An exploration of empathy fatigue in counsellors and their use of self-care strategies

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Yet the very capacity to show empathy and deep understanding of a client’s problems may make counsellors vulnerable to professional fatigue. Experiencing this phenomenon will negatively influence the therapeutic relationship. Self-care measures are at the core of bolstering a therapist’s resilience to ensure a high standard of working with clients. Instead of the more frequently researched compassion fatigue, this qualitative study uses the term empathy fatigue to broaden the scope of reported experiences. It examines the effects of empathy fatigue and self-care strategies reported by six counsellors from Asia-Pacific and Europe. While the lack of conceptual clarity on the different constructs of professional fatigue became apparent, rich data helped to interpret how the individual made sense of this phenomenon. Findings showed that self-care was commonly viewed as a self-mandated regimen satisfying both needs for empathy-free zones and social engagement. To help others, therapists need to help themselves first. Self-directed solution-focussed questions to gauge how effectively self-care measures in place are working prove useful for counsellors in managing and maintaining equilibrium in both professional and private settings. Psychology counsellor empathy fatigue self-care compassion fatigue empathy Figures Figure 1 1. Introduction A counsellor’s ability to facilitate change in a client is grounded in empathy and compassion as well as the use of a therapist’s self, irrespective of the employed method (Whipple et al., 2003 ). A counsellor requires a certain level of resilience to help a client address a problem or overcome a crisis (Noullet et al., 2018 ). Therapists may feel emotionally, mentally, and physically exhausted by the exposure to clients’ presenting issues when exploring their personal history, especially in the context of working with highly distressed clients (Stebnicki, 2000 ). Therefore, self-care measures to help prevent or alleviate professional fatigue are regarded as essential, as is the ability to disengage with a client’s problem post-session (Norcross & VandenBos, 2018 ). In literature, the construct of compassion fatigue features prominently and semantically has the closest relation to empathy fatigue. Yet while compassion refers to the ability to notice the suffering and pain in others and the consequent wish to relieve it, empathy is an instinctual and emotional experience of a fellow human’s feelings. As a relationship-building skill, it has a cognitive and an affective element. The two terms also differ in “emotional output” (M. K. Lee, 2020 ), meaning that one can show compassion while being emotionally distant, whereas empathising requires a greater deal of intense and emotional involvement. Compassion fatigue has its origins in nursing, where being exposed to a patient’s morbidity would negatively impact a frontline health worker’s well-being (Joinson, 1992 ). In counselling, the emphasis lies on empathy regarded as a fundamental tool for becoming an “ideal therapist” (Rogers & Yalom, 1995 ). Consequently, Stebnicki ( 2000 ) reasons that professional exhaustion in the context of psychotherapy should be referred to as empathy fatigue. To deeply understand empathy fatigue in the context of professional fatigue symptoms, this qualitative research uses interviews to explore what counsellors specifically associate with the term empathy fatigue. It examines what measures therapists take to ensure physical and mental health, the importance they attach to it, and how effective they rate it. Expanding the scope, this piece of research assesses to what extent therapists have rediscovered self-care measures to promote well-being. It investigates whether counsellors successfully or unsuccessfully re-engaged in activities they no longer count towards their current self-care measures. Searching for studies which address the concept of whether therapists use solution-centric approaches to explore their own situation and define goals, are scarce. In support, Miller (2005; as cited by Stebnicki, 2007 ) argues that in order to build resilience, solution-focussed questions are at the core of assessing the personal relevance and effectivity of self-care strategies. By self-directing one of the key questions, namely “When was the problem not present?”, counsellors might be able to rediscover strategies they may have forgotten about. These can help to define exceptions in the past to build resilience in the present (de Shazer et al., 2007 ). 1.1 Empathy Empathy is regarded as an integral part of a therapist’s work without which effective counselling cannot be achieved (Rothschild, 2006 ). Empathy can be described as the ability to comprehend and react to the distinctive affective experiences of others where one’s own feelings and those shown by others display a certain similarity (Decety & Jackson, 2006 ). Neuroimaging studies have shown that adopting the perspective of others stimulates regions in the brain responsible for emotional processing suggesting a strong biological link (Ruby & Decety, 2004 ). When a therapist shows empathy, they set the scene for building a rapport and thus initiate the therapeutic process by maximising personal interactions with a client (Moore & Thomas, 2006 ; J. R. Nelson et al., 2018 ; Turgoose & Maddox, 2017 ). This process should ideally lead to a therapeutic relationship, the quality of which determines the outcome of the treatment (Black et al., 2005 ; Langhoff et al., 2008 ). The making of a therapist would centre on the abilities to cooperate, focus, empathise, and be transparent (Langhoff et al., 2008 ). Alfred Adler referred to an anonymous English writer to define empathy: “One must see with the other person’s eyes, hear with his ears, and feel with his heart” (Clark, 2016 ). Yet the very ability to show empathy and deep understanding of a client’s problems may make counsellors vulnerable to professional fatigue (Figley, 2002b ; J. R. Nelson et al., 2018 ; Thompson et al., 2014 ). Empathy itself, regarded as the key building skill in forming a therapeutic relationship, is an attributing factor negatively impacting on a counsellor’s state of health and wellness (Rothschild, 2006 ). Empathy can be viewed as a continuum where on one side of the scale there is “emotional overinvolvement” and on the other “emotional distance or burnout” (Bush, 2009 , p. 26). The precondition of being an effective counsellor, namely the ability to show empathy, simultaneously acts as one of the predictors of an increased risk of incurring exhaustion and fatigue (Delaney, 2018 ; Turgoose & Maddox, 2017 ). Contrasting this, in an integrative literature review Coetzee and Laschinger ( 2018 ) posited that compassion fatigue is not rooted in empathy, yet instead stems from the lack of resources and support as well as the individual’s reaction to stress. Both opposing views raise the question of how self-care measures help to modulate, balance, or even prevent distress and professional fatigue. 1.2 Self-care Measures and strategies put in place to alleviate and manage the impact the therapeutic process has on the practitioner are of great importance, affording much consensus in academic literature (Barnett et al., 2007 ; Butler et al., 2019 ; Miller & Sprang, 2017 ; Owens-King, 2019 ). Such methods form the category of self-care defined as intentionally taking up activities to improve personal well-being and would include most physical and mental measures related to building resilience and managing stress (Glennon et al., 2019 ; Lewis & King, 2019 ; Noullet et al., 2018 ). Newell ( 2010 ) showed that not only practising self-care, but also developing individual coping strategies and skills is considered helpful for counsellors experiencing professional fatigue symptoms. Self-care encompasses a number of domains that attend to “physical, social, emotional, and spiritual needs as a way of ensuring high-quality interactions with others” (Merriman, 2015 , p. 372). Building on this definition, Norrman Harling and colleagues ( 2020 ) consider it important to satisfy these needs as the process acts as a shielding and strengthening factor. Mindfulness-based stress reduction (MBSR) in particular has shown a positive correlation with compassion satisfaction (Thieleman & Cacciatore, 2014 ) and demonstrates a link between self-awareness and well-being (Richards et al., 2010 ). Research has also shown that providing counsellors-in-training with the tools to practise mindfulness increases the positive effect it has on preventing burnout (Christopher & Maris, 2010 ). A study involving special education teachers showed the same positive effectiveness through the use of prayer and mindfulness (Sharp Donahoo et al., 2018 ). The ability to reflect is equally as essential since practitioners need to be aware of their individual risk factors in order to put appropriate self-care measures in place (Norcross, 2000 ). Barnett and colleagues ( 2007 ) elevate this domain by arguing that it is an “ethical imperative” (p. 604) to address the distress a therapist faces in the counselling room to ensure the welfare of the client. Dr Paul Appelbaum, a professor of psychiatry and former president of the American Psychiatric Association (APA) is quoted as saying: “It’s difficult to make an argument against exercise, meditation or other relaxation techniques, sufficient amounts of regular sleep, a healthy balanced diet.” (Kazdin, n.d.). 