Compassion Fatigue and Countertransference: Two Different Concepts

Abstract

There has been considerable conceptual confusion about the differences between compassion fatigue and countertransference. This often results in them being treated as the same phenomena, both in the literature and clinically. This paper maintains that these are, in fact, two different concepts that derive from different sources and serve different functions. Each of these two concepts requires different kinds of interventions as well.

Introduction

In the clinical literature and in teaching, countertransference and compassion fatigue are often confounded, collapsed and presented as one and the same (Figley 1995, 2002a, b). This paper argues that compassion fatigue and countertransference are different concepts, serve different functions, and call for different kinds of solutions.

In a compelling article in the Clinical Social Work Journal in 2007, Kanter (2007) argued that authors writing about compassion fatigue have failed to acknowledge the psychodynamic legacy of this term. Kanter contended that one of the major authors writing about compassion fatigue (Figley 2002a) had defined countertransference in ways that were antiquated, viewing countertransference as a result of unresolved issues within the therapist as evoked by the patient. By defining countertransference as residing strictly within the therapist, Figley then distinguished compassion fatigue as a series of trauma like symptoms in the therapist emerging from the influence of the patient on the therapist. Kanter countered that compassion fatigue was one kind of countertransference reaction based on the mutual influence of the therapist and client. Kanter further contended that compassion fatigue, as a concept, has been overused, was ahistorical and reflected an “intellectual prejudice against psychodynamic thinking” (2007, pp 289–290).

As a part of an American Association for Psychoanalysis in Clinical Social Work 2009 Conference, Kanter and I (JB) engaged in a lively debate about whether compassion fatigue was, in fact, just countertransference, (what Kanter called “old wine in new bottles”), or whether these were quite different concepts. Kanter argued that compassion fatigue was not a new concept while I countered that these concepts were distinct. While we appreciate Kanter’s efforts to demand recognition for psychodynamic theoretical contributions, we maintain that there is something important lost in insisting that compassion fatigue is just countertransference. In this paper, then, we will address the conceptual differences between compassion fatigue and countertransference, the sources from which each derives, and the ways that each should be addressed. Conceptual clarity about these concepts is necessary for adequate supervision and training.

Defining the Terms

According to Figley (1995), compassion fatigue refers to reactions that emerge from the therapist’s overexposure to client suffering: human brutality, war, disasters, loss, illness, rape, and other catastrophies. The clinician’s overexposure is cumulative and takes place over extended periods of time (Adams et al. 2006; Figley 1995; Friedman 1996). Therapists who experience compassion fatigue absorb the emotional weight of their clients’ traumatic experiences in ways that negatively impact both their professional identities and personal lives.

From a psychodynamic perspective, on the other hand, the therapist’s negative response to a client’s suffering is readily recognized as countertransference. Contemporary thinkers define countertransference as ubiquitous and necessary to the therapeutic process. Negative reactions on the part of the clinician in response to a client’s suffering may be a result of projective identifications (Klein 1975; Odgen 1994b), the mutual influence of client and therapist (Aron 1996; Hoffman 1983; McGlaughlin 1991) or, from a more classical perspective, consequent upon a therapist’s “unanalyzed” issues which are being evoked by the patient’s troubles.

Countertransference as a Constant Context

Countertransference has been defined and redefined over time. In the early years of psychodynamic theorizing, countertransference was understood as the unconscious sexual and aggressive wishes, impulses, desires, affects, and defenses that were evoked in the practitioner by her interactions with her client’s intrapsychic life (Freud 1905, 1926). Countertransference was viewed as a clinical mistake, one that could ostensibly be avoided through undergoing a thorough and complete analysis of one’s own.

