The Cost of Caring: Compassion Fatigue and How To Overcome It

The Dark Side of Caring for Others

Compassion is one of the foundational elements of a thriving community.[1] Helping others has numerous benefits for the self— from improvements in emotional and social wellbeing to reductions in stress, anxiety, and depression.[2,3] But is there such a thing as too much compassion?

Compassion fatigue is a specific kind of burnout that occurs after prolonged exposure to others’ trauma. It manifests as a combination of secondary traumatic stress (STS) and general burnout.[4] STS involves vicariously experiencing the emotions of others’ trauma while burnout results in feelings of exhaustion and helplessness.[5] This results in a hindered capability to be empathetic towards others’ suffering, as well as many adverse physical and emotional symptoms.[6,7] 

Mechanisms of Compassion Fatigue

There are various potential psychological mechanisms by which exposure to others’ trauma can result in the onset of compassion fatigue:[8]

1. Countertransference: Countertransference is a concept rooted in psychodynamic therapy. In psychotherapy, it refers to the therapist’s emotional reaction to the client and their experiences. This is essentially the reverse of transference, which refers to the client's emotional reaction to the therapist. Countertransference involves deep identification with the client and the fulfillment of needs through them on the part of the therapist. It is mediated by various sources, such as the therapist’s past experiences, their view of the client, and the specificities of the vicarious trauma brought on by the client’s experiences. Countertransference is seen as an issue in therapy as it can lead to biases in the way therapists provide care. [9]

2. Burnout: Burnout is a state of physical and emotional exhaustion due to prolonged exposure to situations demanding intense emotional involvement.[10] Rather than a static condition, burnout is a progression that gradually increases and worsens over time if not dealt with. It involves job stress, loss of idealism, and a feeling of helplessness and non-achievement. The main manifestation of burnout is feeling helpless in dealing with the other person’s situation. It can also lead to feelings of dehumanization.[11]

3. Emotional Contagion: Emotional contagion is an affective process that involves feeling similar emotions upon observing someone’s experiences— the specific emotional response that results may be based on the actual or expected emotions of the other person.[12] Those who view themselves as a hero or savior to others are the most likely to experience this.[13]

Presently, each of these mechanisms is studied in specific contexts. As compared to countertransference and burnout, emotional contagion is relatively infrequently cited as a mechanism of compassion fatigue. Additionally, countertransference is currently thought to be specific to the setting of therapy while the literature on burnout focuses primarily on professional settings. Emotional contagion, on the other hand, has been documented as a widespread phenomenon that can occur in almost any context involving interactions between people, from interpersonal relationships to therapy. Therefore, as noted by Figley (1995), as these mechanisms are often studied individually by different researchers, it is fairly unclear as of now how these interact to produce compassion fatigue. [14]

Who Is Affected By Compassion Fatigue?

Compassion fatigue was originally defined by Figley (1995) as “the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced or suffered by a person.”[15] Therefore, it follows that people in professions that involve routinely helping others through traumatic experiences are the most susceptible to developing compassion fatigue— healthcare practitioners, social and emergency workers, and those in similar career fields.[16] In fact, the concept of compassion fatigue was originally developed to describe the feelings of people within these professions.[17]

However, even though it is far less researched in other populations, compassion fatigue can be experienced by anyone. A plethora of universal contexts exist that involve supporting others through traumatic experiences— such as leadership, relationships, parenting, etc. — and any of these can potentially bring about an episode of compassion fatigue.[18-20] 

Risk Factors for Developing Compassion Fatigue

Possessing certain qualities can put people at a higher risk of developing compassion fatigue. These include:

1. Empathy: It is well-known that trauma can occur directly through the experience of disturbing events. However, trauma can also occur indirectly, from learning about a traumatic event that happened to a close acquaintance.[21] Empathy propagates this vicarious trauma, as it involves experiencing what the other person is feeling.[22,23] Empathy therefore acts as one of the primary mechanisms of compassion fatigue as it increases the likelihood of becoming traumatized and subsequently burnt out by others’ experiences. In fact, those therapists that are most impacted by compassion fatigue are the ones who are the most effective at empathizing with and mirroring their clients’ feelings.[24]

2. Prior Traumatic Experience: Past, unresolved trauma can make one more susceptible to developing secondary trauma from listening to others’ traumatic experiences. This is particularly likely when there are similarities between the traumatic experience of both people.[25]