1.3 Fatigue terminology Academic literature broadly identifies four terms to describe the negative impact the therapeutic process has on the practitioner: compassion fatigue (Allsbrook et al., 2016 ; Bride et al., 2007 ; Joinson, 1992 ), secondary traumatic stress (Beaumont et al., 2016 ; Figley, 2002a ; Nimmo & Huggard, 2013 ), vicarious trauma (Baird & Kracen, 2006 ; McCann & Pearlman, 1990 ; Newell & MacNeil, 2010 ), and burnout (Craig & Sprang, 2010 ; Maslach, 2003 ; Simionato et al., 2019 ). None of these terms are viewed as pathological and therefore not classified in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-V) published by the American Psychiatric Association ( 2013 ). The 11th Revision of the International Classification of Diseases (ICD, n.d.) refers to burnout as an occupational phenomenon, yet stresses that it is not classified as a medical condition. These observed or self-reported conditions are on a continuum and, depending on the researcher, have certain areas of overlap, but also distinct definitions. Compassion fatigue (CF) has its origins in nursing (Joinson, 1992 ) and can be described as a “cumulative and progressive absorption process of patient’s pain and suffering formed from the caring interactions with patients and their families” (Jarrad et al., 2018 , p. 1). Klimecki and Singer ( 2011 ) define CF as “pathological altruism” where a caregiver would alleviate the pain of others by giving empathic care, which could cause a negative impact on their own physical and mental health. Typically, symptoms related to CF are described as feeling lethargic, hopeless, helpless, as well as disengaged (Day & Anderson, 2011 ). The term was later adopted by emergency relief workers and trauma therapists, where the same correlation and the resulting feelings of being drained and worn down were observed (Craig & Sprang, 2010 ; Walsh et al., 2017 ). Looking at therapy outcome, failing to address CF relates to unfavourable results for clients thus rendering interventions ineffective (Negash & Sahin, 2011 ). A number of studies have examined whether there is a correlation between demographic characteristics and the levels of CF — with a varied outcome. One such study found no significant relationship between the two variables, but rather a notable difference between working experience and compassion fatigue (Kabunga et al., 2016 ). This suggests that it is not age and gender that determines the level of compassion fatigue that a counsellor experiences, but instead the number of years spent in the profession: With an increase in working experience comes a decrease in compassion fatigue. There is an apparent overlap of CF with secondary traumatic stress (STS) as posited by Pirelli and colleagues ( 2020 ), which also becomes observable as the terms CF and STS are often used interchangeably (Sprang et al., 2007 ). In fact, Jenkins and Baird ( 2002 ) use STS as a synonym for CF (p. 423). Baird and Kracen ( 2006 ) emphasise the difficulty in identifying correlates of vicarious trauma (VT) and STS as there is a “lack of conceptual clarity” (p. 183). Figley ( 2002b ) intentionally replaced STS with CF since the term promotes a more positive connotation. Taking the opposite position, Newell and MacNeil ( 2010 ) are very clear in their review of theoretical terms. While they agree that CF, STS, and VT stem from working with trauma clients, and burnout is an occupational hazard, the three trauma-specific phenomena require individual conceptualisation. McCann and Pearlman ( 1990 ) define vicarious trauma as damaging changes that transpire in mental health professionals’ views of themselves and others as well as the world in general. This results from being exposed to graphic or traumatic material and can be viewed as a normal reaction to ongoing processes which may negatively impact motivation, effectiveness, and empathy (Baird & Kracen, 2006 ). The retelling of a client’s traumatic events may lead to a practitioner developing vicarious trauma especially if they have experienced a very similar traumatic event themselves (Pirelli et al., 2020 ). Again, the model lacks clarity as suggested by Jenkins and Baird ( 2002 ). They argue that STS and VT have conceptual similarities yet do not share the same constructs. They ascertained that the symptoms of both VT and STS stem from a counsellor being exposed to the retelling of a client’s traumatic stories, the outcome being distress or burnout. STS links to social and emotional symptoms whereas VT focusses on a variation in cognitive schemas. What unifies these three types of professional fatigue is that they have a common denominator in form of displaying symptoms of post-traumatic stress disorder (PTSD) without being identical to PTSD itself (Bride et al., 2007 ; Figley, 2002b ). Burnout may be explained as the “prolonged response to chronic emotional and interpersonal stressors on the job and is defined here by the three dimensions of exhaustion, cynicism, and sense of inefficacy” (Maslach, 2003 , p. 189). Typical signs of this “occupational hazard” (Merriman, 2015 , p. 370) are withdrawing, not engaging with friends or family members, and adopting an unhealthy diet (Begic et al., 2019 ). A prolonged state of burnout may also impact a counsellor’s ability to work or result in leaving the profession altogether (Sprang et al., 2007 ). Opposing this definition of burnout, Aycock and Boyle ( 2009 ) argue that this type of accumulated stress should be referred to as compassion fatigue and not burnout. The researchers propose that this term does not adequately reflect “the result of the longitudinal workplace ramifications of sadness and despair” (p. 183). Contradicting this assignment of nomenclature, a study on trauma therapists concluded that it was not always viable to diagnostically differentiate between the two constructs of secondary traumatic stress and burnout (Deighton et al., 2007 ). This discourse links back to the descriptions of VT and STS where a lack of clarity in the concept is recognised as being problematic when identifying correlations (Baird & Kracen, 2006 ). Examining the end points of the compassion continuum, a meta-analysis of 33 studies published between 1997 and 2017 concluded that approximately 40 per cent of health care workers (n = 9,409) reported professional exhaustion underscoring the importance counsellors should place on their mental and physical well-being (O’Connor et al., 2018 ). A study based on self-rated inventories by W. Lee and colleagues ( 2015 ) found that 61% of genetic counsellors (n = 402) were at high risk of compassion fatigue. Despite this substantial percentage, experimental research has also shown that moderate mental fatigue does not automatically exclude a counsellor from showing empathy, albeit affording more energy and effort (D. W. Nelson et al., 2003 ). 1.4 A framework of empathy fatigue In contrast to the wealth of literature available on the previously mentioned types of professional fatigue, there are limited papers on empathy fatigue. Neuroscience suggests a strong link between the ability to feel the pain and distress of others, the key definition of empathy, and the activation of one’s own neural networks and mirror neurons (Singer & Klimecki, 2014 ). As shown in Fig. 1 , the authors state that an “empathic response to suffering can result in two kinds of reaction: empathic distress […] and compassion” (p. 875), and hence promote the use of the term empathic distress fatigue. Hofmeyer and colleagues ( 2020 ) also favour this term based on neuroscientific findings showing that compassion itself can neither be quantified nor validated, and does not cause fatigue. However, empathic distress fatigue can be managed through compassion training, by which the unclear self-other distinction is emotionally regulated. Stebnicki suggests that empathy fatigue is set apart from other professional fatigue types. It relates to “emotional secondary stress and grief reactions that occur during helping interactions” (Stebnicki, 2000 , p. 23). A person-centred therapist who uses empathy as a means of connecting with a client’s story might experience an “empathy fatigue reaction” (Stebnicki, 2007 , p. 327). He views this reaction as an impairment caused by an interaction of variables such as age, resilience, organisational support, coping styles, and personality traits. A counsellor is often unaware of experiencing empathy fatigue, as are peers in the professional setting. Stebnicki continues that onset is both acute and cumulative with no “predictable linear path to STS reactions” (p. 319). The experience occurs on an individual level since it depends on how a counsellor perceives a client’s story. Further, Stebnicki ( 2007 ) argues that in order to bolster resilience, self-care measures first require self-assessment. This process involves self-directing solution-focussed questions to evaluate the status quo (Miller, 2005; as cited by Stebnicki, 2007 ). One such typical question reads: “What are self-care activities I have done or would like to do that do not take much time, energy, or money?” (Stebnicki, 2007 , p. 334). In line with the previously mentioned types of professional fatigue, empathy fatigue is disadvantageous to a counsellors’ prospects for “personal growth, professional development, and overall mental, physical, and spiritual well-being” (Stebnicki, 2007 , p. 319). Professional fatigue is the cost of caring that might present in every second practitioner for multidimensional and complex reasons (W. Lee et al., 2015 ). Some researchers see the difference between the terms describing professional fatigue as either negligible or non-existent suggesting substantial overlap. Others posit a need for individual conceptualisation, which raises the question how of useful labelling is in the context of reducing the effects of professional fatigue. In support of this study on empathy fatigue semantic logic might follow: If empathy is the “soul of the counselor” (Stebnicki, 2007 , p. 320), should a waning or even loss of the very same not primarily be referred to as empathy fatigue? 2. Methodology This research uses a qualitative approach as it incorporates an investigative method as well as an in-depth, subjective exploration. To enable the collection of rich data, a semi-structured interview with mainly open-ended questions was used. A call for participants was posted on the British Association for Counselling and Psychotherapy (BACP) research website accessible to over 60,000 members. In addition, an email outlining the proposed research was sent to colleagues and known therapists with the request to disseminate the invitation to participate in the study among their peers. Researcher bias was avoided as participants were not professionally attached or related. This also ensured that there was no pressure to participate and there would be no negative consequences if informed consent was not obtained. 2.1 Recruitment The participants include qualified therapists with a minimum of three years of practical experience in counselling. Stipulating this length served two purposes: (a) to ensure a certain degree of professional experience after graduation; (b) to enable the participant number to be met by convenience sampling. Six interviews were conducted without any withdrawals. The participants were all practitioners with psychology related degrees at BSc, BA, PG, and doctorate levels. Three females and three males took part in the study. Three of the participants practised in Europe and three in Asia-Pacific. No type of covert research or deliberate deception took place, which was explained during debriefing. 2.2 Data collection The interviews were conducted via a video conferencing application and lasted between 30 and 45 minutes. The participants provided permission for recording the interview. They also gave informed consent that contributing was voluntary and they were not coerced or induced to take part. Participants were free to withdraw their data up to four weeks after the interview. To conclude the support of participants, debriefing provided additional information and resources to the participants. 