Rachel: (00:00)
Welcome to episode 10 of you are not a frog – ‘What we’re talking about when we talk about compassion fatigue’.

Rachel: (00:08)
Welcome to You Are Not A Frog, the podcast for GPs, hospital doctors and other busy people in high stress jobs. Working in today’s high-stress environment, you may feel like a frog in boiling water – things have heated up so slowly that you might not have noticed the extra-long days becoming the norm. You’ve got used to feeling constantly busy and are often one crisis away from not coping. Let’s face it, frogs only have two choices – to stay in the pan and get boiled alive or to hop out and leave, but you are not a frog and that’s where this podcast comes in. You have many more choices than you think you do. There are simple changes that you can make which will make a huge difference to your stress levels and help you enjoy life. Again, I’m your host, Dr Rachel Morris, GP, executive coach and specialist in resilience at work. I’ll be talking to friends, colleagues, and experts, all who have an interesting take on this so that together we can take back control to survive and really thrive in our work and lives.

Rachel: (01:12)
I’d like to tell you about our new CPD forms. If you want to learn while you listen and claim CPD points, then go to the link in the show notes and sign up to receive our fully downloadable podcast CPD form. Each one is populated with show notes and links so that you can listen, reflect, and then note down what you’re going to do. A quick, easy and enjoyable way to do your CPD.

(01:34)
Today on the podcast, I’m chatting with Agnes Otzelberger. She’s a facilitator and trainer and researcher into what’s known as compassion fatigue. Agnes has a long history of working in humanitarian aid and she started to question this concept of doing good when she started to realize that actually, perhaps there were a few ethical implications. She was looking at how her colleagues were reacting to constantly seeing suffering and she’s now started looking at this concept of compassion fatigue and what we can do about it.

Rachel: (02:05)
I found it really fascinating to talk to her and I genuinely learned a lot more about neuroscience than I’d known before, for example, how we respond when we hear people suffering and how actually it’s not very helpful for ourselves and, and no wonder we begin to suffer when we have it day in, day out. And it’s not just about experiencing major trauma or witnessing other people experiencing major trauma. It can be the drip drip of everyday things that we see. So in this episode I think there are some really, really good hints and tips about how we can help ourselves avoid the emotional shutdown which happens and how we can avoid this thing that actually is misnamed as compassion fatigue. And I think this episode is going to be really useful not just for doctors but for anybody who’s working in areas where they are regularly dealing with people and hearing their stories and want to carry on working in jobs that they love and helping people but without burning out or experiencing empathetic burnout. So I hope you enjoy this episode.

Rachel: (03:00)
I’m really pleased to have with me on the podcast today. Agnes Otzelberger she’s a trainer, facilitator and researcher and she’s got a special interest in the subjects of doing good. Agnes, if I got that right. What are you particularly interested in?

Agnes: (03:22)
Yeah, that is right. I’m really interested in the nature of doing good and of helping relationships. So altruism, our intentions and the relationships, in helping others and how sometimes or very often they can be quite complicated and messy and doing good is not straightforward.

Rachel: (03:39)
So how did your interest in this come about?

Agnes: (03:42)
So I, think I’ve always known. I’ve always been interested since I was a child in helping other people and always thought that was going to be in some form my career – what I do for a living. I remember in primary school I wanted to start a kid’s parliament and then in early secondary school I started an animal welfare club, baking cookies and sort of gathering donations. And it was really always from the sense that kind of supporting others, helping others, whether they’re people or animals was going to be important in my life. So I started volunteering as a teenager and then ended up in the international development, international aid, to industry, working as an advisor on issues around climate change, food security and poverty. So that’s how I got into this kind of line of work.

Rachel: (04:32)
So what sort of issues were you seeing with doing good?

Agnes: (04:40)
There were many layers to this, but basically I sort of, I pretty early on thought I figured out my career, figured out my vocation. It’s great to be embraced, be a helper or do good and think I’m going to save the world. And then fast forward a few years into my career that was going pretty well at the time I was feeling really bitter and cynical and pretty de-motivated about all of it. And so it took me a while to realize why that was. But with hindsight, I think what happened was that I entered this profession unaware of how when we enter helping relationships with other people, we create these power dynamics and these kind of roles that come with them and how they can have unintended consequences. And I was feeling these unintended consequences in my work on a daily basis. In addition to that, I also wasn’t aware of, or was probably at the time quite naive about the political and colonial connotations of work that involves white people being shipped off to a country populated by brown people and saving the world there.

Agnes: (05:48)
So there were many layers to the helping relationship that were on the surface looking like I was this hero who was doing good, but actually deeper inside I was really quite ashamed

Rachel: (05:59)
And what are the unintended consequences? Did you notice?