This positivistic view has changed over time, most dramatically in the past two decades (Gabbard 1995; Hoffman, 1983; Mitchell 1993; Ogden 1994a, b; Renik 1993; Tansey and Burke 1985). Today, the therapist’s countertransference is anything but neutral. With the advent of object relations, self psychology, and relational theories, countertransference is seen as resulting from dynamics with a client that are both inevitable and essential for meaningful change to occur. Countertransference has come to be seen as a valuable tool for the practitioner to gain empathic access into the world of the client (Racker 1988), as what we feel, what we think, and what we fantasize as practitioners are often the result of the interaction of fantasies of the patient and the reveries of the therapist (Odgen 1994a, b).

Countertransference reactions are also sometimes the medium through which our clients induce in us some of their most difficult affects, thoughts, and conflicts, which cannot be expressed otherwise (Bollas 1989). Klein (1975) first pointed to projective identification as a form of unconscious communication between therapist and client. Klein conceptualized projective identification as a baby’s way to gain control over the mother, through projecting into her unwanted and disavowed feelings and needs. A baby, in phantasy, could force the mother to respond accordingly. Neo-Kleinians (Ogden 1979) took these ideas much further. The therapist needs to be willing to hold and contain the disavowed parts of the client’s self, to respond to the pressures of the patient, and to be able to return the projections back to the client in new ways that can be metabolized (Gabbard 1995).

Racker (1988) further differentiated between concordant and complimentary countertransferences. In a concordant countertransference, the therapist sees a part of herself in the patient and identifies with him or her. In a complementary countertransference, she identifies with what has been unconsciously disavowed by the client. Kernberg (1992) spoke to the controlling role that clients’ projective identifications often play in inducing the therapist into feeling a range of the client’s internal experiences.

Countertransference is a way to feel in one’s bones that which the client cannot convey through language alone. Winnicott (1947), for example, gave voice to normalizing the hate a practitioner may feel in working with unruly and acting out patients. Just as a mother sometimes hates her child’s willfulness or rage, so too do clinicians sometimes hate their clients. Countertransference, in Winnicott’s view, is not something to be gotten rid of, or to be ashamed about, but is an invariable communication between the therapist’s and the client’s inner worlds that is essential to the treatment process.

The acknowledgement of the constant communication between the unconscious of the therapist and that of the client has led to an exploration of the role of enactments. Enactments occur when the therapist is induced into re-enacting a part of the client’s internal world, perhaps forged in early traumatic experiences. The hope is that by getting into an enactment, the therapist can then get out and, in the process of doing so, make the enacted material available for conscious reflection. This requires that the therapist get emotionally involved with the client, quite a different approach than classical theory which might call for an explicit avoidance of such involvement. From this perspective, therapists and their clients will inevitably enact parts of the patient’s mental life and parts of the therapist’s mental life, creating what Odgen (1994b) has called the “third space” in which something new can be understood between them.

Countertransferential enactments are particularly important to understand when working with traumatized clients. Basham and Miehls (2004) have written about the kinds of enactments that ensue when working with survivors of trauma. For example, the therapist may unconsciously enact with the client one of the roles of the early trauma scenario. Here, the therapist may find herself unconsciously acting as the perpetrator, the victim, or the rescuing/abandoning bystander with her traumatized client. This form of countertransference enactment is based on the idea that disavowed affects and experiences of the client are unconsciously induced in the clinician and then enacted in the therapeutic relationship, reviving the traumatic condition. The hope is that in its resurgence in a therapeutic relationship, the original unthinkable trauma will become available for reflection and transformation.

Finally, a postmodern view of countertransference (Aron, 1996; Gabbard 1995; Ogden 1994a; Rasmussen 2005) questions whether or not there is ever anything objective of the client’s that the therapist can grasp. This contemporary conceptualization of countertransference is often referred to as intersubjectivity, and emphasizes the inextricably related aspects of two sets of transferences: the therapist’s and the patient’s. Whereas in earlier conceptualizations, there was one objective person (the therapist) and one subjective person (the patient), now we think of both patient and practitioner engaging in unconscious countertransference enactments that emerge from two subjectivities interacting in the therapy. Paraphrasing Winnicott’s comment about the nursing pair, one might say that from this perspective there is no such thing as a therapist or a client, only a therapeutic dyad. Such intersubjectivity means that therapy is shaped as a result of this bi-directional mutuality. From this perspective, casting countertransference as something to rid oneself of is impossible and perhaps even counter-therapeutic. Again, the interrogation of what is co-created between the inner world of the therapist and of the client becomes the unit of change. Hence countertransference is indispensable, vital, and valuable as a part of the treatment process. The following is an illustration of a contemporary formulation of countertransference:

Gertrude is a 70-year-old professor who survived the Holocaust. She was one of the hidden children during World War II who at age 18 months was taken from her Jewish family and given to a Polish Catholic family, who hid her for the five years of the war. Her mother perished in Auschwitz and she was left with a profoundly depressed father. Because her experiences were preverbal, she had no language for her traumatic experiences. When she came to therapy she was so dissociated that she had no recall of the experience of the Polish family with whom she lived except occasional flashes of their bad treatment.

The social worker treating Gertrude found herself feeling rejected, hurt and filled with self-doubt whenever Gertrude would complain of the bad treatment she was receiving from her. Not surprisingly, Gertrude was highly distrustful and had difficulty maintaining any connection. Although she craved care from her therapist, she was enraged that she did not experience any. Whenever there seemed to be a connection between them, it was quickly followed by an attack on the therapist’s competence and approachability. The therapist came to understand that she was murderously angry at her client. This was a repetition of how Gertrude had felt at being abandoned by her family and how she had dealt with the new family who had taken her in, and who had risked their own lives to do so. It was also a re-enactment of her trauma experiences where she had felt unloved, helpless and incompetent and in danger of real attack from the outside world.

Countertransference responses are ubiquitous to every clinical encounter whether working with traumatized clients or not. When working with traumatized clients, however, countertransference can be particularly difficult to withstand. As Kanter (2007) pointed out, the personal aspects of the practitioner, the therapist’s expectations, the agency setting, and the therapist’s training all influence how the clinician experiences countertransference. How we experience countertransference varies; that we experience it does not.

Compassion Fatigue

What then is compassion fatigue? If it is similarly felt in response to being exposed to the suffering of one’s clients, how is it different than countertransference? Stated simply, countertransference happens in every clinical encounter (and may even characterize it), while compassion fatigue does not. Particular sets of countertransferential responses might be common to working with traumatized clients (such as the victim-victimizer-bystander dynamic), but becoming exhausted by caring for such clients is not necessarily the inevitable result of the intersubjective mix. Though perhaps it could be subsumed into one if it went unaddressed, compassion fatigue is not an enactment. Rather, it is a response to the cumulative experience of caring for people who are suffering, and the personal experience of the persistent excess of suffering despite one’s best efforts at ameliorating it.

Figley (2002a) notes that the cognitive, emotional, and behavioral effects on the therapist who works with people who are traumatized are compassion fatigue. The cognitive aspects of compassion fatigue include the therapist’s lowered concentration, decreased self-esteem, apathy, negativity, depersonalization, minimalization, thoughts of harm to the self or others, and preoccupation with the trauma. Emotionally, the clinician may experience powerlessness, guilt, rage, fear, survivor guilt, depression, an emotional rollercoaster, and depletion. Behaviorally, this may result in impatience, irritation, sadness, moodiness, sleep disturbances, nightmares, hypervigilance, accident proneness, and losing things. Sometimes therapists who suffer from compassion fatigue blame the victim or turn away from the work, deadened by the sheer weight of so much suffering. Sometimes practitioners blame themselves for not being “enough,” withdraw, and become more isolated. Their self-esteem may be impacted. Sometimes practitioners experience somatic distress: headaches, stomachaches, difficulties with sleep, and physical and emotional exhaustion. Different from a secondary stress response or vicarious traumatization—in which the therapist experiences the same post-traumatic stress symptoms of the client—compassion fatigue can have a more global and diffuse impact on one’s professional identity, personal self and existential stance.