2.3 Data analysis Interpretative Phenomenological Analysis (IPA) served as the approach of choice. IPA highlights what things mean to the individual (McLeod, 2003 ) and how one understands life experiences (Smith et al., 2009 ). It is predominantly an interpretive tool, which requires depth and a commitment to the concept that less is more when developing topics enabling detailed and synthesised evaluation (Hefferon & Gil-Rodriguez, 2011 ). The interviews were transcribed verbatim in preparation for analysis. Audio files were converted to text documents using the transcription software Otter and carefully checked for accuracy. This helped to become acquainted with the rich data. Field notes taken during and upon completion of the interviews aided the process of validating the contents. Once transcribed, the research interviews were manually coded with help of the analysis software MAXQDA 2020 by identifying topics, similarities, and dissimilarities. The codes were drawn together, grouped as supra- and subordinate themes, and offered to supervisors and peers for validity purposes. When interpreting the contents, reflexivity logged in a journal captured the immediate process of the author’s engagement with the data and the thoughts that informed the analysis. By this form of personal revelation, the author in his dual role as researcher and practising counsellor gains visibility in the process (Finlay, 2011 ). To add content and enable meaningful interpretations (Sutton & Austin, 2015 ), excerpts from all six interviews are quoted as validated vignettes. 2.4 Personal data, anonymity, and confidentiality The anonymity and confidentiality of the participants of the study was protected so that they could disclose narratives openly. Participants are referred to by anonymised names. In accordance with General Data Protection Regulations, all written and recorded accounts were kept in a lock-protected filing cabinet. Only the researcher had access to media and anonymised transcript. The digital recording was destroyed after the transcription was completed by erasing it from the data carrier, backup media, and cloud-based storage. 2.5 Ethics Prior to the study, ethical consent was obtained from the regulatory board at Leeds Beckett University. Personal safety of researcher or subject was anticipated as within the risks of daily life. The participants were fellow practitioners of early and late middle-aged adults, and not part of a vulnerable group. 3. Findings From the coding process and defining of patterns in the participants’ stories eight topics emerged, which were grouped into supraordinate and subordinate themes. Three supraordinate themes were identified as relevant for this study. They focus on: (a) defining and experiencing empathy fatigue, (b) individual approaches to self-care, and (c) neglected and rediscovered self-care strategies. 3.1 Defining and experiencing empathy fatigue Self-reported individual levels of happiness served as an indicator for a potential relationship between experiencing empathy fatigue and feeling happy in one’s job as a counsellor. All participants emphatically stated that they were extremely happy as mental health practitioners. One clinician “couldn’t imagine being in a different profession” (Grace) and another was “really happy to be a psychologist, it’s rewarding” (Elias). Working directly with clients and playing a meaningful role in their change process was the theme that emerged as the one most beneficial to the overall feeling of professional happiness: […] this sense of being a witness to another individual’s transformation […] seeing the, you know, the blossoming of the individual through. It’s very, very gratifying. It’s a beautiful thing to watch. It’s like nature, it’s like watching a butterfly emerge from the cocoon, […] learning to see that transformation is very enriching. (Grace). Five out of six participants were confident that they had encountered empathy fatigue in their professional setting, at the same time all six were able to offer their own definition of empathy fatigue. One interviewee made a link to the counsellor’s core ability to show genuine empathy and advocated the use of the term empathy fatigue: […] my first thought was that empathy fatigue tends to be used in relation to people who are in extreme situations and helping, or counselling […] I feel that empathy fatigue is much more suited to what we do in a professional, daily way because our […] profession relies on us being empathetic. (Anne). Another participant saw a relation to the chronological connection with experiencing fatigue, which may occur over a defined period: “[…] it is that gradual build-up of empathising with clients over the course of a day or a week or a month, you know, just basically, incrementally, and then it just taking its toll on you as a counsellor.” (Justin). He expanded on this theme: “[…] the longer you spend with the clients, the deeper the window into their world, and therefore you’re more likely to get more into more deep issues, which from an empathy point of view can be a bit more draining.” (Justin). The aspect of providing a high volume of sessions with a particular client was brought into context with familiarity, repetition, and to a certain degree exhaustion or weariness: “I guess tiredness of hearing people complaining, I suppose. […] I would sense a running out of a willingness to hear what the presenting difficulty is or when it is repeated.” (Carl). […] empathy fatigue is about when any individual who is expected to be empathic, and that includes obviously therapists, really struggle to get back to find that empathy. Because they have heard the situation that the client is talking about repeatedly, and they’ve become accustomed to it. And they’ve almost normalised that in their practice. (Catherine). One participant presented a link between empathy fatigue and transference offering a biological connection: “Amygdala hijack […] feeling a lot of big emotions that, you know, might be coming from a client, but maybe at the same time, also activating something of your own material.” (Grace). A common theme was that the lack of conceptual clarity of professional fatigue symptoms. One practitioner mentioned that “everyone has sort of a different idea on what empathy fatigue could mean for them” (Anne). She also stated that empathy fatigue “in a general therapeutic setting, I hear more often referred to as compassion fatigue” (Anne). Another participant questioned her own definition when stating an example from her work as a clinician: “I’m not sure if empathy fatigue is the right term — sometimes it feels more like burnout than empathy fatigue. And I don’t know how you would differentiate that? […] I wouldn’t know.” (Grace). One practitioner, without any hesitation in his response, drew a comparison: “Well, I’d say almost like post-traumatic stress disorder.” (Elias). The interviewed counsellors experienced empathy fatigue differently. Feeling drained, exhausted, tired, or irritable was commonly observed. On occasions, this might present as debilitating: “Sometimes maybe it’s immobilising, like you can’t seem to move, or you can’t seem to flow with it.” (Grace). The response is “an emotional one, but I think it’s also a physical one. I think I tend to carry it in my body, whether that’s feeling drained, feeling tired and exhausted or physically feeling like my muscles ache.” (Justin). Two counsellors experiencing empathy fatigue also saw their relationship with the client diminish: “I know that it could lead to probably questioning your own skills, […] losing the ability to be empathic.” (Elias). “And so obviously, that means that the empathy that is demonstrated is reduced, and in the client relationship, that’s a real disaster.” (Catherine). Two participants, despite being experienced with decades in practice, voiced doubts about their suitability to the profession when experiencing empathy fatigue: “It made me wonder whether I should be doing it at all.” (Catherine). I think when I get stuck with that, it makes me more anxious. It makes me feel a certain sense of inadequacy, you know, feeling like, I’m not being more effective, and what does that mean? What does that say about me as a clinician? And, you know, how can I be better? So, sometimes there’s self-blame that comes up, and you want to push yourself harder, or you extend your limits, in a way that at some point might not be healthy? (Grace). In one therapist’s account, a client once stated that “losing a child is the worst thing that can ever happen. There is nothing, there’s no other grief that is similar to it.” (Catherine). This sparked her own experience to be revisited “where I lost somebody that I loved very much under really difficult circumstances, I think it was hard to empathise with that person that almost minimised — I felt unwittingly minimised how my experience was.” (Catherine). She offered her own interpretation of this interaction: “I think it’s transference really, and countertransference”. (Catherine). Three counsellors found that a combination of years spent in the profession and life experience proved beneficial in dealing with empathy fatigue: “I think as I gain more experience, and I think as I matured also in clinical work, […] that has happened much less.” (Grace). 3.2 Individual approaches to self-care All interviewees mentioned that self-care served two purposes i.e., building one’s own resilience to remain healthy and enable better care for clients. “[…] if you think of a full cup, and then you take away a bit at a time for different needs, then you have less in your cup for your ability to feel empathy.” (Anne). Without adequate self-care the ability to be a good counsellor declines: “[…] using sort of analogy of the oxygen mask in an aeroplane, where they say, put yours on first because if you don’t find the oxygen, you can’t help somebody else.” (Carl). This theme was echoed by another practitioner who shared that one has to “take care of yourself first if you’re trying to take care of the others. My own well-being, I try to keep it as a priority so that I can be as good a psychologist I can.” (Elias). Measures taken to promote self-care covered a wide range of physical and mental activities, such as reflective or creative writing and journaling, meditation, yoga, needlework, music, gardening, and dog walking. Receiving support from spouse, family, and friends was reported as being beneficial. Practicing mindfulness was also seen as “good at really grounding me in the moment” (Justin), “tremendously helpful” (Grace), and practised frequently. One practitioner took a circular approach and remarked that “working with clients has been a joy. And I think that is a source of self-care, like allowing ourselves as clinicians to take to feel joy in the journeys of our clients.” (Grace). Further, Grace stated that “community care is self-care.”, and expanded on this by seeing the benefit of “intentionally nurturing a sense of community” (Grace). 