Agnes: (06:04)
When we support other people, when we help other people driven by a compulsion to help not being clear on where that comes from, we unintentionally create, we unintentionally pass these compulsions on in the relationship. And the helping relationship, so it becomes a transaction where we’re unaware that me helping the other person isn’t such a genuine act of helping. It’s actually me needing something from them. It’s me needing to be needed by the other person. And that sounds a bit vague, but I think that really expresses itself and how all the relationships in the helping professions often pan out and how when we then as helpers don’t get what we want, we become angry. We become disappointed and cynical and demotivated. So I could feel that. I think I could feel that at the time quite viscerally, but I couldn’t put words to it and it took me a few years afterwards to work out what was actually going on.

Agnes: (07:01)
I think another unintended consequence is this thing I got really interested in, which is compassion fatigue, the emotional burnout. So when we’re helping from this compulsive ‘must be giving at all times’ place, we really deplete ourselves. Basically we can end up unable to do our job well. We can end up unable to relate to other people. We can end up unable to empathize with others because the emotions become so overpowering and overwhelming that we try to shut them down. And then from the shutdown we get a whole range of other secondary consequences that are not very desirable in the helping professions, or anywhere for that matter.

Rachel: (07:39)
Do you see this particularly in one type of profession or is it sort of across the board?

Agnes: (07:46)
My experience is mostly in the international development sector or in the humanitarian sector and in charities. But in recent months and years I’ve been talking to people across the helping professions. So I’ve been talking to people in social work and health and mental health in animal welfare charities, people working on environmental issues, picking where people working on human rights, on social justice issues. And I think at the very basis the sort of the key issues are really similar. They’re really shared.

Rachel: (08:13)
So it’s interesting – a lot of the listeners to this podcast are GPS or doctors. You mentioned that people that experienced this or people that must be giving at all times that I guess for doctors that’s almost their job description, that they must be giving at all times. And it’s interesting, I’m just trying to figure out in my head whether we really, you know, the old adage that doctors go into professions to help people is really true because actually a lot of the essence of the profession, because we’re interested in people and we’re interested in physiology and anatomy and science, but then end up sort of in the position where we have to be helping people. And so there’s an element of saying ‘I’ve gone in to help people’, but their limits of then, but I also have been interested in all this sort of stuff. I’m just overwhelmed with the needs and the demands from people. Have you seen that as well with this overwhelm?

Agnes: (09:07)
Yeah, there’s a lot of overwhelm and I think it can be important to distinguish between two things. One is the overwhelm that comes from the sheer quantity of the work, the workload, the pressures, the sort of the relentlessness of it, which you know, I recently read that book, This Is Going To Hurt by Adam Kay. It really brought that relentlessness home to me, the sort of completely insane, crazy amounts of hours people do, the lack of backup. You know how people don’t end up staying hours and hours and hours and hours beyond what they’re supposed to just simply because there isn’t someone else to take over and it’s literally a life and death question. In another professions, people can say we are pretending this is life and death but it isn’t, so we can go home. So there is that. And then there’s also the emotional components, the emotional relentlessness of a job that involves constantly being faced with suffering at human level – animals, planetary, whatever it is.

Agnes: (09:59)
Whether you’re a doctor and you work with ill health and mentally ill health or whether you work with planetary, ill health. But it’s this constant relentless taking on of suffering. And it’s that specifically that I got really interested in. And I think there are many ways in which the workload overload and the emotional overload feed into one another. And also there are some different approaches and some specific ways that we need to understand emotional burnout and compassion fatigue that aren’t the same as burnout from overwork. So the thing that I didn’t know when I was working in international development when I was constantly processing bad news data about how many hundreds of thousands of people were going hungry each year and this natural disaster here and that humanitarian catastrophe there. I was constantly taking that on and the advice I was given by my peers and by my superiors at the time was don’t take it personally, keep your emotions out of it and then you’ll be fine.

Agnes: (11:07)
The more I could compartmentalize and shutdown my feelings about what was going on, the better I could do my job and the healthier I would be as a person. And so to an extent that’s what I achieved. I achieved shutting down my emotions and compartmentalizing things, but I ended up with the same result that I was fearing. So I ended up with the same emotional complete burnout and breakdown that I was so desperately trying to avoid. And so this recipe that I think a lot of people are being passed on informally and I’m in the helping professions. This thing of sort of, you know, you must be ‘professional’, i.e. keep your feelings out of it. I hate people saying things like focus on the job, not on the people. It’s important and it works to an extent and certainly in some situations you want to be really focused on the task at hand.