Compassion fatigue has been studied with many populations. A study in Northern Ireland (Collins and Long 2003) was conducted after a car bombing that led to a massive loss of life. Looking at thirteen health care practitioners on a trauma and recovery team, the researchers found that the helpers complained of a lack of understanding, lack of support, and negative effects upon their well being from their exposure to the chronic anger from bereaved relatives. What they found most stressful was dealing with the content of the each family’s trauma. But they also named mitigating and protective factors. They reported that team spirit, a sense of camaraderie, and seeing clients improve were important factors in protecting against their personal distress and compassion fatigue.

Another marker of compassion fatigue is the similar levels of stress that practitioners report, be they trauma clinicians, first responders, end-of-life care practitioners, child welfare workers, those who work in prisons, or disaster workers. In a study (Fromm et al. 2005) of nurses who provided hematological care for oncology patients going through bone marrow transplants, the nurses, like trauma clinicians, described their own emotional stress in having to continually support others, their exhaustion in having to be present with every patient and family, and their pain in bearing the suffering of the patient and her/his family. Being exposed to patients’ and families’ emotional pain led to their own existential questions. Witnessing repeated deaths and medical failures resulted in their lack of emotional energy. Figley (1995) also wrote about the effects of studying 800 Vietnam veterans who recounted their trauma experiences to him as a researcher. In response, he experienced repeated nightmares, irritability, and excessive frustration. His prolonged engagement with his subjects brought on a range of trauma symptoms in him.

Compassion fatigue then refers to what happens to those caregivers whose job it is to continually support others who suffer and, as a result, are they themselves exposed to such suffering. Nurses, family caregivers, those who work with veterans’ families are all exposed to a great deal of suffering, and they often experience exhaustion and depletion (Collins and Long 2003). Hearing seemingly endless narratives of pain overwhelms the most self-aware practitioner. Trauma work raises existential issues of life and death, as well as moral and ethical issues. Graphic accounts of trauma and suffering almost always have emotional consequences (Shubs 2008). One of those consequences can be a divestment of one’s compassion, or willingness to care, in response to the feelings that engaging with unrelenting suffering evokes.

If a social worker is feeling tired of caring about her clients and the problems with which they contend, is she in the throes of countertransference? Or is she experiencing a more universal (and not only clinical) response to the helplessness and hopelessness one feels when one’s willingness to care is not enough to stop the suffering one sees? We argue that it is the latter. For social workers who are generally practicing with people who are entrenched in complex social problems, within systems that do not provide (or cannot provide) enough of what patients actually need, fatigue is not unusual. Some might argue, however, that when this kind of reaction occurs in the clinical situation it falls under the umbrella of countertransference (Kanter 2007). We propose that the clinician’s experience of being tired of caring, and of having to forego her sense of compassion in an effort to protect herself from despair is distinct and worth treating as such. Conflating this with countertransference implies that the fatigue is something in the worker that, if “worked through,” will dissipate. Recognizing that compassion fatigue might be the reaction of a caring person to the suffering of others positions us to validate such feelings as perhaps a human—not just a professional—response, a particular hazard for those of us who work in the trenches of deprivation.

Distinguishing Compassion Fatigue from Countertransference: The Conceptual Confusion

Although Kanter has argued that compassion fatigue is captured adequately by the construct of countertransference, other writers have done the reverse, and described clinical situations as instances of compassion fatigue instead of countertransference. Figley (2002a), for example, describes supervising the case of Jane, a young worker who has difficulty with the grief of her client based on her unresolved issues with her own mother. Maintaining that Jane suffers from compassion fatigue, not countertransference, Figley goes on to make the case that Jane needs psychotherapy. But Figley is, in fact, describing a countertransference issue. Jane is having difficulty because of her unresolved relationship with her own mother and not because she is overwhelmed by the cumulative losses of her work. His supervisee’s unexamined countertransference might well benefit from some psychotherapy or by gaining further self knowledge through supervision. But the prescription for compassion fatigue, which Figley (2002a) refers to as Jane’s problem, would be neither supervision nor psychotherapy. Instead it would be self care which seems irrelevant in this case. Hence Figley conflates compassion fatigue with countertransference, and undermines the different sources of these concepts and the necessary remediation for them. Countertransference and compassion fatigue need to be differentiated because they require different remedies.