3.3 Neglected and rediscovered self-care strategies Participants were aware of the effects when they neglected self-care strategies. Feeling irritable or not getting enough sleep was identified as “one sign that there’s something going on.” (Elias). Participants observed that phenomena such as feeling depleted could also spill over from the professional to the private setting: “[…] the times that I don’t have time for those activities, all other areas of my life feel more like a struggle.” (Anne). Time constraints kept counsellors from maintaining self-care strategies: “[…] everyone has to be selective with their hobbies, because you don’t have endless time.” (Anne). There was, however, an awareness of the reasons and a resolution: “[…] maybe I’m trying to fit too much in, you know, I don’t have time for meditation […] you have to find the time for self-care sometimes.” (Carl). Two participants realised that they were not tapping into the support network available to them: “And I think all of us probably miss out on asking each other for help or for advice on a regular basis.” (Justin). A participant in private practice remarked he wanted “to be more in touch with my colleagues here […] So that’s something that I know that I would benefit from, which I haven’t done that much yet.” (Elias). Being aware of neglecting this strategy, the participant was determined to address the situation: “But that’s exactly what I’m gonna do in the near future.” (Elias). Another practitioner recognised the “necessity to switch off and not be constantly available” and acknowledged that this was “something that I would like to be better at doing, because I think it would be helpful.” (Anne). One counsellor was prompted by the question on potentially neglected self-care measures to reflect on the reason why yoga, once considered very helpful, was currently not actively pursued: “So, oddly enough, I was doing it at home, in the summertime last year, and then I stopped it. And then I did it again, once about two weeks ago, I thought I must keep doing this, and I haven’t done it again.” (Carl). 4. Discussion The aim of this study was to explore the definition and experience of empathy fatigue and how self-care is practised. The participants were unanimous in their view that empathy constitutes the core quality of a counsellor (Turgoose & Maddox, 2017 ). All therapists had an intrinsic motivation to help others. Unprompted, the majority thought it was the best job imaginable and felt a sense of personal and professional fulfilment, and shared happiness emerging directly from working with clients (Singer & Klimecki, 2014 ). Some considered themselves in a dual role as carers in their relationships with their families indicating an empathic disposition for the profession. One participant made a noteworthy observation when stating that while experiencing empathy fatigue she felt her amygdala was being hijacked. Neuroscientific research shows how the amygdala is involved in the processing of emotions, perspective taking, and empathy (Ruby & Decety, 2004 ). Other participants also remarked that a client’s story could stimulate their own material indicating vicarious trauma (Pirelli et al., 2020 ). While reviewing the different terminology on professional fatigue, it was found that there was a lack of conceptual clarity (Baird & Kracen, 2006 ). In view of the absence of clearly measurable biomarkers there appears to be no valid diagnostic differentiation between syndromes or constructs (Deighton et al., 2007 ). This was mirrored by participants who reported that they were either unsure they were experiencing empathy fatigue or possibly a different type of fatigue, and in one case were unable to tell it apart from burnout. From a constructivist’s point of view, it would seem evident that there was a great deal of variation in defining symptoms of empathy fatigue since no two individuals would be able to gauge their experiences on a common scale. One practitioner argued that, because of the very ability to empathise, its corresponding lack should be termed empathy fatigue (Stebnicki, 2007 ). PTSD was also mentioned, which connects with the construct that PTSD is a common denominator of all types of professional fatigue (Bride et al., 2007 ). A number of participants agreed that empathy itself might cause empathy fatigue (Figley, 2002b ). The account of another counsellor that the amplified frequency of sessions with a client would potentially relate to an increase in empathy fatigue shows a link to the concept of empathy being on a continuum: Emotional overinvolvement with subsequent exhaustion might result in professional fatigue (Jenkins & Baird, 2002 ). Feeling depleted, weary, but also hopeless and helpless are typical symptoms associated with both compassion fatigue (Day & Anderson, 2011 ) and empathy fatigue (Stebnicki, 2007 ). Other topics emerged while exploring empathy fatigue, namely anxiety, self-doubt, blame, a sense of inadequacy, and a detrimental effect on the therapeutic relationship. Doubting one’s own ability might be associated with the early stages of entering the profession and making mistakes in the counselling room (Merriman, 2015 , p. 374) and not so much being an experienced therapist. Yet in view of the fact that two proficient practitioners were at the moment of facing empathy fatigue highly analytical of their general suitability, shows an ingrained ability to critically reflect and question all aspects of the client relationship, including themselves (Glennon et al., 2019 ). At times, counsellors tend to view their own actions or interventions as insufficient. Gentry ( 2002 ) lists “inadequacy as a caregiver” (p. 43) as an intrusive symptom of compassion fatigue. In this same comparison table, increased anxiety, as mentioned by another participant, is classified as an arousal symptom. The observation of one practitioner that reduced empathy can have a disastrous effect on the client relationship is in line with the textbook definition of an empathic counsellor (Rothschild, 2006 ). One therapist absorbed a trauma survivor’s story, which when being connected to her own material of loss and grief ultimately led to a break in empathy. This transference describes part of the therapeutic process, yet also counts towards the cost of caring (Pirelli et al., 2020 , p. 7). Although literature is ambivalent when it comes to assessing whether years spent in the profession aid resilience (Kabunga et al., 2016 ), the participants’ accounts are in support of this hypothesis. Experiencing empathy fatigue correlates with lower life experience and fewer years spent in practice i.e., it occurs earlier on in the career. The more experience a counsellor has, the more effective their approach to dealing with empathy fatigue is seen. A study by Coetzee and Laschinger ( 2018 ), which posits that a lack of resources leads to compassion fatigue and not empathy itself, found little support. Although some participants reported occasionally feeling frustrated in the line of work or experienced a lack of structural support, all dealt with this through coping strategies or self-care measures. There was no indication that comparatively low renumeration or the structure of the organisation was linked to experiencing empathy fatigue. Unsurprisingly, clients are at the core of the phenomenon of empathy fatigue, especially when they repeat themselves and will not do the work. Time chips away at the willingness to listen to clients. The deeper a counsellor gets into a client’s story, the deeper the abyss may potentially become. What emerged was an understanding that most practitioners had experienced some type of professional fatigue, which in the context of this study they would readily define as empathy fatigue. There is a distinct possibility that had this term been replaced with empathic distress fatigue (Klimecki & Singer, 2011 ), the same observed phenomena might have been reported. All participants felt that they needed to practise self-care to be present and at their best for their clients. They viewed self-care as a requisite foundation to deliver therapy work. It seemed that this construct was deeply embedded in their thinking; they did not question its necessity or efficacy. It was viewed as an ethical imperative by which the therapist needs to address the issues encountered in the counselling room to ensure the welfare of the client (Barnett et al., 2007 ). However, the activities the counsellors engaged in did not go against their nature, meaning they did not force themselves or step outside their comfort zone. None of the participants mentioned that they pursued measures that they did not enjoy yet knew that they were per se suitable to add to their resilience. In essence, self-care served two purposes: maintaining one’s own mental and physical fitness by leading a healthy lifestyle, and ensuring that engaging with a client remained on a professionally high level to work towards a favourable outcome (Simionato et al., 2019 ). This implies that all participants had high ethical standards and would not compromise the therapeutic alliance by ignoring their own well-being. Self-care was in fact a self-mandated regimen. Two contrasting approaches to self-care emerged. Some participants explicitly stated that they required empathy-free zones to mentally remove themselves from the day spent in the counselling room. They specifically sought regenerating sanctuaries in areas that were free from fellow human beings. Meditating, enjoying nature, being creative, or writing poetry assured them an inner space which they needed to switch off from the office and regain resilience (Newell & MacNeil, 2010 ). A number of participants commented on highly beneficial effects of practising mindfulness remarking on its positive outcome (Richards et al., 2010 ). Contrasting this, some interviewees stated that socialising with others after work hours or being with family and friends was their preferred way of switching off. There was a sense of feeling sprightlier when resuming work the next day, especially when they had stepped outside of both domestic and professional life. Singing in a choir or being in band would also involve doing things together with fellow humans. Interestingly, both approaches were present in the same counsellors suggesting the wish to satisfy both needs albeit at different times: the need for self-centred solace and the need for social engagement and support. Meeting these needs serves as a bolstering and protective measure (Norrman Harling et al., 2020 ) with a favourable outcome: It promotes higher levels of resilience. The study participants were very much aware of when a tipping point between managing the cost of caring and feeling overwhelmed was imminent. One counsellor noticed she was on “autopilot” (Anne) with others reporting a reduced capacity to reflect in and out of session. A disruption to their normal sleep pattern also emerged when they felt that levels of resilience were becoming increasingly depleted. Identifying these signs as an alarm bell would help to make time to re-engage in activities in the domain of self-care. Being able to assess risk factors and put alleviating measures in place is an essential quality of a counsellor (Norcross, 2000 ). None of the participants mentioned that things had gone beyond a tipping point resulting in prolonged absence, illness, or burnout. Long weekends and holidays served as sufficient breaks to ensure that meaningful client relationships could be maintained. Self-monitoring helped to identify tipping points. All participants were clear about potential insufficiencies in the domain of self-care and were able to name their previously pursued