Agnes: (11:59)
Like when you’re doing open heart surgery, it’s probably really good to be able to focus on the job and not the people. But a lot of these jobs involve a lot of relationships and relationships with people we work with that work. The patients, the clients that are beneficiaries of you want to call them. And these relationships break down when we shut down our emotions and we experience an isolation from others and from ourselves that ends up really depleting us. So the thing I was avoiding was kind of having a breakdown. And the breakdown I had that slowly crept up on me was that I became cynical. I became hopeless, I became demotivated, I felt really ashamed because I wasn’t really putting my 150% in anymore. I was kind of trying to do 80% and trying to pretend I was doing a hundred because I couldn’t really connect with the motivation from my work anymore.

Agnes: (12:49)
And I think in a job where you know you’re vastly underpaid and doing too many hours, when you’re losing motivation, there’s not much left. So yeah, it was important to see that that hadn’t worked. And then what came late, several years afterwards, was the realization that there are ways, there are, there is a different way. I don’t want to call it a recipe, but there is another way where we can manage the emotional engagement in our work in a way that is sustainable and healthy. So you mentioned being financially motivated. Are there any other symptoms that people should look out for with compassion fatigue? Yeah, I think so. What I’ve been learning about secondary trauma, vicarious trauma, which in some ways is, you know, a form of compassion fatigue or maybe an intense form of compassion fatigue, is that the symptoms can also be quite physical.

Agnes: (13:39)
So it’s not just an emotional sign, but also when we find ourselves, you know, in some ways unhealthy, a depleted energy levels down that can be psychosomatic symptoms such as headaches and back pain and other forms of pain that can be signs that things aren’t right. And of course it’s hard to tell if this from something else or if this is from compassion fatigue. But overall when people are in huge amounts of tangent, all the times I’ve experienced that in the symptoms. And I think apathy is an important one. So this kind of going from, ‘I really, really care about this’, going from having a real spark for the work and a real passion that we bring to it to not really giving a damn. So people have told me things like I used to enjoy thinking about my work outside of work sometimes and I had, I actually kind of managed that and made sure I don’t take too much of it home. It was just because I was so excited about it.

Agnes: (14:34)
So going to, ‘I can’t wait for 5:00 PM’, or 10:00 PM or whatever it is and all of my free time is designed to help me escape. I had to help myself not think about it. That’s when sort of, you know, healthy self care that is about nurturing yourself and looking after yourself is actually more like a sign of the coping mechanism. Not be very sustainable when we need to run from it, when we need to escape and numb ourselves. And when we stopped caring when we just don’t really feel like we give a damn anymore. That’s a sign of that kind of fatigue.

Rachel: (15:07)
So just in survival mode?

Agnes: (15:09)
Yeah, yeah. When we’re in survival mode and when the work, you know, for a lot of people. A lot of people bring a fair amount of passion into this kind of work and an amount of care. And when those reduce, then that might be a sign of experiencing secondary traumatisation, compassion fatigue, empathic distress, the various ways of phrasing that. Another one I’ve heard from people working in directly with sort of clients in social work is when people start being aggressive and sadistic or short or aggressive with their clients, with the patients, with benfeciaries of the organisation. So when kindness turns into unintended viciousness.

Rachel: (15:56)
Yeah, yeah. So kindness, turning into viciousness today I think, and I can certainly recognize, you know, and I look back at when working as a GP, you know, seeing situations that should have really moved me but instead just irritated me. And I think that was, you know, a variation of compassion fatigue. I guess. It’s a spectrum isn’t it? You can get a little bit in and get serious levels of it. And it just strikes me about how similar the symptoms of compassion fatigue are. They are sisters. Symptoms of stress and symptoms of burnout are probably very hard to distinguish. My guess is that for GPS and doctors with high clinical loads there’s always a bit of compassion fatigue going to be built into any form of overwhelm and stress and then what happens to your brains under compassion fatigue?

Agnes: (16:50)
The neurosciences, and this is, this is kind of something I also wasn’t aware of during my years working directly inside the organizations in special development. Science says compassion fatigue doesn’t exist. The thing we’re actually talking about when we’re talking about compassion fatigue in science lingo is called empathic distress fatigue or empathic burnout or secondary trauma. It’s called compassion fatigue because the word, the term compassion fatigue, got coined somewhere at some point that was in the the late nineties or early noughties. Somebody wrote about compassion fatigue, unaware of how neuroscience was later going to look at people’s brains and discover that empathy and compassion have two very different emotions or mechanisms. So that term got coined, but actually compassionate fatigue is neuroscientifically speaking an imprecise term. So basically a number of years ago, neuroscientists, Tania singer and some others, and also Richard Davidson’s done some of this work, took some Tibetan Buddhist monks and put them in a brain scanner, in an MRI scanner, and looked at their responses – their neurological responses to stimuli that suggested somebody was suffering.