3. Exposure to Children’s Trauma: Suffering in children is particularly evocative of secondary trauma due to its emotional salience. Emergency workers report that they feel most susceptible to developing compassion fatigue upon witnessing children facing traumatic events.[26]

Signs & Symptoms of Compassion Fatigue

Since compassion fatigue involves both burnout and secondary traumatic stress, its symptoms can be organized based on which of these are their root cause.[27]

The symptoms caused by burnout are:[28]

• Feeling unable to help the other person

• Overwhelmed and exhausted

• Feelings of failure

• Perceived inability to do one’s job well

• Frustration

• Skepticism and loss of idealism

• Apathy and withdrawal from others

• Depression

• Substance use

The symptoms caused by secondary traumatic stress are:[29]

• Fear in situations that don’t necessarily warrant it

• Paranoia about something bad happening to the self or loved ones

• Constantly feeling on edge

• Physiological symptoms of anxiety such as high heart rate, breathlessness, and tension headaches

• Persistent, uncontrollable thoughts about others’ traumatic experiences

• Experiencing others’ trauma as if having gone through it

Compassion fatigue can also result in physiological and behavioral changes such as:[30]

• Lack of concentration

• Sleep disturbance

• Appetite changes

Compassion fatigue is sometimes difficult to distinguish from burnout since it involves the same symptoms in addition to those related to secondary traumatic stress. However, besides the fact that compassion fatigue involves additional symptoms, burnout is also distinct in that it gradually advances whereas secondary traumatic stress has a more sudden onset. Moreover, secondary traumatic stress has a faster recovery rate than burnout. Figley (1995) designed the Compassion Fatigue Self-Test for Psychotherapists to help people differentiate whether they are going through only burnout or also the additional component of secondary traumatic stress that characterizes compassion fatigue.[31,32] 

How to Overcome Compassion Fatigue

There are many strategies that individuals can adopt in order to reduce their risk of developing compassion fatigue. These include:[33]

• Keeping a healthy work-life balance

• Taking the time to practice relaxation techniques, such as meditation

• Engagement in creative activities to help with emotional expression

• Learning how and when to set boundaries

• Cognitive restructuring through routinely running through situations with a problem-solving lens

• Development of a plan for when compassion fatigue emerges

Additionally, there are myriad ways for individuals to alleviate symptoms if they are suffering from compassion fatigue. These are:[34]

• Prioritizing self-care and a healthy lifestyle that involves the right amount of exercise, diet, and sleep

• Journaling about feelings and takeaways related to caregiving

• Using stress management techniques can help ameliorate physical symptoms 

• Delegating tasks to co-workers during the recovery process

• Reflecting on successes and other positives related to providing care to others 

• Joining a support group of others going through compassion fatigue

All of these strategies essentially involve prioritizing self-care and drawing boundaries when necessary. In addition to these, seeking out professional help through counselors with specializations in trauma and its processing is also another way to alleviate compassion fatigue.[35]

The Costs of Caring Affect All of Us

Although the actual symptoms of compassion fatigue only impact the caregivers who are afflicted by it, its impacts are far more widespread than expected. Particularly within the healthcare industry, compassion fatigue has far-reaching consequences that impact not only the caregiver, but also co-workers, managers, patients, and even the healthcare system as a whole.[36,37] The performance of professionals can be severely hampered by poor judgment, frequent errors, and disconnected interactions during an episode of compassion fatigue. This leads to lower quality and less impactful care for clients. Additionally, compassion fatigue can lead to healthcare practitioners quitting their jobs. This is especially harmful to the current healthcare system, wherein there is already a lack of manpower.[38] 

As compassion fatigue can be costly to patients, professionals, and even institutions, its treatment and alleviation are key to facilitating an abundance of improvements. In order to promote well-being for all, it is important for both individuals and organizations to take the time to understand and treat compassion fatigue.[39]

Contributed by: Sanjana Bakre

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Lonczak, H. S. (2022, August 6). 20 reasons why compassion is so important in psychology. PositivePsychology.com. Retrieved September 12, 2022, from https://positivepsychology.com/why-is-compassion-important/#:~:text=There%20are%20numerous%20proven%20benefits,psychopathology%2C%20and%20increased%20social%20connectedness

2 Ibid.

3 Pogosyan, M. (2018, May 30). In helping others, you help yourself. Psychology Today. Retrieved September 15, 2022, from https://www.psychologytoday.com/us/blog/between-cultures/201805/in-helping-others-you-help-yourself 

4 Cocker F, Joss N (2016). Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. Int J Environ Res Public Health. 2016 Jun 22;13(6):618. doi: 10.3390/ijerph13060618. PMID: 27338436; PMCID: PMC4924075.