activities. By reflecting they became aware of measures that were currently not in place. A number of the underused strategies were the result of government-imposed regulations in light of the SARS-Cov-2 situation. Some counsellors realised that they had fallen short of adequately tapping into support networks available to them, preferably by engaging with colleagues. Others noticed that they lacked the capacity to disengage after sessions, particularly at the end of a working day or week. Being able to disconnect will help to define a border between professional and personal life (Norcross & VandenBos, 2018 ). Leaving distress at the office should be a priority. Findings show that some counsellors consciously neglect self-care measures indicating that practitioners do not display an inherent exceptional ability or superiority to observe strategies. Anecdotal evidence suggests that strictly adhering to self-care measures is not per se their forte and does not set therapists apart from the rest of the population (Norcross & VandenBos, 2018 ). Counsellors do not always practise what they preach. The data collected did not reveal niche or novel ways of practising self-care with one noteworthy exception: viewing client work itself as self-care. Serving as a reflective statement (Finlay, 2011 ), the author noted this as a “busman’s holiday” where one seeks change or relief from the daytime job by repeating it in one’s own spare time. Spirituality might be an aspect of this concept as caring for the community and its reciprocal effect is promoted in many a world religion. Culturally, there seemed to be little variance in what counsellors counted towards their self-care measures. If cooking helped a practitioner mentally leave therapy work at the office, then this would work for counsellors in England and the Philippines alike. Solution-focussed questions are important when assessing personal effectivity and relevance of self-care measures (Miller, 2005; as cited by Stebnicki, 2007 ), and thus aid rediscovery of self-care measures. These questions can be self-directed in a type of stocktaking exercise to ensure that helpful strategies remain in place and are not neglected. 4.1 Significance, limitations, and future research The degree of empathy fatigue and how a practitioner is experiencing this phenomenon will influence the counselling relationship. To help others, therapists need to help themselves first. Adding underused or rediscovered strategies to the domain of self-care brings a further dimension to the scientific discussion of professional fatigue among therapists. Specifically using the term empathy fatigue positively broadens the spectrum both on experiencing and reporting. A potential inherent weakness of this research lies in the design of a qualitative study since findings cannot be generalised. The purposive non-randomised sample of such a low number cannot claim to be representative or replicable. Future quantitative studies on the perception of all terms of professional fatigue, including empathy fatigue and empathic distress fatigue, would provide valuable insights into whether the use of particular terms yielded different results. Conducting randomised studies in a number of populations would show whether significant differences emerged when identifying and reporting professional fatigue symptoms. If dissimilarities between the various concepts were negligible, contesting all professional fatigue syndromes in favour of an integrative model as posited by neuroscientists has a practical side to it. A new umbrella term would integrate all types of fatigue syndromes, making professional fatigue easier to identify and act upon with suitable interventions. 5. Conclusion This piece of research brought together the experiences of empathy fatigue of six therapists from three continents. There was both overlap and uniqueness in the reporting of their strategies in the domain of self-care. Commonly, self-care was viewed as a self-mandated regimen satisfying both needs for empathy-free zones and social engagement. Five out of six practitioners had experienced professional fatigue, yet were unclear where the syndrome sat within the academic framework. There was much support favouring the counselling-specific term empathy fatigue over the more widespread compassion fatigue. A recommendation for practitioners would be to regularly take stock of one’s personal wellbeing, connect with one’s inner self, and assess the effectiveness of self-care strategies. By doing so, any early warning signs would become noticeable and one could react accordingly through improving on personal self-care strategies. Increasing measures in this detection period would make achieving equilibrium in both professional and personal life easier and faster as one’s personal baseline would remain in sight. Additionally, highlighting the importance of self-care in training would help prospective counsellors to adopt the ethical imperative: Look after yourself first so that you can look after others. Declarations Acknowledgement and affiliation: This work is self-funded with no conflict of interest. Source data is available upon request. This study has been reviewed and approved by the Research Ethics Committee, Leeds Beckett University. All participants gave their written consent to being interviewed as well as the anonymised publication of this piece of research. References Allsbrook, K., Atzinger, C., He, H., Engelhard, C., Yager, G., & Wusik, K. (2016). The relationship between the supervision role and compassion fatigue and burnout in genetic counseling. 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Journal of Counseling Psychology , 50 (1), 59–68. https://doi.org/10.1037/0022-0167.50.1.59 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4258196","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":290561118,"identity":"368793bd-51b7-42d8-9b89-2e0ad135a7bd","order_by":0,"name":"Marc Alexander Venner","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBACNgbGBwwfSNTCbMA4g0R7mA2YeUjSwCfdzPjYNscun39G8rHHBRX3GPjbuxPwO0zmMLNx7rZkyxk30tKNZ5wpZpA4c3YDfi0S+cekc7cxGxjwnDGT5m1LYDCQyCWkJZlN2nJbPVDL+W/SvP+I1cK47bCBAXsPmzRvA3FamA17tx03kDjeZibNcyyBh6Bf5GckMz74ua3agL+Z+Zk0T02CHH97L34tGIC0OBoFo2AUjIJRgB0AAFJvOYUnpx9eAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-2510-751X","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Marc","middleName":"Alexander","lastName":"Venner","suffix":""}],"badges":[],"createdAt":"2024-04-12 13:53:32","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4258196/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4258196/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54862850,"identity":"8fb0e09a-7b6a-4f99-8897-73c036ecb7e5","added_by":"auto","created_at":"2024-04-17 20:20:12","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":293430,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCompassion and empathic distress.\u003c/strong\u003e A schematic model depicting two different forms of an empathic reaction to the suffering of others (Singer \u0026amp; Klimecki, 2014).\u003c/p\u003e\n\u003cp\u003eNote: The author created this figure based upon the schematic depiction in Singer, T., \u0026amp; Klimecki, O. M. (2014). Empathy and compassion. \u003cem\u003eCurrent Biology\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(18), R875–R878. \u003ca href=\"https://doi.org/10.1016/j.cub.2014.06.054\"\u003ehttps://doi.org/10.1016/j.cub.2014.06.054\u003c/a\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4258196/v1/71f170f14ae0fcb922dc3540.jpeg"},{"id":54863679,"identity":"3de3745d-754d-4b35-9aee-27dd1ca582db","added_by":"auto","created_at":"2024-04-17 20:28:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":368944,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4258196/v1/25c88762-52ea-4f81-9ed6-31a76a9cd87b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAn exploration of empathy fatigue in counsellors and their use of self-care strategies\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eA counsellor\u0026rsquo;s ability to facilitate change in a client is grounded in empathy and compassion as well as the use of a therapist\u0026rsquo;s self, irrespective of the employed method (Whipple et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e). A counsellor requires a certain level of resilience to help a client address a problem or overcome a crisis (Noullet et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Therapists may feel emotionally, mentally, and physically exhausted by the exposure to clients\u0026rsquo; presenting issues when exploring their personal history, especially in the context of working with highly distressed clients (Stebnicki, \u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e). Therefore, self-care measures to help prevent or alleviate professional fatigue are regarded as essential, as is the ability to disengage with a client\u0026rsquo;s problem post-session (Norcross \u0026amp; VandenBos, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn literature, the construct of compassion fatigue features prominently and semantically has the closest relation to empathy fatigue. Yet while compassion refers to the ability to notice the suffering and pain in others and the consequent wish to relieve it, empathy is an instinctual and emotional experience of a fellow human\u0026rsquo;s feelings. As a relationship-building skill, it has a cognitive and an affective element. The two terms also differ in \u0026ldquo;emotional output\u0026rdquo; (M. K. Lee, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e), meaning that one can show compassion while being emotionally distant, whereas empathising requires a greater deal of intense and emotional involvement. Compassion fatigue has its origins in nursing, where being exposed to a patient\u0026rsquo;s morbidity would negatively impact a frontline health worker\u0026rsquo;s well-being (Joinson, \u003cspan class=\"CitationRef\"\u003e1992\u003c/span\u003e). In counselling, the emphasis lies on empathy regarded as a fundamental tool for becoming an \u0026ldquo;ideal therapist\u0026rdquo; (Rogers \u0026amp; Yalom, \u003cspan class=\"CitationRef\"\u003e1995\u003c/span\u003e). Consequently, Stebnicki (\u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e) reasons that professional exhaustion in the context of psychotherapy should be referred to as empathy fatigue.\u003c/p\u003e\n\u003cp\u003eTo deeply understand empathy fatigue in the context of professional fatigue symptoms, this qualitative research uses interviews to explore what counsellors specifically associate with the term empathy fatigue. It examines what measures therapists take to ensure physical and mental health, the importance they attach to it, and how effective they rate it. Expanding the scope, this piece of research assesses to what extent therapists have rediscovered self-care measures to promote well-being. It investigates whether counsellors successfully or unsuccessfully re-engaged in activities they no longer count towards their current self-care measures. Searching for studies which address the concept of whether therapists use solution-centric approaches to explore their own situation and define goals, are scarce. In support, Miller (2005; as cited by Stebnicki, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e) argues that in order to build resilience, solution-focussed questions are at the core of assessing the personal relevance and effectivity of self-care strategies. By self-directing one of the key questions, namely \u0026ldquo;When was the problem not present?