Agnes: (18:09)
So they used, I think, the sounds of people crying out in agony. And they looked at what happened and they got these monks and one of them was very well known. He’s a French molecular biologist who later on turn into a Tibetan monk and then had a really famous conversation with his dad, who was a philosopher in France, John Paul SWAPO, and then they published a dialogue. So he’s really well known for sort of his role with bridging the East and the West and the contemplative world and the science world. So he was one of the people in the brain scanner and they got these monks to meditate on compassion whilst listening to the sounds of people crying out in agony. And so then they mapped out the difference between average people hearing the sounds and what happened when a monk was hearing the sounds of somebody crying out in agony and meditating on compassion and they could see really different areas of the brain fire up in response.

Agnes: (19:08)
And then also they could report that people were feeling quite different. So there was a greater sense of, I wouldn’t call it happiness because that’s not the right word, but a sort of a more, safer containment of these emotions in the people who were meditating on compassion. And so empathy or what they call effective empathy, sort of the effect that we respond to suffering with is processed by areas of the brain that are associated with pain. And compassion is a different response where we activate the areas that are affiliated with kinship and maternal love or parental love. So it is essentially a contemplative love, a love in the presence of pain. So the thing is we do need empathy. That has been a lots of you know, conversation in the media in the last couple of years in response to a book from someone called Paul bloom I believe, who wrote against empathy.

Agnes: (20:05)
There’s been a lot of backlash against empathy saying, Oh it’s bad. It makes us, it makes us irrational. We shouldn’t use it. They probably actually use things like, you know, medics and surgeons as examples for why empathy can be bad. But actually they didn’t consider that people who stop being empathic and shut down their feelings will shut down in various ways and cannot selectively numb emotions. So they’ll end up numbing. And they’ll end up being quite dysfunctional in some way. Socially speaking and also health-wise cause basically humans need connection and humans feel and um, felt and unprocessed emotion isn’t benign. So there has been a backlash but they didn’t see that empathy actually serves a really important role and that it’s kind of a gateway. It can be used as a gateway towards compassion. So people do not suspend empathy to feel compassion.

Agnes: (20:58)
They, they use empathy as a way of tuning into what’s happening and then they respond from that place of compassion. And that’s kind of, that’s a process that they’re trained in and anyone can learn and it doesn’t take, you know, those marathon levels of meditation practice to learn this. Some of the really encouraging research I’ve seen is that actually with compassion practice in particular, you build these skills incrementally from the moment you stop practicing and they have a lasting impact. So some forms of meditation work while you’re using them, like focus takes a lot more practice to go from I am mindful and focused while I’m meditating to I’m mindful and focused while I’m meditating and when I’m not meditating. It takes a lot more practice to reach that sort of state of altered neuroplasticity. Basically with compassion based practice, we can experience those changes that last beyond the time that we practice a lot more quickly. So, yeah, so compassion is a mechanism that we can draw on that lives in a different part of the brain from empathy. That’s the important takeaway.

Rachel: (22:07)
Right? So the, the monks, when they had these dreadful crying things, they accessed empathy but they went straight to their compassion in the sort of mother love. And then other people would stay in that empathy zone where they’re actually feeling it as physical pain. And then that makes sense then that actually there’s only so much physical pain you can feel and take before you become really traumatised by it.

Agnes: (22:32)
Yeah. So what happens is we become traumatised by it and that’s what we call secondary trauma or vicarious trauma, which now also neuroscience increasingly shows is in its mechanism not very different from primary trauma. And what happens is that traumatisation occurs in the system, the body learns very quickly to avoid that trauma happening. So when it happens again and again and again and again, when we work in environments where we’re constantly bombarded with that level of suffering, we become desensitised, which is essentially physiologically speaking a healthy defence mechanism. Cause it stops us from, you know, having a complete meltdown but also then has consequences, which you know, when we become desensitised, as we lose our ability to feel, we lose our ability to relate. We give up not just pain and suffering and agony, but also we lose joy and hope and inspiration and connection. We pay a price for this defence mechanism.

Rachel: (23:28)
Yeah. And I can see that it’s going to be very hard to sort of shut off your empathy towards your patients but keep it for your family. It presumably just covers the whole of life. And so when you have compassion fatigue at work that’s going to come into your home life and affect your relationships and how you are with your friends and your family, your partner, your kids. So it’s got to be really taken very, very seriously cause it affects the whole of your life.