Neumann and Gamble (1995) have also described as compassion fatigue the ways in which therapists may experience, with traumatized clients, excessive rescue fantasies, and the ways in which the therapist may become intensely preoccupied with the client. While they refer to these as compassion fatigue, we would argue that these are examples of countertransference enactments. Here the therapist’s loss of boundaries, of becoming the rescuer (or the victim or the victimizer) are projective identifications, the acted-out of parts of a client’s un-integrated experience. Patients who have been traumatized often dissociate, leaving the clinician to hold traumatic fragments of the client’s experience. The clinical task is to slowly give back the dissociated experiences, in digested form, to the client in the hope that she can integrate them.

For example, I (JB) supervised a young female practitioner who was working with an attractive and anguished male poet who had been severely physically abused by his alcoholic father and neglected by both of his parents. The client was highly evocative, and his poetry was haunting and compelling. The therapist found herself obsessed with this client, listening to his poetry on a CD in her car and in her home. She fantasized about him, thought that a real relationship with him could perhaps cure him, and dreamed about him. She mused about him and was generally preoccupied with him.

This young practitioner was not experiencing compassion fatigue, despite the significant trauma her client had experienced. Instead, she was experiencing a set of countertransference responses in which she had become erotically engaged at a fantasy level with her client. Her rescue fantasies, her blurred boundaries, her sexual feelings were both his and hers. They re-enacted parts of his trauma history of blurred boundaries, over-sexualization, and over-stimulation, and they interacted with her unconscious world, preoccupations, reveries, and dreams. Pointing this out in supervision led her to be curious about and aware of the enactment and less ashamed of her feelings, so that she was then able to bring them back into the treatment process with her client. A second example is offered that shows the existence of countertransference enactments compounded by compassion fatigue:

A medical social worker, working on a bone marrow treatment floor, was having great difficulty leaving her office and could not see her patients. She would do paperwork, concrete services, and make herself available by telephone and pager, but she could not enter the floor on which she was working. Her own mother had died of lymphoma, and her grief had been complicated by her mother having left the family a few years before to pursue her own career. Now this social worker, unaware of her anger towards her mother and also experiencing high levels of trauma on the ward, was unable to do her job. She experienced unexamined countertransference determined by an unresolved history of loss and abandonment and she experienced compassion fatigue which grew out of the cumulative trauma that made her lose faith in any capacity to be helpful.

It is therefore unfortunate that in the literature these kinds of reactions would be described mutually exclusively as compassion fatigue or as countertransference. Certainly social workers who are engaged in professional relationships with clients who are suffering can be expected to be vulnerable to both countertransference and compassion fatigue.

A Both/And Perspective

Judith Herman (1997) has offered a both/and position when she described traumatic countertransference. Here she describes the ways in which trauma in the clinician, coupled with excessive exposure to trauma, can result in traumatic enactments. Munroe et al. (1995) also offered a nuanced view of the intersection of compassion fatigue and countertransference. As noted by Munroe et al. (1995) when therapists become caught up in patterns generated by the client, they are experiencing both compassion fatigue and countertransference responses. Noting the ways in which splitting is often inevitable under such circumstances, they recommend having clinical teams which can accept the reality of the trauma, see and name the therapist’s countertransference reactions, and then offer group support and caring from a team approach as valuable parts of the therapeutic process to avoid compassion fatigue. Let me (JB) use another example from my own work to show the both/and nature of compassion fatigue and countertransference.