5 Substance Abuse and Mental Health Administration. (2014). Tips for Disaster Responders: Understanding Compassion Fatigue. Understanding Compassion Fatigue | SAMHSA Publications and Digital Products. Retrieved September 28, 2022, from https://store.samhsa.gov/product/Understanding-Compassion-Fatigue/sma14-4869 

6 Adams RE, Boscarino JA, Figley CR (2006). Compassion fatigue and psychological distress among social workers: a validation study. Am J Orthopsychiatry. 2006 Jan;76(1):103-8. doi: 10.1037/0002-9432.76.1.103. PMID: 16569133; PMCID: PMC2699394.

7 Cleveland Clinic (2021, August 29). Empathy fatigue: How it takes a toll on you. Cleveland Clinic. Retrieved September 16, 2022, from https://health.clevelandclinic.org/empathy-fatigue-how-stress-and-trauma-can-take-a-toll-on-you/ 

8 Adams et al. (2006)

9 Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge. 

10 Pines, A., & Aronson, E. (1988). Career burnout: Causes and cures. Free Press.

11 Figley (1995)

12 Miller, K. I. , Stiff, J. B. , & Ellis, B. H. (1988). Communication and empathy as precursors to burnout among human service workers. Communication Monographs , 55 (9), 336–341.

13 Figley (1995)

14 Ibid.

15 Ibid.

16 Adams et al. (2006)

17 Figley (1995)

18 Smith, D. (2022, March 30). Compassion Fatigue is real and it may be weighing you down. Harvard Business Review. Retrieved September 20, 2022, from https://hbr.org/2022/03/compassion-fatigue-is-real-and-it-may-be-weighing-you-down 

19 Koza, J. (2019, August 21). 5 signs you're experiencing compassion fatigue. One Love Foundation. Retrieved September 21, 2022, from https://www.joinonelove.org/learn/5-signs-youre-experiencing-compassion-fatigue/ 

20 Robertson, B. (2021, February 26). Preventing compassion fatigue in Foster and adoptive parents through therapeutic support and self-care. enCircle. Retrieved September 21, 2022, from https://encircleall.org/blog-2/preventing-compassion-fatigue-in-foster-and-adoptive-parents-through-therapeutic-support-and-self-care#:~:text=Compassion%20fatigue%20is%20a%20combination,apathy%2C%20exhaustion%20and%20ultimately%20burnout

21 Figley (1995)

22 Ibid.

23 American Psychological Association. (n.d.) Empathy. American Psychological Association. Retrieved September 13, 2022, from https://dictionary.apa.org/empathy

24 Figley (1995)

25 Ibid.

26 Ibid.

27 Substance Abuse and Mental Health Administration (2014)

28 Ibid.

29 Ibid.

30 Administration for Children & Families. (n.d.). Secondary Traumatic Stress. Administration for Children & Families. Retrieved September 21, 2022, from https://www.acf.hhs.gov/trauma-toolkit/secondary-traumatic-stress

31 Figley (1995)

32 Stamm, H.B. (1998). Compassion Satisfaction/Fatigue Self-Test for Helpers National Child Welfare Workforce Institute. Retrieved September 30, 2022, from https://ncwwi.org/files/Incentives__Work_Conditions/Compassion-Satisfaction-Fatigue-Self-Test.pdf

33 Administration for Children & Families (n.d.).

34 Ibid.

35 Ibid.

36 Chaudoin, K. (2020, July 27). Pandemic leads to compassion fatigue, burnout for health care workers. Lipscomb University. Retrieved September 30, 2022, from https://www.lipscomb.edu/news/pandemic-leads-compassion-fatigue-burnout-health-care-workers

37 Lombardo, B., Eyre, C., (Jan 31, 2011) "Compassion Fatigue: A Nurse’s Primer" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 1, Manuscript 3. https://doi.org/10.3912/OJIN.Vol16No01Man03 

38 Chaudoin, K (2020)

39 Ibid.

Understanding Burnout: Does Zoom Make It Worse?