Agnes: (23:55)
Yeah. For some people this is definitely the case. From what I know anecdotally and what I could observe in my environments. And I’ve also seen people who seem have more of a compartmentalising capacity with regards to protection. And this is interesting because I think this is where, you know, there isn’t a great amount of research into this yet and some of the early indications from some of the research, but also from my own experience talking to people is that there are huge variations between people in terms of their coping mechanisms and their ability to respond compassionately. So if you have a team of people, you’ll probably have, you know, if there’s 10 people, you may have one or two who are dealing with this exceptionally well. You may have a couple who are on the brink of, you know, leaving the job or have already left or are on extended sick leave because they can’t handle it.

Agnes: (24:50)
And then you’ll have a large population in the middle who are sort of muddling through and maybe using some unhealthy coping mechanisms and experiencing some of those symptoms we talked about earlier. So there are variations between people. And what’s really encouraging is that anyone can learn it. So it’s, you know, it’s not like it’s a fixed trait because one of the really nice side benefits of this research into empathy and compassion was the discovery of neuroplasticity. That we, that brains, change in response to experience and experiences. Not just what happens to us externally, but also stimuli we give ourselves. So what we think, what our mind does, how, how we talk to ourselves and so on. So all of these practices, which are quite inward facing practices that I’m working on, are things that we can all learn and that can alter the structure of our response to suffering.

Rachel: (25:45)
That is encouraging. Cause it would be awful to think, you know, you’re either born with this, you know, ability to cope, or you’re not. But is there an innate difference between people who deal with it fine. And people who get really affected? Is it genetic or is it that the people who seem to deal with that have already got some of these skills?

Agnes: (26:05)
I wouldn’t be able to answer whether it’s genetic or not. I don’t know if that research exists. I would venture a guess that it doesn’t yet. But you know, I think this isn’t it. This is a growing field from what I can observe. There are people who seem to have a natural ability to be incredibly compassionate and empathic with people without it destroying them. So there are people where when you observe them at work, and you know, they may be nurses, they may be doctors, they may be community workers, social workers who seem to be gaining strength from this work. And so there may be a genetic, there may be a life history that has encouraged that. But the really exciting thing for me is the question, what can we learn from them? You know, how, how do they do it and how can we learn to do that? And I think that’s where this emerging neuroscience on compassion and empathy is really exciting.

Rachel: (26:58)
Yeah. So what can we do? What can be learned to do, what small things can be learned to do that can make a difference for us?

Agnes: (27:05)
So I think the very basic first step is to recognize that shutting down my feelings, avoiding emotion is not going to have benign consequences for both myself and for the people I work with. And that’s a scary, that’s a scary admission because it means, okay, I’m going to have to equip myself to deal with the really difficult, painful stuff I’ve been trying to shut out over the last however many years. So the things we can do are basically to develop. So the way I’ve structured this work on compassion is kind of leans on the work by Christine Neff and Chris Germer on self-compassion. But basically this idea that if you’re going to have compassion for other people, sort of outward facing compassion, it needs to be inward-facing first. So it’s really strengthening, learning self-compassion, that step. That’s a key step. That’s the foundation we need to build first because we need to learn to have compassion with the impact the onslaught of other people’s suffering is going to have on me. So if empathy is effective, empathy means my system is going to mirror somebody else’s pain. I need to have compassion with that pain.

Rachel: (28:22)
So how do you develop self-compassion?

Agnes: (28:25)
There are basically a set of practices, you can call them meditation practices or mind practices. I sometimes avoid the term meditation or mindfulness because a lot of people think, Oh, it’s just about, you know, kind of chilling out and being okay with everything and becoming quite passive. And I think that’s a huge misunderstanding of the contemplative tradition this comes from. But basically they are practices that develop something called metacognition. So the ability to observe and be present with your own experience from a sort of, yeah, from a vantage point, so to speak. So instead of being my pain, my agony, my, my fear of getting overwhelmed by other people’s stuff, I can notice it. So it’s that capacity to notice that retrain through meditation and meditation does another thing which can be creative. It can develop that metacognition and it can also be creative.

Agnes: (29:19)
It can create stimuli that are going to have an impact on the way my nervous system works, on the way that I respond to external stimuli. So those meditation practices are geared towards strengthening that observing capacity and the capacity to create certain states within myself. And specifically by that I mean self compassion. And so very simply, one of the practices that we do is called rain is an acronym that stands for R. A. I. N. recognizing, allowing, investigating and nurturing. It comes from someone called Tara Brock. And in this practice we basically tried to break down that moment of a stimulus reaching me. Say it is that, you know, it is that recording of somebody crying out in pain. And I’m really trying to kind of take a microscope or a magnifying glass and go inside that experience of what happens inside me when I hear that cry.

