even though I WANT to care.Even though that’s “who I am” - a caring person.
In fact, this very contrast between who I’ve defined myself to be and how I’m feeling and presenting now creates a core identity conflict. And that dyssynchrony creates pain for the care giver, (note: care-giver), adding to their negative emotional load and further depleting their emotional bank account.
In this way, the overall dysphoric state of burnout itself becomes its own pain syndrome, and combined, they intensify each other. And the more one can’t make it go away, the more frustrated and trapped one feels, one’s emotional reserves are depleted even further. It’s like the “depression of depression” – not only do I have depression, I’m depressed that I’m so depressed.
As you can see, the syndrome is wired to create its own self-acceleration.
Often the compound effect of burnout and “depression about burnout” leads one into a psychological downward spiral which can easily become a death spiral. The analogy to a plane’s death spiral is an apt one. Pilots describe the death spiral as a phenomenon in which the rapidly-diving plane can no longer right itself as the lift adjusters on the back of the wings can not long hold up or make sufficient timely difference in pulling the plane away from its nosedive and correcting the accelerated descent.
When a clinician feels they’re shortchanging their patients by not manifesting the authentic spirit of caring they normally provide, they feel like they’re not being true to themselves.
“This is not me, it’s not who I am. I’m a caring person who has chosen to take care of sick people.”
But that coexists with the observation
“But this non-caring person is who I am right now.”
And then concurrently, perhaps unconsciously, a sentiment surfaces that says
“But I don’t want it to be who I am” as if to say to oneself, “make it go away.”
But you can’t make it go away until you understand what's causing it and name its core components. The longer that discrepancy stays in place, the longer the persistence of pain. It’s a deep internal dissonance, a contrast between the present self and the former self. And that deep dissonance, that pain, causes emotional depletion. And that emotional depletion blends with the emotional depletion of the burnout syndrome itself, causing a massive draw on one’s emotional bank account. It accelerates emotional bankruptcy.
Thus, the detrimental impact of compassion fatigue is not just its pulling back of kindness and compassion. This seldom recognized complex component of compassion fatigue intensifies my war not just with the syndrome but with myself for having it and being stuck in it.
That's why one of the early tasks of the coach or therapist is to help the burned out doc or nurse (for short - clinician) stop adding to their misery via such compounding and self-criticism.
What Is The Impact Of Compassion Fatigue?
A person with compassion fatigue is not only less available emotionally and authentically, that diminished emotional energy (or “chi”) diminishes their clinical effectiveness. Further, due to this tying them up in a war with themselves, it makes them less available overall for the complex healthcare work at hand.
Imagine being betrayed by a friend, for example by that friend’s having hurtfully revealed a shared confidence or by their abandoning your relationship without warning and then bad-mouthing you.
You’re likely to experience many feelings all at once - hurt, anger, sadness …. Most of us have experienced some sort of betrayal at some point in our personal lives and have felt its intense emotional impact.
What is moral injury? At its core, it’s an occurrence of a hurtful act rooted in a betrayal.
Dr. Jonathan Shay extensively studied this phenomenon in Vietnam veterans grappling with their war experience. Initially, he presumed it was part of PTSD but eventually concluded that it was really a separate phenomenon.
Here's Shay’s definition:
Moral injury is present when:
There has been a betrayal of what's right
… by someone who holds legitimate authority
… in a high-stakes situation.
Failure of leadership in addressing the injustice, or worse, complicity of leadership in causing the betrayal (what he refers to as leadership malpractice) has profound effects.
It destroys the capacity for social trust in that person’s mental and social worlds.
Shay regards this as a kind of wound contamination in the mind, preventing healing and leaking toxins. He says that when the capacity for trust is destroyed, its place is filled by the active expectancy of harm, exploitation, or humiliation.
Needless to say, living in that state of mind is counter to, and even obstructive of, wellbeing.
Moral injury can occur when someone, generally in a position of authority or influence betrays us and it has hurtful consequences. We can also be betrayed by whole institutions, for example, by being fired unfairly, or not being supported in a truth-speaking stance we have taken, or not being treated fairly by the justice system. Shay later expanded the syndrome definition to include betrayal by oneself of one's own higher moral values.
No matter its source, moral injury is never emotionally neutral; it invariably rouses intense negative emotions manifesting as some combination of hurt, anger, sadness, and shame.
Where Does Moral Injury Fit In To The Clinician Distress Matrix?
Increasingly, moral injury is being experienced by clinicians in the setting of their caregiving work. Thus, burnout and moral injury can go hand in hand, one intensifying the detrimental impact of the other. When Moral Injury occurs in the context of burnout, it intensifies the diminished self-efficacy component of the burnout criterion. It is vital that coaches and therapists draw out this aspect of the client’s presentation; simply dismissing it as part of the overall burnout picture is inadequate and the client inevitably stays stuck as this important dynamic remains unresolved.
I have failed myself or I have been betrayed by another and harmed by the betrayal. It is my saying “I feel ineffective, even worthless,” because I have failed my higher self, or because my ideal self has been assaulted by another person in authority and made inaccessible to me.
