Posted: March 3, 2022
Author: Caitlin Brown, LMSW-Macro, E-RYT 500, Social Work Part-time Faculty

Introduction

 Whatever you do is never enough. You know, it's always do more... . And the more you do, the more it's expected." (de Figueiredo et al., 2014, p. 293)

"A lack of progress or feeling stuck with one or more clients can lead to compassion fatigue because it starts, for me, bringing up questions of 'What am I really doing here? Am I making any kind of difference?' Am I doing something wrong?'" (de Figueiredo et al., 2014, pp.291-292)

The quotes above are from service providers who work with highly traumatized children. What they are describing are some of the elements of burnout (BO) and compassion fatigue (CF). This paper will explain what burnout and compassion fatigue are, common signs and symptoms, various perspectives on BO and CF, and how yoga therapy can serve both as a treatment approach for existing BO and CF and as tool for prevention. The self-care aspects of yoga put it in a unique position for burnout prevention.

The term burnout was developed in the 1970s by two American psychologists, Herbert Freudenberger and Christina Maslach, and has been most studied in helping professionals but could occur in any profession (Schaufeli, 2017). According to Maslach (2003), burnout is defined as a condition in which one becomes exhausted and hopeless in response to long-term workplace stressors. Maslach (2003) identified 3 dimensions of burnout: exhaustion (emotional, physical, spiritual), depersonalization (cynicism), and a sense of ineffectiveness and lack of accomplishment. Rate of burnout vary by profession and study, but to synthesize the data, a meta-analysis of 40 studies on burnout prevalence among psychotherapists found the average proportion of therapist reporting moderate-high level of burnout was 55% (Simionato & Simpson, 2018).

A related but different term is compassion fatigue. It is "the exhaustion and negative emotional, physiological, biological, and cognitive effects resulting from the cumulative effects of empathic engagement with, and secondary exposure to, trauma." (de Figueiredo et al., 2014, p.286). Out of this experience with the indirect or secondary trauma exposure, one can develop secondary traumatic stress (STS) or vicarious trauma, which can mirror the symptoms of posttraumatic stress disorder (PTSD).   

Sometimes there is confusion between the terms BO, CF and STS. Burnout is generally a broader term that could occur in any occupation or cause, and is seen as a component of CF. CF is more specific, involves empathy as a core component of the work, and thus is seen as occurring in helping professions such as health care (doctors, nurses, etc.), teachers, social workers, caregivers, first responders and psychotherapists.  One model (Figure 1) of CF posits that BO + STS = CF. CF can also be conceptualized as a broader term that may not always include STS, but just working with people who are suffering in some way. For example, Newell and Nelson-Gardell (2014) state, "The chronic use of empathy combined with the day-to-day bureaucratic hurdles that exist for many
social workers such as agency stress, billing difficulties,
 and balancing clinical work with administrative work generate the experience of compassion fatigue" (p. 430). As a social worker myself, I am interested in not only the general issue of burnout but also in addressing compassion fatigue. Throughout the paper, there will be references to both BO and CF.

Important to note are the corresponding concepts of engagement and compassion satisfaction. Engagement is often thought as the positive antithesis of burnout and can be thought of along the same dimensions of burnout mentioned above but the positive end: "High energy, strong involvement, and a sense of efficacy" (Maslach & Leiter, 2016, p.104). Compassion satisfaction (CS) is the positive antithesis to CF and "is defined as the positive effect on providers' sense of fulfillment and pleasure resulting from effective clinical practice, particularly with traumatized populations" (de Figueiredo et al., 2014, p.287).

Causes, signs, and symptoms

Some of the causes of burnout are explored in the Areas of Worklife (AW) model of burnout (Maslach & Leiter, 2016). This model examines 6 key areas where imbalances can occur: workload, control, reward, community, fairness, and values.  Each of these areas exists on a continuum and chronic extremes on one end can lead to burnout. For example, "work overload contributes to burnout by depleting the capacity of people to meet the demands of the job" (Maslach & Leiter, 2016, p.105). If this is chronic, there is little time for people to recover and restore balance.

Symptoms can often manifest along the 3 dimensions of burnout (exhaustion, depersonalization, and a sense of ineffectiveness). The dimension of exhaustion often manifests in health-related symptoms such as "headaches, chronic fatigue, gastrointestinal disorders, muscle tension, hypertension, cold/flu episodes, and sleep disturbances" (Maslach & Leiter, 2016, p.106). Cardiovascular issues and mental health problems, including substance abuse are also commonly associated health issues. Burnout is especially correlated with depression (Maslach & Leiter, 2016). Depersonalization can manifest as interpersonal conflict or less engagement with clients. It can manifest as feelings of suspiciousness, frustration, or anger.  A sense of ineffectiveness can manifest as lower productivity and quality of work. For those with CF, additional symptoms of traumatic stress are often also present like intrusive thoughts, avoidance, hyperarousal, and feelings of fear or helplessness (de Figueiredo et al., 2014).