Agnes: (30:17)
Notice the rising, you know, um, reaction, which could be my own pain in response to that than stopping and looking at that more closely, giving it permission to be there. So that’s the recognizing and allowing, giving it, like recognizing that it’s there, giving it permission to be there, investigating it with curiosity as opposed to judgement. So instead of saying, I don’t know how to feel this, to go, huh, what’s this like, what is this experience like right now? Can I hang out with it a little bit longer? And then some nurtured in some way, which is the part that most people struggle with. But it’s too basic. You’re just kind of adopting a self-compassionate kind of stance towards myself in that moment. And that basically gradually builds and increases our ability to stay present with those moments and to not shut it down. So basically the aim of this is to avoid the shutdown, which we’re also well-practiced in. That’s one of the practices.

Rachel: (31:10)
Hmm. That’s really interesting. I’m just thinking, you know, what can we do with the nurturing practice? And often, you know, when I’m coaching doctors this, you know, there’s a lot of, I shouldn’t be like this and I shouldn’t be feeling this and I’m a bad doctor and being this and these sort of beliefs, but just reframing it and going, it’s okay to feel like this and anyone in this position would feel like this and we’re only human. And I’ve done my best for this patient. I guess particularly if you got a patient who’s dying or maybe even if you’ve made a mistake or there’s been clinical error or even though they’ve had brilliant treatment, things still haven’t gone right because they don’t see, because you know, we’re all just human and just going, it’s okay, I tried my best and my best is good enough. Is that the sort of thing that you’re meaning by nurturing yourself?

Agnes: (32:00)
Yes, definitely. So self-compassion has an element of saying it’s fine, you know, it’s okay, this is allowed to be. This pain, this, this fear, this anger, whatever is present in that moment has a valid reason to be here. And it’s okay, I’m human. I’m guessing that in, you know, in the medical profession there is that sort of projection of the same. So the superhuman capacities, the qualities that we expect from people. I’m getting the impression that in environments like this, much like the humanitarian world, I’m more familiar with, isn’t that people put expectations on themselves to respond superhumanly to very overwhelming situations without realizing that actually a human response also benefits the people they work for or with. So it’s not self-indulgent. It’s actually a courageous act of giving to other people as well to allow oneself to be more human in those moments because we create a stronger connection with people.

Agnes: (32:58)
We can give more empathy, we can be more present, we can make them feel human as well. And the other thing I wanted to say to that is that a really important part of this work on compassion fatigue, in my view, is to recognize that self care doesn’t work in isolation. So in building that meta-cognition and that self-compassion and also the outward compassion. So those are the three kind of pillars is really important. I don’t see that working as a standalone solo. You do it at home with yourself. Exercise. I think that’s problematic on a number of levels. I think first of all, in all those conversations on resilience and self care, I often observe a trend to put additional pressure on people to be fine and to get there on their own. And also I can see that a lot of people feel very ashamed of their responses they’re having to other people’s suffering. And that’s being with other people in processing that sharing that reality with others has a healing effect in its own right. So that kind of sense of, I’m not alone. This is human experience, I’m human, these guys are human, we’re all having these shared experiences is a really important part of dealing with compassion fatigue and that really chimes with the research into self-compassion by Kristin Neff and Chris Germer who basically say that a sense of shared humanity and breaking through a sense of isolation is a really crucial aspect of developing self-compassion.

Rachel: (34:24)
Wow, that just rings so true, doesn’t it? And I guess it doesn’t have to be in these sort of, you don’t have to join a meditation group or become a monk to do this. Actually, it’s just chatting to your colleagues. Maybe having a bit of a debrief after something’s happened. Bit of a reflection and a bit of admitting. Actually I was feeling like this. What do you guys think? And sharing experiences.

Agnes: (34:45)
Yeah, we are, we’re social animals and our nervous systems calm down and regenerate through social connection so you know kind of basically connection with other people you know from developmental research into early childhood connection with others has a really calming, soothing health strengthening effect on our bodies. So it’s no surprise that sharing this challenge with other people is really important and that you know why not calling it through on your own is going to increase some of the symptoms of compassion fatigue.

Rachel: (35:20)
Yeah, it’s really interesting. I think in general practice certainly there is no regular time built in for any sort of debriefs. I know in in hospitals, certainly particularly emergency departments and now you know if there’s been a very nasty trauma happened or something like that, they will make sure they have a debrief with the team. Although not everyone does, but you know, I know this practice is coming in more often, but I guess it’s the people that are working on their own with patients day in, day out, they’ve got these sort of almost these little microtraumas just happening. You know, people don’t often die in front of you in general practice, but you’re hearing really sad stories and there’s really difficult stuff going on and this can just be all stored up and then you’re so busy you don’t actually get to see people at coffee time or stuff, you know? What advice would you give to people in that sort of situation?