And when I feel that I and what I stand for, my higher values, have been betrayed - or worse, assaulted - by authorities above me which have compromised my ideal self, or when I am put in a situation where I am forced to act against my own higher values, or where I myself have knowingly acted in violation of my own higher values, then I may experience that syndrome we now refer to as moral injury.
In many ways, such a self-failure results in a disconnection from one’s self. Like compassion fatigue, that disconnection itself results in a fundamental misalignment with our operational schema of who one is as a person and results in a state of pain. And that pain blends with the dysphoria present in any other concurrent distress syndrome.
In a broad sense, independent of burnout, moral injury exists in its own realm, that of one’s schema of one’s self, who you really are and what you stand for. Again it's important to emphasize that moral injury’s response cascade with its internal dialogue, complex emotions and behavioral response can operate entirely separately from one’s burnout. In many ways, the moral injury (or moral assault) exists as its own separate stress event resulting in its own stress response cascade.
As Shay has emphatically argued, moral injury is perhaps even more profound in its detrimental psychological impact than PTSD.
Moral injury can cause virtually irreparable alterations in one’s core character, i.e. personality configuration, in one’s schema of themselves and the world, in one’s very way of being in the world. One retreats from the world much in the same way that a wounded animal retreats from view to the shaded bushes.
What is the impact of moral injury?
Those who have experienced major moral injury often become overwhelmed with cynicism and bitterness, or in the case of betrayal of one's own moral code, shame and self-recrimination.
They begin to isolate themselves from others and progressively retreat from the ordinary communal world. In many ways, the residual symptoms of moral injury look remarkably similar to chronic depression.
Intensification of burnout and compassion fatigue.
Retreat from investment and full engagement with work and diminished investment in patient care and team collaboration.
Who’s At Risk For Burnout, Compassion Fatigue, and Moral Injury?
Every committed, compassionate, altruistic person who pursues “people work,” whether in direct patient care or larger humanitarian endeavors working for the greater good of mankind such as in social justice; education of the underprivileged; peace work; law enforcement; and social work to name a few. Each is at risk of each of these syndromes – burnout, compassion fatigue and moral injury – occurring individually or in combination, simply by nature of the immensity of the task.
One of the key challenges is to help these highly motivated people understand the nearly inevitable dysphoria that results when we don’t meet our objectives or have become so depleted that we’ve lost our compassion or our investment in the work.
How do people customarily deal with that demoralization, that disillusionment?
Except in the case of externally caused distress, most of us are prone toward self blame. “I failed.” And further … “not only did I fail, look at me, I’m a mess! What kind of a helper am I?”
Here, compounding the self-sabotage, we see an intensification of the self-devaluation that leads to worthlessness and generates into shame and self-loathing. That experiential state inevitably recruits from our memory of past experience and builds on any earlier such experience. And in reactivating those past experiences with their attendant hurt, anger and shame, it re-enlivens those experiences as though they were currently occurring. And, bringing that emotional complex into the psychic stew blurs the clear demarcation between present and past. So in addition to the current distress, the past distress is re-enlivened and re-experienced as though currently occurring. This reactivation of the memories of prior experience is generally true of all psychological trauma.
This key concept bears repeating: these are separate phenomena that often co-exist.
Compassion fatigue can occur independently from burnout or moral injury.
Moral injury can occur independently from burnout or compassion fatigue.
And burnout can occur with neither compassion fatigue or moral injury.
What makes it confusing for so many is that we often see both compassion fatigue and moral injury in the context of a clinician’s burnout.
But when concurrently occurring in any combination and also stemming from events in the same arena of our work life, albeit often in some vague reciprocal cause-and-effect way, their combined psychological effect is exponentially more intense. And it can be very challenging to disentangle. This is especially so if all three are present. Nevertheless, distinguishing amongst them is critical to successfully addressing them.
Reflecting Back To The Clinician Distress Scenario Early In The Article
So going back to the earlier scenario in Part 1 where I said it had elements of all three.
What component of this distress is burnout?
If one has exhaustion, stress-induced detachment and a progressive sense of futility and diminished effectiveness in one’s role, burnout is most likely present.
What component of this distress is compassion fatigue?
It’s hard to feel compassionate when you’re furious, exhausted, and afraid. In fact, when you’re emotionally shutting down, it’s hard to feel anything. But compassion fatigue could exist entirely independently of the presence or absence of burnout.
What component of this distress is moral injury?
Thinking here of the vaccine and social protection protocol, here I am as a caregiver and I’m feeling that after all I’ve done, it feels like I’ve been betrayed by the people I’ve so willingly served. Betrayed also perhaps also by a state government or a socio-political movement that has incentivized this defiance. And perhaps even by my own healthcare institution that doesn’t want to hear my voice and doesn't really appreciate the complexity of what I feel nor apparently particularly care and simply wants me to keep working. This sense of betrayal of a common set of shared values leads to moral injury.
The Necessity And Challenge Of Careful Deconstruction Of The Distress Matrix
Too often, psychotherapists (who are psychological clinicians) and coaches are quick to arrive at the syndrome naming phase and call it a day, as if simply giving the phenomenon a label should magically make the distress disappear.