Perspectives on burnout and compassion fatigue

Western Medical Model

American culture, with puritanical roots focused on austere values of hard work, as well as America's focus on individualism and capitalism, often values burnout and does little to prevent it or treat it. "Pushing through", long hours, doing it all yourself, are all valued in the American work ethic. So although there are many recent research studies examining burnout (Shaufeli mentions 75,000 on Google Scholar in 2017) and a whole burnout prevention intervention industry, it is not surprising that this perspective (on ignoring burnout) would also translate to the American healthcare system. Burnout is not recognized by the American medical establishment as a diagnosable condition. This is not true in some other Western countries, most notably Sweden & the Netherlands. They both have burnout diagnoses and use the Maslach Burnout Inventory (this covers the 3 dimensions mentioned above) to aid in diagnosis, with a heavy focus on exhaustion. However Maslach & Leiter (2016) caution that this type of medical diagnosis can imply a one-dimensionality to burnout, which they argue is limiting.

In addition to American cultural values dictating recognition (or lack thereof) of burnout, the way the American healthcare system is set up also plays a role:

It is interesting that North American jurisdictions have been reluctant to recognize burnout as a clinical diagnosis, partially due to concerns about a flood of requests for disability coverage. The lack of an official diagnosis of burnout limits access to treatment, disability coverage, and workplace accommodations. Alternatively, disability applications have referred to depression, neurasthenia, or chronic fatigue. An unfortunate consequence is that inaccurate diagnoses may reduce possibilities for successful recovery and return to work. (Maslach & Leiter, 2016, p.108)

The current Western medical systems are either treating burnout with a narrowly-focused diagnosis or with indirect diagnoses that do not address the whole range of symptoms and experiences one may experience. For example, symptoms such as anxiety, depression, PTSD, fatigue, and trouble sleeping are often addressed through medication. Researchers have found correlations between psychotropic medication (particularly antidepressants) use and burnout (Leiter, 2013). Interventions are also focused on the individual level and do not address social or organizational factors, although there is research evidence that points to the contribution of these factors (Maslach & Leiter, 2016).

Yogic Model

The word yoga comes from the Sanskrit word "yuj", which means to yoke or unite. Yoga is union; union of the body with the breath, the mind and the spirit; in order to feel complete and whole; connected to a sense of higher Self or consciousness (Devi, 2007). It is a practice of self-actualization. Yoga therapy is the specific therapeutic application of yoga, generally done one-on-one with an individual to explore specific health, mental health or spiritual concerns. These concerns are examined from a yogic perspective and empower the individual to make changes using the teachings and practices of yoga (Lawrence, 2019). Yoga in the West is often associated with exercise, but it involves many different aspects, such as the chakras, the koshas, and the gunas, which will now be explored as they pertain to BO and CF.

Chakras

Chakra translates as wheel or vortex of energy. The chakras are energy centers in the body located within the shushumna, the main energy channel that parallels the spine. The chakras form where the ida and pingala (energy channels on each side of the shushumna) cross over each other at the shushumna, similar to the shape of a strand of DNA. There are seven main chakras in the body (Devi, 2020). Burnout is most closely associated with an imbalance in the manipura chakra, located in area of the solar plexus. The element associated with manipura is fire. The manipura chakra is also associated with our sense of efficacy, confidence, control, power, intellect, and vitality (Devi, 2020). From a chakra perspective, burnout can be seen as literally burning out the fire of the manipura chakra. This can happen from pushing too hard, overworking (perhaps from the work overload as mentioned previously) and can leave one feeling powerless, depleted, angry, and impatient with others. An imbalance in this chakra can also lead to digestive issues (burning out the digestive fire as well), substance abuse, and interpersonal conflicts, which correspond to some of the symptoms found in the research literature and mentioned previously. It is interesting to see how the symptoms of an imbalanced manipura chakra can align with symptoms within the 3 dimensions of burnout (exhaustion, depersonalization, and a sense of ineffectiveness).