Every year, for the last ten years, eighteen seasoned social work professionals have arrived from all over the country to attend the Smith College School for Social Work End-of-Life Certificate Program. They range in age from 30 to 65. Each of the participants is engaged in practice with the dying, whether in hospice, palliative care, medical centers, or in outpatient bereavement. Their mean years of experience are ten, so that many of these social workers have been in practice for over twenty years. Because we know that the personal is the professional, we, the faculty, begin the Certificate Program each year by asking how the participants came to this work. It is a way to develop a collegial group and a way to locate one’s own life history in relationship to the work. The faculty start with ourselves—telling our own stories of personal loss and grief, and how these led to the work that we are doing. The students then follow our lead and talk about their own personal histories with illness, loss, grief, and bereavement. This is a way of introducing the concept of countertransference—that our own histories influence whom we work with and how we work. We further elucidate that we are always influenced by our clients’ histories as they interact with our own. These social workers tell very poignant, personal narratives of how their work chose them. When they tell their stories of their own personal losses, they are again beginning to connect their own life histories to that of the patients and families with whom they are so intimately engaged.

But in that first two-hour meeting, these practitioners also form another narrative, and it is one of their isolation in this work, fears about losing compassion, and their own experiences of burnout. Some speak to a worrisome and growing loss of idealism; others speak of the cynicism of the team members with whom they work and of the ways in which their colleagues seem to blunt their feelings or withdraw. One theme reverberates consistently: that there has been nowhere to talk about this difficult work, no group of colleagues with whom to share their work, no group to support them in interdisciplinary teams where their voices have been overshadowed, no place to learn how to advocate forcefully for themselves and their profession, and no place to routinely process grief and bereavement. Some say that they are growing tired; many feel beleaguered; a few express thoughts about leaving the field. Others say that they are saddened by a lack of compassion around them. Most say that they have come to this program to be re-energized. Many are suffering from what we would call compassion fatigue.

Compassion fatigue, we maintain, co-exists with countertransference in most settings where people work with suffering. However, these terms also require differentiation in several important ways. First, compassion fatigue is based on the experience of caring for those who are suffering, while countertransference is based on the interaction between the client and clinician’s intersubjective and unconscious worlds. Second, compassion fatigue develops over time from the accumulated experiences of providing care, while countertransference is immediate and ubiquitous, detectable by an attuned therapist in just one session with one client. Third, compassion fatigue can undermine the therapist’s ideals and disturb the therapist’s hope and meaning, resulting in emotional exhaustion, depletion, and turning away from the work. Countertransference, on the other hand, takes many forms, some of which may be difficult to withstand, but are not necessarily fatiguing. Finally, countertransference is an essential component of therapeutic work, which needs to be interrogated and understood in every case. Where there is no countertransference, we would think, there is no real engagement or treatment. Compassion fatigue, however, is not essential and can actually interfere with a therapist’s ability to make use of countertransference.

Let us give one final example.

I (EK) recently met with a man released from prison after serving a year-long sentence for robbery. His file indicated that he had a long history of drug- and theft-related convictions. During the course of his initial mental health assessment, he described having a horrific history of abuse at the hands of his father, a Vietnam veteran. He recounted his father waking him up in the middle of the night and showing him pictures of execution scenes, ostensibly to prepare him for the cruel and violent world he would face (never mind that he was 4 years old at the time). His symptomology reflected a classic post-traumatic response, centering around intrusion, avoidance and numbing.

About mid-way through the session, he alluded to having had done some things that weighed on him, things that he felt he could not talk about with his friends. Already reticent to find out what they might be, I only minimally inquired further. Despite this, he quickly disclosed that he had killed numerous people and had never been apprehended, charged or convicted. He surmised that he had wanted “to see what it felt like to be in those pictures.” Before I could even soothe myself with the thought of telling his parole agent or the police, he reminded me of doctor-patient confidentiality. By the end of the session, it seemed likely that these were confessions and not fantasies. My final count was eleven murders for which he had not been caught.