\u0026rdquo;, counsellors might be able to rediscover strategies they may have forgotten about. These can help to define exceptions in the past to build resilience in the present (de Shazer et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\n\u003ch2\u003e1.1 Empathy\u003c/h2\u003e\n\u003cp\u003eEmpathy is regarded as an integral part of a therapist\u0026rsquo;s work without which effective counselling cannot be achieved (Rothschild, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). Empathy can be described as the ability to comprehend and react to the distinctive affective experiences of others where one\u0026rsquo;s own feelings and those shown by others display a certain similarity (Decety \u0026amp; Jackson, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). Neuroimaging studies have shown that adopting the perspective of others stimulates regions in the brain responsible for emotional processing suggesting a strong biological link (Ruby \u0026amp; Decety, \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e). When a therapist shows empathy, they set the scene for building a rapport and thus initiate the therapeutic process by maximising personal interactions with a client (Moore \u0026amp; Thomas, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e; J. R. Nelson et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Turgoose \u0026amp; Maddox, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). This process should ideally lead to a therapeutic relationship, the quality of which determines the outcome of the treatment (Black et al., \u003cspan class=\"CitationRef\"\u003e2005\u003c/span\u003e; Langhoff et al., \u003cspan class=\"CitationRef\"\u003e2008\u003c/span\u003e). The making of a therapist would centre on the abilities to cooperate, focus, empathise, and be transparent (Langhoff et al., \u003cspan class=\"CitationRef\"\u003e2008\u003c/span\u003e). Alfred Adler referred to an anonymous English writer to define empathy: \u0026ldquo;One must see with the other person\u0026rsquo;s eyes, hear with his ears, and feel with his heart\u0026rdquo; (Clark, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eYet the very ability to show empathy and deep understanding of a client\u0026rsquo;s problems may make counsellors vulnerable to professional fatigue (Figley, \u003cspan class=\"CitationRef\"\u003e2002b\u003c/span\u003e; J. R. Nelson et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Thompson et al., \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). Empathy itself, regarded as the key building skill in forming a therapeutic relationship, is an attributing factor negatively impacting on a counsellor\u0026rsquo;s state of health and wellness (Rothschild, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). Empathy can be viewed as a continuum where on one side of the scale there is \u0026ldquo;emotional overinvolvement\u0026rdquo; and on the other \u0026ldquo;emotional distance or burnout\u0026rdquo; (Bush, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e, p. 26). The precondition of being an effective counsellor, namely the ability to show empathy, simultaneously acts as one of the predictors of an increased risk of incurring exhaustion and fatigue (Delaney, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e; Turgoose \u0026amp; Maddox, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). Contrasting this, in an integrative literature review Coetzee and Laschinger (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e) posited that compassion fatigue is not rooted in empathy, yet instead stems from the lack of resources and support as well as the individual\u0026rsquo;s reaction to stress. Both opposing views raise the question of how self-care measures help to modulate, balance, or even prevent distress and professional fatigue.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e1.2 Self-care\u003c/h2\u003e\n\u003cp\u003eMeasures and strategies put in place to alleviate and manage the impact the therapeutic process has on the practitioner are of great importance, affording much consensus in academic literature (Barnett et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; Butler et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Miller \u0026amp; Sprang, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e; Owens-King, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Such methods form the category of self-care defined as intentionally taking up activities to improve personal well-being and would include most physical and mental measures related to building resilience and managing stress (Glennon et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Lewis \u0026amp; King, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Noullet et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Newell (\u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e) showed that not only practising self-care, but also developing individual coping strategies and skills is considered helpful for counsellors experiencing professional fatigue symptoms. Self-care encompasses a number of domains that attend to \u0026ldquo;physical, social, emotional, and spiritual needs as a way of ensuring high-quality interactions with others\u0026rdquo; (Merriman, \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e, p. 372). Building on this definition, Norrman Harling and colleagues (\u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e) consider it important to satisfy these needs as the process acts as a shielding and strengthening factor. Mindfulness-based stress reduction (MBSR) in particular has shown a positive correlation with compassion satisfaction (Thieleman \u0026amp; Cacciatore, \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e) and demonstrates a link between self-awareness and well-being (Richards et al., \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e). Research has also shown that providing counsellors-in-training with the tools to practise mindfulness increases the positive effect it has on preventing burnout (Christopher \u0026amp; Maris, \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e). A study involving special education teachers showed the same positive effectiveness through the use of prayer and mindfulness (Sharp Donahoo et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). The ability to reflect is equally as essential since practitioners need to be aware of their individual risk factors in order to put appropriate self-care measures in place (Norcross, \u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e). Barnett and colleagues (\u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e) elevate this domain by arguing that it is an \u0026ldquo;ethical imperative\u0026rdquo; (p. 604) to address the distress a therapist faces in the counselling room to ensure the welfare of the client. Dr Paul Appelbaum, a professor of psychiatry and former president of the American Psychiatric Association (APA) is quoted as saying: \u0026ldquo;It\u0026rsquo;s difficult to make an argument against exercise, meditation or other relaxation techniques, sufficient amounts of regular sleep, a healthy balanced diet.\u0026rdquo; (Kazdin, n.d.).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e1.3 Fatigue terminology\u003c/h2\u003e\n\u003cp\u003eAcademic literature broadly identifies four terms to describe the negative impact the therapeutic process has on the practitioner: compassion fatigue (Allsbrook et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Bride et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; Joinson, \u003cspan class=\"CitationRef\"\u003e1992\u003c/span\u003e), secondary traumatic stress (Beaumont et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Figley, \u003cspan class=\"CitationRef\"\u003e2002a\u003c/span\u003e; Nimmo \u0026amp; Huggard, \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e), vicarious trauma (Baird \u0026amp; Kracen, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e; McCann \u0026amp; Pearlman, \u003cspan class=\"CitationRef\"\u003e1990\u003c/span\u003e; Newell \u0026amp; MacNeil, \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e), and burnout (Craig \u0026amp; Sprang, \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e; Maslach, \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e; Simionato et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). None of these terms are viewed as pathological and therefore not classified in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-V) published by the American Psychiatric Association (\u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e). The 11th Revision of the International Classification of Diseases (ICD, n.d.) refers to burnout as an occupational phenomenon, yet stresses that it is not classified as a medical condition. These observed or self-reported conditions are on a continuum and, depending on the researcher, have certain areas of overlap, but also distinct definitions.\u003c/p\u003e\n\u003cp\u003eCompassion fatigue (CF) has its origins in nursing (Joinson, \u003cspan class=\"CitationRef\"\u003e1992\u003c/span\u003e) and can be described as a \u0026ldquo;cumulative and progressive absorption process of patient\u0026rsquo;s pain and suffering formed from the caring interactions with patients and their families\u0026rdquo; (Jarrad et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e, p. 1). Klimecki and Singer (\u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e) define CF as \u0026ldquo;pathological altruism\u0026rdquo; where a caregiver would alleviate the pain of others by giving empathic care, which could cause a negative impact on their own physical and mental health. Typically, symptoms related to CF are described as feeling lethargic, hopeless, helpless, as well as disengaged (Day \u0026amp; Anderson, \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e). The term was later adopted by emergency relief workers and trauma therapists, where the same correlation and the resulting feelings of being drained and worn down were observed (Craig \u0026amp; Sprang, \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e; Walsh et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). Looking at therapy outcome, failing to address CF relates to unfavourable results for clients thus rendering interventions ineffective (Negash \u0026amp; Sahin, \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e). A number of studies have examined whether there is a correlation between demographic characteristics and the levels of CF \u0026mdash; with a varied outcome. One such study found no significant relationship between the two variables, but rather a notable difference between working experience and compassion fatigue (Kabunga et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). This suggests that it is not age and gender that determines the level of compassion fatigue that a counsellor experiences, but instead the number of years spent in the profession: With an increase in working experience comes a decrease in compassion fatigue.