Source: Canva

What, Exactly, is Burnout?

Burnout is a psychological symptom that results from chronic work-related stress (Melamed et al., 2006). Melamed et al. define burnout simply as “emotional exhaustion, physical fatigue, and cognitive weariness.”[1] Specifically, Maslach et al. find that burnout can be conceptualized along three dimensions:[2,3] 

1. Exhaustion - stress and chronic fatigue due to overwhelming demands.

2. Cynicism - apathy, loss of interest in work, and a sense of futility and meaninglessness toward one’s job.

3. A decrease in quality of work performance - the manifestation of reduced feelings of performance-effectiveness or accomplishment

The multivariate impact of burnout is quantifiable. Burnout negatively impacts productivity and can be measured by: quantity of sick leave days, job retention, and the intention to change jobs.[4] Studies have also found higher levels of burnout have correlated with increased inflammation biomarkers, risk of cardiovascular disease, sleep disturbances, fatigue, and mood disturbances.[5-8]

How Does Burnout Arise?

In addition to more obvious factors like an overwhelming workload, two decades of research on burnout have illuminated some lesser known factors that influence one’s likelihood of burning out. If people perceive that they have the capacity to influence decisions within their workplace and believe they have access to resources necessary to perform well, job engagement is likely to increase. When people feel insufficient recognition or reward (i.e. financial, social, institutional) for their work, both they (as individuals) and their work can feel devalued; this is found to be closely related to feelings of inefficacy and decreased satisfaction. Interpersonal dynamics within the workplace also affect one’s experience of burnout; relationships characterized by support and trust protect against burnout, while unresolved conflict and a lack of trust between peers or coworkers are correlated with greater burnout risk. Fair and equitable policies are also important, as people who feel that they are not being appropriately respected can become chronically cynical, angry, or hostile. Finally, a conflict of values between an individual and their organization can increase one’s likelihood of developing burnout, as the continual pressure to make trade-offs between their values and obligations can affect stress and exhaustion levels.[9]

Figure 1: List of possible burnout symptoms

Image based on a list produced by Schaufeli & Enzmann (1998) [10]

Who Burns Out the Quickest?

Different individuals working under the same job conditions will not necessarily feel burned out at the same time or to the same degree. This is because burnout is a response to stress and individuals evaluate, cope with, and respond to stressors differently. One study by Ghorpade et al. (2007) finds that differences in personality can influence whether one conserves resources (consequently protecting themselves) or becomes susceptible to stressors. Further, extroversion and emotional stability have been found to be negatively related to emotional exhaustion.[11] Openness and agreeableness are also negatively correlated with burnout, while conscientiousness and neuroticism appear to be positively associated.[12,13] 

Something that researchers have struggled to account for is how often burnout might be mislabeled as depression or anxiety, and how such misdiagnoses can lead to ineffective treatment interventions. People suffering from burnout might appear to be depressed, as the symptoms of burnout resemble those of depression (e.g. loss of interest, fatigue, impaired concentration, depressed mood).[14] As there are no diagnostic criteria for burnout and it is not mentioned in the DSM-5, one cannot be formally diagnosed with the condition. One major distinction between depression and burnout is that burnout arises specifically in work-related contexts whereas depression is pervasive across different contexts.[15]

Burnout from Online and Telecommunication-Based Environments

It is often contended that screen time is associated with copious amounts of stress-related symptoms, including psychological, cognitive, and muscular impairments.[16,17] Mheidly et al. (2020) write that pandemics “are often associated with a state of stress and panic. Accordingly, strain resulting from telecommunication can accumulate with other stressors to lead to exhaustion, anxiety, and burnout.”[18] They note that imposed lockdowns, quarantines, and the inability to socialize as a result of the COVID-19 pandemic have led to considerable disruptions in lives, often accompanied by increased tension, anxiety, boredom, and disturbed sleep cycles. Within workplaces, promotions have been delayed and wages have been cut; these negative changes can create adverse levels of pressure and anxiety within people.