Of course, correctly naming a phenomenon or identifying such as a syndrome has inherent therapeutic benefit. But that’s just the beginning of the work. Simply making the general diagnosis and assigning a diagnostic label - “You’re burned out.” “You’ve got compassion fatigue.” “You’re experiencing moral injury.” is ultimately unproductive if not counter-productive.
These may be entirely valid observations, but all they are is terms, descriptions of the lived phenomena. They’re damaging because if you simply leave it there and don’t give the person the means to make sense of their experience including their uniquely composed distress syndrome and help them develop effective remedies, then they remain awash in their distress.
Approaches to Remedy – Systematically Dismantling Burnout, Compassion Fatigue and Moral Injury
In brief, here are the core tasks for the coach / therapist and the client:
Understand the array of phenomena and initially entertain as a tentative hypothesis what the syndrome is and what are its core manifesting symptoms.
Be able to tease them apart, and help the client do so.
In fact, as noted, simply being able to name what one is feeling and to know that there are well-supported approaches to their resolution can in and of itself be tremendously therapeutic. The suffering individual all but says “finally somebody who understands this multi-knotted complexity and has a way out.” And in doing so, you are then in a position to more accurately home in and collaboratively develop effective approaches to resolving them.
Because, let’s be frank, feeling crappy itself is a form of pain. It’s like the depression of depression I mentioned earlier. Not only do I have Major Depression with all of its symptoms, I’m depressed by the fact that I’m so depressed and can’t snap out of it.
Help that person talk about their intensely mixed emotional state and their “psychological stuckness” talking it out helps one make sense of it. It’s tremendously relieving.
Implant early on the fact that burnout and the other syndromes of distress are remediable. Emphasize that “there is a future that is free of this glum state, and that you can indeed get there. But it’s going to take patience and collaborative effort.” Remember that the more intense and more prolonged a distress syndrome, the more likelihood of there being a sense of hopelessness and despair. Perhaps more important than any other factor, these are significant drivers of suicide. The combination of pain and insolubility wear you down, cloud your thinking, and lead one to extreme measures.
Help the person identify the full array of stressors – the events, issues, and situations that are contributing. Be assured, there’s a truckload of them. They need to be articulated and elaborated upon.
Help the person begin to envision both a future state free of burnout and distress and also an ideal state of job, career and overall life wellbeing. What would that look and feel like? What ingredients should it have? As importantly, what should not be in the mix? Help them craft that vision and then help them explore the pathways toward achieving that.
Using the practical coaching mindset, help them focus on specific steps to address these and find an optimal way to introduce accountability for taking those steps.
Caution here: you can’t fix everything at once. Your ongoing task is to help them identify what’s one thing they can work on right now to alleviate their situation.
And an additional caution: this is not an invitation for a stern taskmaster approach. That will not only be counter-productive, it will psychologically harm the client. In essence, if they’ve not done the steps they said they would work on, your role is not to scold them and shame them into compliance. When someone is already brimming over with pain, fear, sadness, anger and shame, anything that adds to that is liable to cause overload and shutdown.
Simple mandates like “you need to be more compassionate” or “you need to get over that hurt - it’s just the way the system is” are indicative of the coach/therapist’s ignorance and insensitivity. A client who’s subjected to that ought to end the session and walk out. That counselor is in urgent need of supervision.
What can we who are not coaches or therapists but rather patients or even bosses do to help?
Cut our treaters some slack.
Stop being entitled and demanding and acting like a disgruntled consumer or a scolding boss. Recognize that your treater is a human being too who is not there to serve just you. They also have a life outside of medicine which may be stressed as well.
Feel and show appreciation; express it. Let them know that you’re aware of how much stress they’re under and you’re amazed at the work they do and how they’ve held up. And this applies to offering appreciation to the institution itself. Many dedicated administrators are working behind the scenes to keep their teams healthy and fully operational and staffing their areas in such a way as to ensure abidance by safety and non-contamination protocols. They could most definitely use your appreciation too. There are very few of us who are not touched by another's expression of appreciation.
Spread the word about how important this is to our healthcare workforce. Help others understand the clinician’s plate so that they're able to remain invested in the awesome challenge of providing compassionate care to all in need in these extremely challenging times.
Consider random acts of kindness. A flower arrangement, a gift basket, an appreciation card, whether to the treater him/herself or to the team or the front office - all go a long way in bringing a sense of acknowledgment and worthwhileness to the treater’s efforts. (And by the way, your act of kindness makes you feel good too!)
Here’s hoping by understanding these more fully, we can better utilize our diverse skills to resolve this parallel epidemic of clinician distress with its multiple components of burnout, compassion fatigue, and moral injury. And it’s not only vital that we do this for those mired in distress. It’s also in our own best interests. We too need a healthy, rested, engaged workforce who are fully invested in the challenging work of healthcare as all of us are the recipients of their extraordinarily skilled compassionate care.
In Part 3, we’ll examine the other syndromes often co-occurring in the matrix of clinician distress.