Of all of the reactions that I could have had—horror, excitement, disgust, terror—mine was, “Damn it! I can’t believe that I have to deal with this now. I have so much other stuff to do today.” I was aware of my lack of empathy, my lack of fear, and—as unscientific as it might sound—my fatigue. I just felt so tired of working at parole, of my job as a social worker, of the relentless narratives of traumatized and traumatizing people. All I had done was show up for work that day, and now I had to go home psychically holding eleven murders. When I considered the fact that I was also going to have to figure out how to provide meaningful treatment for this man, my tiredness turned into sheer exhaustion.

I was also vaguely aware of my countertransference. In the session, I felt the fragmentation characteristic of sitting with someone fractured by dissociation. I also felt the eerie feelings that I have come to understand as marking the presence of psychopathy. I was aware that there was some way that he was communicating his experiences to me: rousing me from my routine to frighten me with graphic images of murder. This time, they were not photos like the ones his father showed him, but images that my own mind generated in response to his confession. All of this was dynamic grist for the mill that perhaps could be used to help him and his potential victims. His confession could also have been understood as a request for help, a hopeful sign of his willingness to engage in treatment.

The problem was that I didn’t care: caring was what had gotten me into this situation and on that day and in that moment, the last thing I wanted to do was be aware of my own compassion. I did not want to empathize with him as that little boy, or with his father as a traumatized Vet, or with his victims because if I did, I would be overcome with a sense of helplessness and futility. How was I going to help him? How was I going to prevent him from offending and how could I tolerate not being able to do so? The disparity between how much I cared and how little power I had to make that count for something was too great, and I withdrew my own feeling of compassion as a result. The only solution that I had to the problem of the suffering before me was to stop feeling my own compassion for him and his victims.

Doing so solved one problem, but it created another: without caring, I could not make use of the countertransferential information that was being transmitted, which I would surely need to use to be able to figure out how to work with him. Much like the severing of mentalization that one may engage in response to the horror of a traumatic event, vacating one’s mind offers a temporarily protection from strong and painful affects but it is at the price of being able to access one’s own capacity to think and reflect. Had I not been able to muster the energy to consult with a colleague (who, fortunately, was not as beleaguered as me that day), I may have easily continued a descent into the symptomatology that Figley (2002a) has detailed so well.

Methods for Dealing with Compassion Fatigue and Countertransference

Finally, the methods for lessening compassion fatigue are quite different than those employed to process countertransference (Hafkenscheid 2005). The literature on compassion fatigue (Linley and Joseph 2007; Nelson-Gardell and Harris 2003; Neumann and Gamble 1995) suggests that the remedy for it lies in various forms of self-care, such as: finding ways to soothe the self as with meditation, yoga, spirituality, or connecting with nature; finding things to laugh and cry about; attending to one’s needs for relaxation, exercise, and diet; leading a more balanced life; and, maintaining social supports. Often, this is framed as nurturing oneself (Trippany et al. 2004). Additionally group support through education or collegial sharing is recommended (Ulman 2008). The needed responses to countertransference, on the other hand, revolve around understanding and addressing the intrapsychic and interpersonal roots of the practitioners’ psychological reactions to the client, including the clinician’s own trauma and/or loss history. Such responses include self-reflection, self-analysis, supervision, or psychotherapy. Compassion fatigue calls for forms of renewal that are active and very often cognitive, whereas processing countertransference requires the opposite: the interrogation of feelings and subjective responses to projective identifications and enactments, self-analysis and self-awareness.

Supervision is essential, and can function to both address countertransference and act as a form of self-care. The supervisor who works with the clinician who suffers from compassion fatigue can offer support, validation, and ways of replenishing the self based on her own experience. She can refer the clinician to peer-led groups, to helpful readings, and to educational settings. The supervisor can help the clinician to develop greater professional supports as a way of maintaining personal coherence (Saakvitne 2002). Further, the supervisor who can name the symptoms of compassion fatigue (as we do in the end-of-life certificate program)—numbing, distancing, flooding—can be very helpful to the practitioner. Naming these feelings and reactions depathologizes the clinician’s overexposure to trauma. Finally, educational support or group support normalizes what the clinician is feeling, and re-enlivens the clinician’s senses of efficacy, well being, and commitment to this work. Clinical supervision, length of time in the field, workloads, and social support are some of the other important variables to prevent compassion fatigue and to support a sense of coherence (Linley and Joseph 2007).