Agnes: (36:09)
So I think it’s important to recognize the role that sort of the drip, drip, drip impact of small things plays in traumatising our systems. I think often when we hear the word trauma, we think of the big stuff of, you know, kind of big massive shock events that heavily traumatised us and we think of Woolworth veterans and PTSD and that kind of thing. But neurobiology trauma includes sort of this idea that and a steady onslaught of small things can have cumulative effects. So even if it’s just small to recognize that you know the 50th patient saying they’re depressed this week is also going to have a really difficult impact on our sense of cuddles – finding it difficult to stay. Carrying throughout those 50 conversations I think would be really good. And also to really draw on, I think what nurtures us. So I’ve been looking into something called the window of tolerance by Daniel Siegel.

Agnes: (37:12)
He works on something called interpersonal neurobiology and he looks at what the window of tolerance is. Basically something where he talks about how you know daily ups and downs in our nervous system where we kind of get a little bit activated towards fight or flight or we get a little bit pushed down into a sort of freeze kind of response. That’s pretty normal. And our systems are well adept at handling that sort of back and forth. But we can get stuck outside of the window of tolerance so we can get stuck in fight and flight or we can get stuck in freeze. And when we start looking at what kind of activities would help us unstick ourselves from those stuck places, those are basically things that will either tell our nervous system. So if it’s fight and flight we’re in. So we’re really activated and really tense and angry and shouty and irritable and think so fast, we can’t think clear anymore.

Agnes: (38:03)
Then it’s basically that’s kind of the system is goal. Then we need to find the things that bring the system down. So whatever is calming and it can be, it can be a physical activity that calms us down, such as walking around or it can be a connection with somebody. It can be a quick chat with a good friend. It can be a smell that makes us feel relaxed. Um, you know, I sense something like people work with essential oils. When we get stuck in freeze, which is where we’re feeling a bit despondent and dissociated and disconnected and powerless and not really there. That’s where activating activities can really help. So can be music, it can be drumming, it can be singing, it can be something that energizes us, like going for a run.

Agnes: (38:51)
So it’s basically to recognize is my system stuck in goal or is my system stuck in stop. And to counteract that move a little bit with something soothing. The space within the window of tolerance is also called the space of social engagements as where we’re able to connect and empathize with other people. And so whatever connects us with other people is going to have a positive impact. So for me personally, the people that I know that really understand me, that you know, the people who can kind of finish my sentences, the soulmates kind of friends, you know, those people where I feel really understood and had even a five minute chat with one of them kind of really support me and help me ground myself in a situation that’s difficult.

Rachel: (39:36)
Wow, that’s, that’s so interesting and it makes total sense. And I was reading a book and someone was saying that they’d advise this woman who was constantly in, in that fight, um, thing to actually do some skipping every time to distract herself and that just relax the muscles, calm, sit down. But it’s interesting that the thing about doing something that activates you and like, you know, musical signals, something that yeah, puts you to that happy place but a good place and gives you energy really, really important. So there’s three things we’re picking up. The first one is the daily sort of meditative practices. The second one is to sort of debrief and make sure you’re chatting with colleagues and, and being vulnerable and open about your feelings. And the third thing is sort of do some stuff that gets us unstuck from our fight, flight or freeze zones in some way. Any other quick wins that you can think of or quick tips?

Agnes: (40:25)
Oh, let me, let me think. So one thing that really helps me is to connect with the bigger picture. So that was some research that was done. I don’t have the study off the top of my head right now, but basically a bunch of researchers looked into the compassion fatigue, present among psychotherapists, mental health professionals, and try to work out, you know, what makes the difference between somebody who’s doing a right and somebody who’s drowning in compassion fatigue. And what they found was that one of the key variable separating those who were doing alright and those who weren’t was a sense of greater meaning in their lives. So for some people that’s faith and spirituality. And for some people it’s not, that can be other ways of accessing a sense of greater meaning. But basically those things that connect us with the sense that what we’re doing and who we are is greater than the parts of it all. So for some people that’s nature. For some people it’s music. For people, it’s architecture or art, music, beauty, accessing something that is sort of beyond the spoken word and the cognitive thought that feels deeper than that. People who have really connected in to something greater than themselves in that way seem to find it easier to be in that, you know, constant onslaught and be constant ups and downs and find ways of resourcing themselves.

Rachel: (42:00)
That’s really interesting. So connect me with something sort of out outside of yourself really. Wow. Are there any good resources you could point people to say some places where they can find some of these meditations that they can do or any further reading? What would you suggest?