\u003c/p\u003e\n\u003cp\u003eThere is an apparent overlap of CF with secondary traumatic stress (STS) as posited by Pirelli and colleagues (\u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e), which also becomes observable as the terms CF and STS are often used interchangeably (Sprang et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e). In fact, Jenkins and Baird (\u003cspan class=\"CitationRef\"\u003e2002\u003c/span\u003e) use STS as a synonym for CF (p. 423). Baird and Kracen (\u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e) emphasise the difficulty in identifying correlates of vicarious trauma (VT) and STS as there is a \u0026ldquo;lack of conceptual clarity\u0026rdquo; (p. 183). Figley (\u003cspan class=\"CitationRef\"\u003e2002b\u003c/span\u003e) intentionally replaced STS with CF since the term promotes a more positive connotation. Taking the opposite position, Newell and MacNeil (\u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e) are very clear in their review of theoretical terms. While they agree that CF, STS, and VT stem from working with trauma clients, and burnout is an occupational hazard, the three trauma-specific phenomena require individual conceptualisation.\u003c/p\u003e\n\u003cp\u003eMcCann and Pearlman (\u003cspan class=\"CitationRef\"\u003e1990\u003c/span\u003e) define vicarious trauma as damaging changes that transpire in mental health professionals\u0026rsquo; views of themselves and others as well as the world in general. This results from being exposed to graphic or traumatic material and can be viewed as a normal reaction to ongoing processes which may negatively impact motivation, effectiveness, and empathy (Baird \u0026amp; Kracen, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). The retelling of a client\u0026rsquo;s traumatic events may lead to a practitioner developing vicarious trauma especially if they have experienced a very similar traumatic event themselves (Pirelli et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Again, the model lacks clarity as suggested by Jenkins and Baird (\u003cspan class=\"CitationRef\"\u003e2002\u003c/span\u003e). They argue that STS and VT have conceptual similarities yet do not share the same constructs. They ascertained that the symptoms of both VT and STS stem from a counsellor being exposed to the retelling of a client\u0026rsquo;s traumatic stories, the outcome being distress or burnout. STS links to social and emotional symptoms whereas VT focusses on a variation in cognitive schemas. What unifies these three types of professional fatigue is that they have a common denominator in form of displaying symptoms of post-traumatic stress disorder (PTSD) without being identical to PTSD itself (Bride et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; Figley, \u003cspan class=\"CitationRef\"\u003e2002b\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eBurnout may be explained as the \u0026ldquo;prolonged response to chronic emotional and interpersonal stressors on the job and is defined here by the three dimensions of exhaustion, cynicism, and sense of inefficacy\u0026rdquo; (Maslach, \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e, p. 189). Typical signs of this \u0026ldquo;occupational hazard\u0026rdquo; (Merriman, \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e, p. 370) are withdrawing, not engaging with friends or family members, and adopting an unhealthy diet (Begic et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). A prolonged state of burnout may also impact a counsellor\u0026rsquo;s ability to work or result in leaving the profession altogether (Sprang et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e). Opposing this definition of burnout, Aycock and Boyle (\u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e) argue that this type of accumulated stress should be referred to as compassion fatigue and not burnout. The researchers propose that this term does not adequately reflect \u0026ldquo;the result of the longitudinal workplace ramifications of sadness and despair\u0026rdquo; (p. 183). Contradicting this assignment of nomenclature, a study on trauma therapists concluded that it was not always viable to diagnostically differentiate between the two constructs of secondary traumatic stress and burnout (Deighton et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e). This discourse links back to the descriptions of VT and STS where a lack of clarity in the concept is recognised as being problematic when identifying correlations (Baird \u0026amp; Kracen, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eExamining the end points of the compassion continuum, a meta-analysis of 33 studies published between 1997 and 2017 concluded that approximately 40 per cent of health care workers (n\u0026thinsp;=\u0026thinsp;9,409) reported professional exhaustion underscoring the importance counsellors should place on their mental and physical well-being (O\u0026rsquo;Connor et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). A study based on self-rated inventories by W. Lee and colleagues (\u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e) found that 61% of genetic counsellors (n\u0026thinsp;=\u0026thinsp;402) were at high risk of compassion fatigue. Despite this substantial percentage, experimental research has also shown that moderate mental fatigue does not automatically exclude a counsellor from showing empathy, albeit affording more energy and effort (D. W. Nelson et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e1.4 A framework of empathy fatigue\u003c/h2\u003e\n\u003cp\u003eIn contrast to the wealth of literature available on the previously mentioned types of professional fatigue, there are limited papers on empathy fatigue. Neuroscience suggests a strong link between the ability to feel the pain and distress of others, the key definition of empathy, and the activation of one\u0026rsquo;s own neural networks and mirror neurons (Singer \u0026amp; Klimecki, \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). As shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, the authors state that an \u0026ldquo;empathic response to suffering can result in two kinds of reaction: empathic distress [\u0026hellip;] and compassion\u0026rdquo; (p. 875), and hence promote the use of the term empathic distress fatigue. Hofmeyer and colleagues (\u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e) also favour this term based on neuroscientific findings showing that compassion itself can neither be quantified nor validated, and does not cause fatigue. However, empathic distress fatigue can be managed through compassion training, by which the unclear self-other distinction is emotionally regulated.\u003c/p\u003e\n\u003cp\u003eStebnicki suggests that empathy fatigue is set apart from other professional fatigue types. It relates to \u0026ldquo;emotional secondary stress and grief reactions that occur during helping interactions\u0026rdquo; (Stebnicki, \u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e, p. 23). A person-centred therapist who uses empathy as a means of connecting with a client\u0026rsquo;s story might experience an \u0026ldquo;empathy fatigue reaction\u0026rdquo; (Stebnicki, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e, p. 327). He views this reaction as an impairment caused by an interaction of variables such as age, resilience, organisational support, coping styles, and personality traits. A counsellor is often unaware of experiencing empathy fatigue, as are peers in the professional setting. Stebnicki continues that onset is both acute and cumulative with no \u0026ldquo;predictable linear path to STS reactions\u0026rdquo; (p. 319). The experience occurs on an individual level since it depends on how a counsellor perceives a client\u0026rsquo;s story. Further, Stebnicki (\u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e) argues that in order to bolster resilience, self-care measures first require self-assessment. This process involves self-directing solution-focussed questions to evaluate the status quo (Miller, 2005; as cited by Stebnicki, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e). One such typical question reads: \u0026ldquo;What are self-care activities I have done or would like to do that do not take much time, energy, or money?\u0026rdquo; (Stebnicki, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e, p. 334). In line with the previously mentioned types of professional fatigue, empathy fatigue is disadvantageous to a counsellors\u0026rsquo; prospects for \u0026ldquo;personal growth, professional development, and overall mental, physical, and spiritual well-being\u0026rdquo; (Stebnicki, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e, p. 319).\u003c/p\u003e\n\u003cp\u003eProfessional fatigue is the cost of caring that might present in every second practitioner for multidimensional and complex reasons (W. Lee et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e). Some researchers see the difference between the terms describing professional fatigue as either negligible or non-existent suggesting substantial overlap. Others posit a need for individual conceptualisation, which raises the question how of useful labelling is in the context of reducing the effects of professional fatigue. In support of this study on empathy fatigue semantic logic might follow: If empathy is the \u0026ldquo;soul of the counselor\u0026rdquo; (Stebnicki, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e, p. 320), should a waning or even loss of the very same not primarily be referred to as empathy fatigue?\u003c/p\u003e\n\u003c/div\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eThis research uses a qualitative approach as it incorporates an investigative method as well as an in-depth, subjective exploration. To enable the collection of rich data, a semi-structured interview with mainly open-ended questions was used. A call for participants was posted on the British Association for Counselling and Psychotherapy (BACP) research website accessible to over 60,000 members. In addition, an email outlining the proposed research was sent to colleagues and known therapists with the request to disseminate the invitation to participate in the study among their peers. Researcher bias was avoided as participants were not professionally attached or related. This also ensured that there was no pressure to participate and there would be no negative consequences if informed consent was not obtained.