When we are tired of compassion: how mental healthcare fails

by Alicia Lukman

“A single death is a tragedy, a million deaths is a statistic.” Not only does desensitization occur upon witnessing atrocities, prolonged exposure to more mundane life-events can trigger similar responses. Mental health professionals, and more broadly, workers in the care sector, have reported being exhausted, irritable, and unable to concentrate on helping their clients recover. This is compassion fatigue. Unsurprisingly, this can severely reduce the quality of care mental health sufferers receive.

Compassion fatigue [1] occurs when one becomes distressed emotionally, physically, and/or spiritually due to frequent interaction with individuals suffering from trauma and mental health problems. As a result, it becomes difficult for one to empathise with others. This is a major issue in mental health care since many patients rely on long-term support from their therapists. If therapists distance themselves from the patients’ emotional states, whether it be deliberate or not, patients might not get the guidance they need to recover.

A related issue is the medicalisation of mental health. In campaigns countering mental illness stigma, depression is often likened to  physical ailments. It is a result of a chemical imbalance in the brain, which can be corrected with the use of antidepressants.  However, depression seems to be different from physical illnesses in the sense that the patient’s individual agency is disrupted, resulting in guilt or a sense of responsibility that people with physical illnesses generally don’t feel. Hence, depression must be treated in a manner which recognises the experiences of the sufferers from their perspective. The health professional, in this situation, does not have absolute authority over knowledge of the illness. Unfortunately, this has far too often been neglected in favour of more ‘efficient’ ways of treating depression such as the consumption of antidepressants.

Data from NHS Digital shows that in 2018, 70.9m prescriptions for antidepressants were given out in the UK, compared to 36m in 2008 [2]. While some of the rise can be credited to reduced stigma of seeking professional help, the flip side is that more patients are being prescribed antidepressants as they are much cheaper than regular therapy sessions, and hence seen as a more efficient way of dealing with mental health problems in an overstretched healthcare system.

Compassion fatigue and a medicalised approach are causally linked. Continued experiences of compassion fatigue may lead doctors to be more open to prescribing antidepressants to reduce the strain on the healthcare system. Antidepressants are seen as a ‘backup’ in case sufferers cannot get the therapy they need. How can we facilitate mental health care better, then? The natural answer points towards relieving the strain on the current system through investing in more resources. However, any approach which sought to ensure both the patient’s and therapist’s health must also consider minimising compassion fatigue in patient-therapist relationships.

We feel compassion fatigue because we take on the experiences of the other as our own. Listening to harrowing stories has the effect of vicariously living through these experiences ourselves. From the therapeutic perspective, the central issue is whether the experiences of another person are epistemically available to us, given that situations are not objectively perceived – rather, when we encounter any situation, it seems more likely that it is interpreted based on our past experiences. When we take experiences of the other as our own, we put ourselves in their shoes: how would we feel if we came across the situation they were in?

Using our imagination to place ourselves in the other person’s shoes causes us to presume the strong emotions involved in that situation. Repeated exposure to these kinds of emotions, especially as a caregiver or therapist, eventually may lead to a conscious effort to minimise the emotional effect involved in each interaction. Frazer, in providing a reinterpretation of Nietzsche’s concept of compassion, argues that the experience of pain in compassion causes us to ‘risk developing contempt for the compassion that forces us to suffer with them’ [3]. This contempt may lead us to get rid of compassion, severing this imaginative connection. Unfortunately, this causes the carer to be less effective in caring for the patient.

The core problem is that we assume that when we ‘place ourselves in another person’s shoes’, we are capable of re-living other people’s experiences through stories alone, adopting emotional states which we presume the other person to have had. The experiences of the other is inaccessible to us in the way that they experience it, however, since it is impossible to adopt the way other people see the world in its entirety. While this imaginative force does not prevent one from experiencing Mitleid, or ‘suffering-with’, it does limit one from recognising that each individual experiences and derives meaning from events uniquely. We can suffer, in the sense that we feel strong negative emotions when we place ourselves in the imagined situation. In doing this, however, we tend to ignore the other person’s experiences as their own.

A consequent issue is that because we try to prevent ourselves from being overwhelmed with negative emotions, we do not grant the other person adequate space to communicate their suffering to us. When someone confides in us, we may be compelled to quickly offer solutions to the issues we are told about. We want to offer methods we have ourselves found helpful in similar situations, or help them look at the problem in another, more productive way. Nietzsche, however, argues that this may stem from a less altruistic motivation:

“The “religion of compassion” (or “the heart”) bids him help, and he thinks he has helped best when he has helped most speedily! If you adherents of this religion actually have the same sentiments towards yourselves which you have towards your fellows, if you are unwilling to endure your own suffering even for an hour, and continually forestall all possible misfortune, if you regard suffering and pain generally as evil, as detestable, as deserving of annihilation, and as blots on existence, well, you have then, besides your religion of compassion, yet another religion in your heart (and this is perhaps the mother of the former) – the religion of smug ease.”