Mheidly et al. (2020) recommend promoting awareness regarding stress and burnout as a result of increased telecommunication. They note the following measures are likely to combat this type of burnout: increasing the frequency of breaks between virtual lectures and teleconferences to both reduce eye strain and prevent attention loss, increasing podcast-based communication as a substitute for visual screen time, and implementing healthy practices throughout the work or school day. Yoga, in particular, has received growing research attention, with evidence indicating it can be an effective intervention to reduce stress, increase physical activity, and improve well-being.[19-21]

How to Recover from Burnout

Just as the onset and development of burnout change depending on the individual, so too does the recovery. While Heng & Schabram (2021) believe that the best cure for burnout is prevention altogether, that isn’t always realistic. Therefore, they emphasize the importance of agency in the restoration process. Their research finds that to “effectively overcome burnout, employees must feel empowered to take control over their own lives and decisions.” Rather than expect or request a manager to intervene and improve coworker relations, they note that it is more effective for employees to reaffirm their own social networks. In a subsequent study where they surveyed social service workers (people prone to chronic burnout), Heng & Schabram found “those who were already suffering from burnout had a harder time engaging in acts of self- or other-care, [while] those who were able to muster the energy to practice compassion showed significant reductions in burnout.”[22] Other research has found that mindfulness practices such as breathing exercises, gratitude exercises, yoga, and movement can be effective at cultivating compassion, and that compassion meditation training can rewire neural circuitry in the brain.[23,24]

Self-care and healthy practices are crucial to implement for burnout recovery. Such practices can include: 

• reducing screen time

• increasing time in nature

• stretching to mitigate tension brought on by extended sitting

• practicing agency and taking control in areas of work or school where one can make changes for themselves

• reflecting on one’s support system and building relationships where trust and respect are foundational

• engaging in self-compassion

It’s also important to be aware that the symptoms of burnout can resemble those of depression; if one’s cynicism and exhaustion begin to pervade other areas of life besides work, then different approaches (e.g., therapy or medication) may be more effective or necessary for healing to occur. 

For more information, click here to access an interview with SAS Therapist, Jim McDonnell, on high-stress employment.

Contributed by: Maya Hsu

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Melamed, S., Shirom, A., Toker, S., Berliner, S., & Shapira, I. (2006). Burnout and risk of cardiovascular disease: Evidence, possible causal paths, and promising research directions. Psychological Bulletin, 132(3), 327–353. https://doi.org/10.1037/0033-2909.132.3.327 

2 Maslach, C., Jackson, S. E., & Leiter, M. P. (1997). Maslach Burnout Inventory: Third edition. In C. P. Zalaquett & R. J. Wood (Eds.), Evaluating stress: A book of resources (pp. 191–218). Scarecrow Education.

3 Koutsimani, P., Montgomery, A., & Georganta, K. (2019). The Relationship Between Burnout, Depression, and Anxiety: A Systematic Review and Meta-Analysis. Frontiers in psychology, 10, 284. https://doi.org/10.3389/fpsyg.2019.00284

4 Storm, K., & Rothmann, S. (2003). The relationship between burnout, personality traits and coping strategies in a corporate pharmaceutical group. South African Journal of Industrial Psychology, 29(4), 35-42. Retrieved from https://www.researchgate.net/publication/47739448_The_relationship_between_b urnout_personality_traits_and_coping_strategies_in_a_corporate_pharmaceutical _group

5 Toker, S., Shirom, A., Shapira, I., Berliner, S., & Melamed, S. (2005). The association between burnout, depression, anxiety, and inflammation biomarkers: C-reactive protein and fibrinogen in men and women. Journal of Occupational Health Psychology, 10(4), 344-362. http://dx.doi.org/10.1037/1076-8998.10.4.344

6 Toppinen-Tanner, S., Ahola, K., Koskinen, A., & Vaananen, A. (2009). Burnout predicts hospitalization for mental and cardiovascular disorders: 10 - year prospective results from industrial sector. Stress and Health, 25(4), 287-296. http://dx.doi.org/10.1002/smi.1282

7 Rosen, I. M., Gimotty, P. A., Shea, J. A., & Bellini, L. M. (2006). Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout 39 among interns. Academic Medicine, 81(1), 82-85. Retrieved from http://journals.lww.com/academicmedicine/Fulltext/2006/01000/Evolution_of_Sl eep_Quantity,_Sleep_Deprivation,.20.aspx