Agnes: (42:15)
Yeah, there are a few places I can point you to. So something I’ve basically been trying to do over the last couple of years is to take some of the contemplative research and contemplative neuroscience, but also that the actual practices and unpack them and translate them for people not in that world because the language can be quite sciencey or it can be sort of quite alienating for people who don’t like Tibetan singing bowls. And I tried to really break those things down in a very accessible way. And I’ve written a few blog posts about that. So I’ve written a couple of the good jungle.org where I talk about the practices I mentioned and the difference between empathy and compassion and how crucial it is in this work. Also in the last few years, I’ve been constantly referring back to a book called how can I help by Ram Dass and Paul Gorman

Agnes: (43:12)
Yeah, it’s actually from the 1980s. So it’s not really cutting edge. But I do find it really cutting edge in my own life and in my own work and I keep using it. It’s basically a book about the nature of the helping relationship. It’s called, how can I help, stories and reflections on service. It talks a lot about the complications of, you know, putting ourselves in those categories of the helper and the helpee. And it talks about the, you know, in, in various forms of language, but it talks about empathic distress and empathic burnout and things we can do to resource ourselves. So I’d really recommend that book. Also, more recently someone called Joan Halifax, who is a Zen Buddhist, but also, uh, she, I think she works on care of the dying. And on hospice work on palliative care.

Agnes: (44:09)
She wrote a book called standing at the edge finding freedom where fair and courage meets, which was published I think last year, the year before. And it’s interesting because she’s been in some ways on a similar journey from, you know, being a white Westerner, do gooder and set out to stop, say in Africa, to research people in other countries and came into contact with some quite dysfunctional ways of trying to do good in the world. And then reflected on that. And in the book standing at the edge, she talks about a series of qualities that people who want to do good in the world need to have, which need to be held in real balance. Because if they’re taken to an extreme on either side, you can kind of fall off the edge. So you need to kind of stand at the edge.

Agnes: (44:55)
So, for example, she talks about altruism, which can in its highest form be a really positive force in our world, but can also turn into something she calls pathological altruism. And she talks about empathy and how empathy is a really important tool and a really wonderful capacity that we have as human beings. But again, if taken to an extreme and kind of going out of balance can turn into empathic distress and burnout. So yeah, it’s a really wonderful book. Yep. Got one more. I have been, yeah, that’s sort of the meditation called Rain by Tyra Brach on her website is freely accessible and in various different lengths and shapes. So you can do 10 minutes and it’s a really good place to start exploring self-compassion. And it’s something that’s quite portable. So once we know how it works and we’ve practiced it a few times in a sort of, in a more quiet, secluded setting or maybe with other people, ideally it becomes easier to do it ourselves on the go, so to speak, you know? In the consulting room or on the bus or in the queue for a sandwich or as I walk past a homeless person in the street and so on.

Rachel: (46:11)
Brilliant. Thank you. That’s a really helpful list of resources. We’ll put everything there in the show notes as well as links to your website. Agnes. So, what’s next for you? What are you working on at the moment?

Agnes: (46:21)
I’m really excited about sort of those more recent neuroscience developments around something called polyvagal theory by Dr. Stephen Porges, which can explain, which seemed to have some explanatory power for how and why certain things like yoga, meditation, contemplative practice, connection with nature and so on have the effects that we experienced them to have. So I think all of this is really relevant to the work that I’m doing and I’m really excited to find out more. And also there has been, I’ve sort of mentioned this backlash against this whole individualised isolating notion of self care. Like there’s a common, an emergent conversation on collective care, which I’m following and trying to be involved in.

Rachel: (47:08)
Right. Wow. And if people want to contact you, how could they contact you?

Agnes: (47:12)
So my website is called the good jungle.org and if you go to the website and scroll down, there is a little box there where you can put your email address in. My email newsletter is very rare. So for those of you wanting to hear more regularly, maybe Facebook is the better place. There’s a Facebook page called the good jungle and also I’m available on email on hello app, the good jungle.org. Brilliant.

Rachel: (47:42)
Thank you Agnes. Thank you so much for being on, it’s been absolutely fascinating for me. There’s lots to think about and I’m sure that’d be really, really helpful for a lot of my colleagues as well. So I’m going to have to get you back. There’s loads more we could talk about. So thank you so much for being on.

Agnes: (47:57)
Great, thanks Rachel. I look forward to that. Bye.

Rachel: (48:02)
Thanks for listening. If you’ve enjoyed this episode, then please do subscribe to the podcast and also please rate it on iTunes. And other people can find it too. Do you follow me on Twitter at Dr. Rachel Morris? You can find out more about the face to face and online courses, which I run on the Shapes For Doctors website. Bye for now.