Anahatha, the heart chakra, is above manipura and issues in manipura often affect the heart. The element of air is associated with anahatha so the fire from manipura that is burning out seeks the air of anahatha (Devi, 2020).  Compassion fatigue and vicarious trauma can be closely connected to an imbalanced anahatha chakra. This can manifest as having less compassion and empathy, a walled off heart. The cardiovascular issues found in the research literature and mentioned in signs and symptoms also connect with an anahatha imbalance (Devi, 2020).

Gunas

The gunas are the three main attributes of nature: Tamas (inactivity), rajas (activity) and sattva (balance). We need both inactivity and activity in balance (sattva). However, tamas can go to the extreme, inertia, and rajas can go to the opposite extreme, overactivity (Devi, 2020).  The tools of yoga can help one find sattva. Burnout can be a vacillation between too much tamas and much too rajas. In a rajasic state there can be a tendency to push beyond ones limits and then crash, which leads to a tamasic state, a feeling of being stuck, unable to get anything done, feeling unmotivated and uninspired (C. Stiles, personal communication, May 13, 2020).

Koshas

Burnout and CF can also be examined from the perspective of the panchamaya kosha model. Pancha means five, maya means consists of, but also illusion, and kosha means sheath or layer, often referred to as bodies. The sheaths can separate one from their true nature (one can get stuck in one of the layers), but this separation is an illusion (the maya) because we are already whole, we have the divine within. There are five koshas or layers of embodiment. They go from the outer to the inner layers of our being (Lawrence, 2019).  The outermost layer is the annamaya kosha or physical body.  From the view of this kosha, burnout manifests as physical health issues, such as digestive issues, muscle tension, and to some extent, fatigue (at least physical fatigue). Fatigue, the sense of just being zapped of energy, also manifests in the pranamaya kosha, the energy body. Sleep disturbances also manifest in the energy layer. Moving inward to the manomaya kosha, the mental/emotional layer, this is where compassion fatigue (the empathy fatigue) manifests, as well as difficulty concentrating. This is also where depression or other mental health issues associated with BO, CF, and vicarious trauma manifest. The fourth sheath is vijnyanamaya kosha, the wisdom or personality layer. Burnout here can show up as being directionless, unmotivated, forgetting the reasons one went into their profession in the first place. This is where values that brought one to their profession might feel like they're fading or that their values clash with the organization's values. Anandamaya kosha, the bliss body, is closest to our true nature. When one is able to see through this veil or sheath, one realizes the ultimate connection with higher Self, the divine, the cosmos. Burnout here is a deep separation of ourselves from our Self, the people we serve and the people we work with. It is a sense of disconnection, feeling unfulfilled, that all joy has been removed from our work. Later I will use the panchamaya kosha framework to explore various yogic tools that can impact the burnout on each of these layers to begin to find peace and to help one connect to their true Self.

Ayurvedic Model

Ayurveda is the sister science to yoga. It is the traditional Indian medical system. In Ayurveda, each person has a unique constitution or prakriti, made up of 3 mind-body energies, the doshas. Each person also has vikritis or imbalances in their doshas that can change throughout their life (Sharma, 2020). The doshas are vata, pitta, and kapha. Vata is movement, flow. The elements of vata are air and ether. Vata governs creativity and intuition. Pitta is heat and transformation. The associated elements are fire (mainly) and water. Pitta is leadership, vision, courage, responsibility. Kapha is stability, unwavering. Its elements are water and earth. Kapha is support, compassion, protection (Stiles, 2020). 

From an Ayurvedic perspective, burnout can be seen as an imbalance of pitta (the fire is burnt out), vata (Stiles, 2020), and to some extent kapha.  Because of pitta's strong drive and vision, there can be an overload of too much action, a tendency towards workaholism and to push beyond limits, to become angry and lose the warmth of their heart, all indicative of burnout. Vata is the dosha that becomes imbalanced most easily due to its fluid, moving nature. Vata is the burnout vacillation between tamas and rajas mentioned above. Vata's movement can also cause issues with boundaries. An imbalanced vata dosha has trouble saying no to increased workload demands and can feel overextended and overwhelmed by emotions (Stiles, 2020).  When someone is feeling the tamasic inertia aspect of burnout that can indicate a kapha imbalance. Kapha burnout qualities are feeling stuck, powerless and unmotivated physically.

Conclusion

In this post, I have established a foundation of what burnout and compassion fatigue are, common signs and symptoms, and how varied perspectives understand BO and CF. It's important to have a clear understanding of what they are and why they occur, before jumping into how to prevent and address them. Now that they have been operationalized and examined, in part 2 I will move into how yoga and Ayurveda can be used to prevent and treat BO and CF.

Stay tuned for Part 2: Using Yoga Therapy for Burnout Treatment & Prevention