8 Ahola, K., Honkonen, T., Kivimäki, M., Virtanen, M., Isometsä, E., Aromaa, A., & Lönnqvist, J. (2006). Contribution of burnout to the association between job strain and depression: The Health 2000 Study. Journal of Occupational and Environmental Medicine, 48(10), 1023-1030. http://dx.doi.org/10.1097/01.jom.0000237437.84513.92

9 Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: Recent research and its implications for psychiatry. World psychiatry : official journal of the World Psychiatric Association (WPA). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4911781/#wps20311-bib-0024 

10 Schaufeli, W., & Enzmann, D. (1998). The burnout companion to study and practice: A critical analysis. Taylor & Francis. 

11 Ghorpade, J., Lackritz, J., & Singh, G. (2007). Burnout and personality. Journal of Career Assessment, 15(2), 240–256. https://doi.org/10.1177/1069072706298156 

12 Anvari, M. R., Kalali, N. S., & Gholipour, A. (2011). How does personality affect on job burnout? International Journal of Trade, Economics and Finance, 2(2), 115-119. Retrieved from http://www.ijtef.org/papers/88-F00068.pdf

13 Dargah, H. G., & Estalkhbijari, Z. P. (2012). The relationship between the Big Five Personality Factors and job burnout. International Journal of Asian Social Science, 2(11), 1842-1850. Retrieved from http://www.aessweb.com/pdffiles/ijass%20pp.1842-1850.pdf

14 American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). Washington, DC: American Psychiatric Pub.

15 Iacovides, A., et al. (2003). The relationship between job stress, burnout and clinical depression. Journal of Affective Disorders, 75(3), 209-221. https://doi.org/10.1016/S0165-0327(02)00101-5

16 Lemola, S., Perkinson-Gloor, N., Brand, S., Dewald-Kaufmann, J. F., & Grob, A. (2014). Adolescents' electronic media use at night, sleep disturbance, and depressive symptoms in the smartphone age - Journal of Youth and adolescence. SpringerLink. Retrieved January from https://link.springer.com/article/10.1007/s10964-014-0176-x?r=1&l=ri&fst=0&error=cookies_not_supported&code=20def7ff-647e-4b3f-923a-66c0a437f01b 

17 Hossmann, K.-A., & Hermann, D. M. (2002). Effects of electromagnetic radiation of mobile phones on the Central Nervous System. Bioelectromagnetics, 24(1), 49–62. https://doi.org/10.1002/bem.10068 

18 Mheidly, N., Fares, M. Y., & Fares, J. (2020). Coping with stress and burnout associated with telecommunication and online learning. Frontiers in public health. Retrieved from https://www.frontiersin.org/articles/10.3389/fpubh.2020.574969/full 

19 Pascoe, M. C., & Bauer, I. E. (2015). A systematic review of randomised control trials on the effects of yoga on stress measures and mood. Journal of Psychiatric Research, 68, 270–282. https://doi.org/10.1016/j.jpsychires.2015.07.013 

20 Büssing, A., Michalsen, A., Khalsa, S. B., Telles, S., & Sherman, K. J. (2012). Effects of yoga on mental and physical health: A short summary of reviews. Evidence-Based Complementary and Alternative Medicine, 2012, 1–7. https://doi.org/10.1155/2012/165410 

21 Fares, J., & Fares, Y. (2016). The role of yoga in relieving medical student anxiety and stress. North American Journal of Medical Sciences, 8(4), 202. https://doi.org/10.4103/1947-2714.179963 

22 Heng, Y. T., & Schabram, K. (2021). Your Burnout is unique. your recovery will be, too. Harvard Business Review. Retrieved from https://hbr.org/2021/04/your-burnout-is-unique-your-recovery-will-be-too 

23 Kirby, J. N. (2016). Compassion interventions: The programmes, the evidence, and implications for research and Practice. British Psychological Society. Retrieved from https://bpspsychub.onlinelibrary.wiley.com/doi/abs/10.1111/papt.12104 

24 Weng, H., Fox, A., Shackman, A., Stodola, D., Caldwell, J., Olson, M., Rogers, G., & Davidson, R. (2013). Compassion training alters altruism and neural responses to suffering - journals.sagepub.com. Psychological Science. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/0956797612469537?cited-by=yesl0956797612469537v1p0956797612469537v1r0956797612469537v1