Supervision (group or individual) is also essential for examining countertransference with traumatized clients. Looking at relational impasses, trying to understand a clinician’s own resonance to the work with each individual client, identifying the ways in which therapist and client are interacting and shaping each other’s responses, learning what to do with enactments—all of these are essential to understanding countertransference in clinical work with suffering clients. Supervision that can evoke the supervisee’s curiosity about her responses to the client and begin to interrogate them is essential. Referrals to psychotherapy are appropriate when early history or undigested projective identifications block the clinician’s capacity for empathy or curiosity.

David Browning (2004) offers a nuanced view of compassion and empathy, and reminds us that both are essential in work with those who are suffering. Writing about a bereaved young girl with whom he worked, he remembers hoping to see her longer than the twelfth session, when she announced that she was ready to terminate. She told him that she carried two buckets of tears: a little bucket and a big bucket. While parents, teachers, friends, and her therapist had helped her to empty the little bucket, she knew that she will always carry the big bucket of suffering alone.

He goes on to say that compassion involves finding our vulnerabilities in our own experiences in order to join with a client to make meaning of his or her suffering. The openness and emotional availability that this requires can be fatiguing. Empathy, on the other hand, which is forged in complementary countertransference, depends on a well developed capacity to understand the self, and to be separate and connected at the same time. “In the most basic human sense, when we sit with another who is suffering, the only thing we truly have to offer is our own knowledge of suffering, our own wounds, our own broken hearts. Paradoxically, as we recognize our mutual vulnerability, we may help our clients find the strength to carry their buckets as they help us to find the strength to carry our own.” (p. 40). Our vulnerabilities are essential in understanding both compassion fatigue and countertransference and are inevitable when we are exposed to human suffering.

From our perspective, compassion fatigue is different than countertransference in that it results from the cumulative effect of being confronted with more suffering than one is able to ameliorate. The compassion that we feel opens us up to being impacted by the suffering that we see. As social workers, many of us have set out to work with society’s disenfranchised members and by doing so we expose ourselves to the same suffering that characterizes their lives. Casting such reactions as only countertransferential, however, relegates them to the consulting room and detracts attention from the fact that all of us who care about others react to their suffering. Such recognition perhaps positions us to help each other, colleagues and clients alike, to carry all those little buckets.

Conclusion

We want to end on a more positive note, one that is not always made explicit when we talk about compassion fatigue. That is, work with the dying, with those who have been violated and hurt, or with those who have suffered, shakes up our assumptions and tires us out. But such work also has the potential to transform who we are. Those in the end-of-life certificate program who say this work “chose them” derive enormous satisfaction from being present in one of life’s most mysterious moments. They report finding profound satisfaction in entering into an intimate space with a dying client. They feel that they are made aware daily of the gifts of living, and that their exposure to the dying makes what is important in living very immediate. We think that those are the gifts of compassion. Compassion does not always result in fatigue: whether in working with military combat, sexual and physical abuse, or the ill. We would do well, when we think about compassion fatigue, then, to appreciate how compassion brings us closer to understanding the mysteries of resilience, the complexity and capacity of the mind to survive, and the creativity of the human spirit that can find meaning in some of life’s worst events. This compassion is ultimately, we think, what compels us to do this work and what keeps us engaged in it.

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Correspondence to Joan Berzoff.

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Berzoff, J., Kita, E. Compassion Fatigue and Countertransference: Two Different Concepts. Clin Soc Work J 38, 341–349 (2010). https://doi.org/10.1007/s10615-010-0271-8

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Keywords

  • Compassion fatigue
  • Countertransference
  • Enactment
  • Projective identification
  • Intersubjectivity
  • Self-care