The Gay Science §338 [4]

Nietzsche proposes that the persistence we have to ‘cure’ the sufferer actually means that we regard their suffering as less valuable than our own. We generally would allow ourselves to feel sadness and pain – so why do we attempt to extirpate this in others? For Nietzsche, happiness and pain comes hand in hand. Both are essential for human experience. Not allowing ourselves to feel negative emotions is a mistake. We are essentially running away from a core part of what it takes to become a person who is fully engaged with the world around us.

Cognitive behavioural therapy, which provides patients with thinking frameworks which position their concerns and fears in a more positive manner, faces criticism on this end. I remember coming out of a CBT appointment feeling frustrated by being told that I should ‘de-catastrophise’. While I rationally could see how my line of thought is only one of the multitudes of possibilities available to me, this rational awareness does not translate into emotional calmness.

The focus on cognition made me feel like my emotions were dismissed, that it was the ‘wrong’ way to react to situations like this. More pertinently, I was unable to ‘get out’ of my depressive lens to adopt one which my therapist used when recommending me these thought strategies. The experience of depression does not only involve negative thinking patterns and low mood but an overarching sense of detachment from a ‘consensus reality’ experienced by those not depressed [5]. While someone with mild depression may still be able to recognize this alternative mode of perception, those suffering from major depression may no longer be able to conceive any other way to see the world. While the therapist may mean well, CBT fails to recognize this distinct mode of perception. It implies ‘that reality is not a problem, only the way we construe it’ [6]. For those with major depression, reality is the problem. This must first be understood in order to formulate the most fitting treatment for each individual suffering from depression.

The goal of ‘feeling better’ is present in practically every single mental health treatment. There seems to be a template, albeit approximate, on steps one can take to alleviate their pain. Nietzsche would doubtless be distasteful towards such hasty attempts to heal those in distress. While these templates may be practically necessary due to budgetary constraints in the healthcare system (there are simply not enough resources to provide personalised treatment for each patient), mental health care professionals should remain vigilant of their potential failure, given that these templates inherently do not recognize that the depressed person views the world from a completely different lens. Hence, mental health care professionals should not place the burden of failed treatments on themselves – if they do, they risk burnout and compassion fatigue, which only reduces their ability to help those they want to help.

One way mental health professionals can minimise compassion fatigue is to avoid suffering-with (mitleid) in favour of identifying-with (mitempfindung). While mitleid means we embody the negative emotions of others as if they were our own, with mitempfindung, the affective response remains: we identify with the suffering, but we also recognize that it is not ours. This allows mental health professionals to remain empathetic to the patient’s worries and emotional states while preventing themselves from getting sucked into these negative emotions. 

“While mitleid means we embody the negative emotions of others as if they were our own, with mitempfindung, the affective response remains: we identify with the suffering, but we also recognise that it is not ours”

The beauty of this idea is that it does not require the person to ‘mute’ their empathetic faculties. Rather, it rests on a simple, and perhaps unimpressive, premise: the experiences of any other person are opaque to us, so we should not attempt to place ourselves in their shoes. Any attempt to do so would only result in perceiving a translation of the series of events based on our lens of being in the world, which is not the same as accessing the other person’s mode of experience.

Alternatively, we may draw upon similar experiences in our past and reflect upon how we felt in those situations, but to always keep in mind that experiences are not felt in isolation, but in reference to the sum total of our past. The entirety of anyone’s past, and their interpretations, are simply inaccessible to an outsider. We must thus temper the visceral push to suffer with the other person, since this would only reinforce the pain the other is feeling, and is not an accurate reflection of what they feel.

This method allows us to become more empathetic towards another person’s suffering. Learning to not be overwhelmed by the intensity of others’ emotions enables us to become a better listener and provide more sustained support. Once we recognize that other’s experience of pain and sadness is opaque to us, the form of empathy exercise would be a more deliberative kind, rather than a gut reaction to hearing about a negative situation. We would then understand that while we might not be able to access another person’s mode of experience, their emotions are just as valuable as our own, and therefore must be regarded with the same degree of respect that we would grant ourselves. Our gut reaction may be difficult to overcome, but the important step is to go past this reaction to view the situation from a lens of putting the other in their shoes, rather than putting ourselves in their shoes. I am certainly unable to construct a fully fledged theory of secondary experience here, but in a practical sense this involves truly active listening and constant awareness of the experiences not being our own.

How one could develop this capacity without first experiencing the strong negative emotions associated with secondhand trauma, and then recovering from them, is still a foggy area. Further studies would greatly benefit the work of both mental health professionals and regular people helping their loved ones live with, and hopefully heal from, depression.

A compassionate way of life with minimal pain is possible. To find it, we would have to navigate the complexity of emotional experience and aim to work with it in a productive manner, rather than attempting to completely eliminate it to avoid pain.

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[1] www.compassionfatigue.org

[2] BMJ 2019;364:l1508

[3] Frazer, M. (2006). The Compassion of Zarathustra: Nietzsche on Sympathy and Strength. The Review Of Politics, 68(1), 49-78. doi: 10.1017/s0034670506000052

[4] GS §338

[5] Ratcliffe, M. (2015). Experiences of depression: a study in phenomenology. Oxford: Oxford University Press.

[6] Bentall, D. (1999). The medicalisation of misery: A critical realist analysis of the concept of depression. Journal Of Mental Health, 8(3), 261-274. doi: 10.1080/09638239917427

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