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Recruitment\u003c/h2\u003e \u003cp\u003eThe participants include qualified therapists with a minimum of three years of practical experience in counselling. Stipulating this length served two purposes: (a) to ensure a certain degree of professional experience after graduation; (b) to enable the participant number to be met by convenience sampling. Six interviews were conducted without any withdrawals. The participants were all practitioners with psychology related degrees at BSc, BA, PG, and doctorate levels. Three females and three males took part in the study. Three of the participants practised in Europe and three in Asia-Pacific. No type of covert research or deliberate deception took place, which was explained during debriefing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data collection\u003c/h2\u003e \u003cp\u003eThe interviews were conducted via a video conferencing application and lasted between 30 and 45 minutes. The participants provided permission for recording the interview. They also gave informed consent that contributing was voluntary and they were not coerced or induced to take part. Participants were free to withdraw their data up to four weeks after the interview. To conclude the support of participants, debriefing provided additional information and resources to the participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data analysis\u003c/h2\u003e \u003cp\u003eInterpretative Phenomenological Analysis (IPA) served as the approach of choice. IPA highlights what things mean to the individual (McLeod, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) and how one understands life experiences (Smith et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). It is predominantly an interpretive tool, which requires depth and a commitment to the concept that less is more when developing topics enabling detailed and synthesised evaluation (Hefferon \u0026amp; Gil-Rodriguez, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). The interviews were transcribed verbatim in preparation for analysis. Audio files were converted to text documents using the transcription software Otter and carefully checked for accuracy. This helped to become acquainted with the rich data. Field notes taken during and upon completion of the interviews aided the process of validating the contents. Once transcribed, the research interviews were manually coded with help of the analysis software MAXQDA 2020 by identifying topics, similarities, and dissimilarities. The codes were drawn together, grouped as supra- and subordinate themes, and offered to supervisors and peers for validity purposes. When interpreting the contents, reflexivity logged in a journal captured the immediate process of the author\u0026rsquo;s engagement with the data and the thoughts that informed the analysis. By this form of personal revelation, the author in his dual role as researcher and practising counsellor gains visibility in the process (Finlay, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). To add content and enable meaningful interpretations (Sutton \u0026amp; Austin, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), excerpts from all six interviews are quoted as validated vignettes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Personal data, anonymity, and confidentiality\u003c/h2\u003e \u003cp\u003eThe anonymity and confidentiality of the participants of the study was protected so that they could disclose narratives openly. Participants are referred to by anonymised names. In accordance with General Data Protection Regulations, all written and recorded accounts were kept in a lock-protected filing cabinet. Only the researcher had access to media and anonymised transcript. The digital recording was destroyed after the transcription was completed by erasing it from the data carrier, backup media, and cloud-based storage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Ethics\u003c/h2\u003e \u003cp\u003ePrior to the study, ethical consent was obtained from the regulatory board at Leeds Beckett University. Personal safety of researcher or subject was anticipated as within the risks of daily life. The participants were fellow practitioners of early and late middle-aged adults, and not part of a vulnerable group.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Findings","content":"\u003cp\u003eFrom the coding process and defining of patterns in the participants\u0026rsquo; stories eight topics emerged, which were grouped into supraordinate and subordinate themes. Three supraordinate themes were identified as relevant for this study. They focus on: (a) defining and experiencing empathy fatigue, (b) individual approaches to self-care, and (c) neglected and rediscovered self-care strategies.\u003c/p\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1 Defining and experiencing empathy fatigue\u003c/h2\u003e\n\u003cp\u003eSelf-reported individual levels of happiness served as an indicator for a potential relationship between experiencing empathy fatigue and feeling happy in one\u0026rsquo;s job as a counsellor. All participants emphatically stated that they were extremely happy as mental health practitioners. One clinician \u0026ldquo;couldn\u0026rsquo;t imagine being in a different profession\u0026rdquo; (Grace) and another was \u0026ldquo;really happy to be a psychologist, it\u0026rsquo;s rewarding\u0026rdquo; (Elias). Working directly with clients and playing a meaningful role in their change process was the theme that emerged as the one most beneficial to the overall feeling of professional happiness:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e[\u0026hellip;] this sense of being a witness to another individual\u0026rsquo;s transformation [\u0026hellip;] seeing the, you know, the blossoming of the individual through. It\u0026rsquo;s very, very gratifying. It\u0026rsquo;s a beautiful thing to watch. It\u0026rsquo;s like nature, it\u0026rsquo;s like watching a butterfly emerge from the cocoon, [\u0026hellip;] learning to see that transformation is very enriching. (Grace).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eFive out of six participants were confident that they had encountered empathy fatigue in their professional setting, at the same time all six were able to offer their own definition of empathy fatigue. One interviewee made a link to the counsellor\u0026rsquo;s core ability to show genuine empathy and advocated the use of the term empathy fatigue:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e[\u0026hellip;] my first thought was that empathy fatigue tends to be used in relation to people who are in extreme situations and helping, or counselling [\u0026hellip;] I feel that empathy fatigue is much more suited to what we do in a professional, daily way because our [\u0026hellip;] profession relies on us being empathetic. (Anne).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eAnother participant saw a relation to the chronological connection with experiencing fatigue, which may occur over a defined period: \u0026ldquo;[\u0026hellip;] it is that gradual build-up of empathising with clients over the course of a day or a week or a month, you know, just basically, incrementally, and then it just taking its toll on you as a counsellor.\u0026rdquo; (Justin). He expanded on this theme: \u0026ldquo;[\u0026hellip;] the longer you spend with the clients, the deeper the window into their world, and therefore you\u0026rsquo;re more likely to get more into more deep issues, which from an empathy point of view can be a bit more draining.\u0026rdquo; (Justin). The aspect of providing a high volume of sessions with a particular client was brought into context with familiarity, repetition, and to a certain degree exhaustion or weariness: \u0026ldquo;I guess tiredness of hearing people complaining, I suppose. [\u0026hellip;] I would sense a running out of a willingness to hear what the presenting difficulty is or when it is repeated.\u0026rdquo; (Carl).\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e[\u0026hellip;] empathy fatigue is about when any individual who is expected to be empathic, and that includes obviously therapists, really struggle to get back to find that empathy. Because they have heard the situation that the client is talking about repeatedly, and they\u0026rsquo;ve become accustomed to it. And they\u0026rsquo;ve almost normalised that in their practice. (Catherine).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eOne participant presented a link between empathy fatigue and transference offering a biological connection:\u0026nbsp;\u0026ldquo;Amygdala hijack [\u0026hellip;] feeling a lot of big emotions that, you know, might be coming from a client, but maybe at the same time, also activating something of your own material.\u0026rdquo; (Grace).\u003c/p\u003e\n\u003cp\u003eA common theme was that the lack of conceptual clarity of professional fatigue symptoms. One practitioner mentioned that \u0026ldquo;everyone has sort of a different idea on what empathy fatigue could mean for them\u0026rdquo; (Anne). She also stated that empathy fatigue \u0026ldquo;in a general therapeutic setting, I hear more often referred to as compassion fatigue\u0026rdquo; (Anne). Another participant questioned her own definition when stating an example from her work as a clinician: \u0026ldquo;I\u0026rsquo;m not sure if empathy fatigue is the right term \u0026mdash; sometimes it feels more like burnout than empathy fatigue. And I don\u0026rsquo;t know how you would differentiate that? [\u0026hellip;] I wouldn\u0026rsquo;t know.\u0026rdquo; (Grace). One practitioner, without any hesitation in his response, drew a comparison: \u0026ldquo;Well, I\u0026rsquo;d say almost like post-traumatic stress disorder.\u0026rdquo; (Elias).\u003c/p\u003e\n\u003cp\u003eThe interviewed counsellors experienced empathy fatigue differently. Feeling drained, exhausted, tired, or irritable was commonly observed. On occasions, this might present as debilitating: \u0026ldquo;Sometimes maybe it\u0026rsquo;s immobilising, like you can\u0026rsquo;t seem to move, or you can\u0026rsquo;t seem to flow with it.\u0026rdquo; (Grace). The response is \u0026ldquo;an emotional one, but I think it\u0026rsquo;s also a physical one. I think I tend to carry it in my body, whether that\u0026rsquo;s feeling drained, feeling tired and exhausted or physically feeling like my muscles ache.\u0026rdquo; (Justin). Two counsellors experiencing empathy fatigue also saw their relationship with the client diminish: \u0026ldquo;I know that it could lead to probably questioning your own skills, [\u0026hellip;] losing the ability to be empathic.\u0026rdquo; (Elias). \u0026ldquo;And so obviously, that means that the empathy that is demonstrated is reduced, and in the client relationship, that\u0026rsquo;s a real disaster.\u0026rdquo; (Catherine). Two participants, despite being experienced with decades in practice, voiced doubts about their suitability to the profession when experiencing empathy fatigue: \u0026ldquo;It made me wonder whether I should be doing it at all.\u0026rdquo; (Catherine).\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eI think when I get stuck with that, it makes me more anxious. It makes me feel a certain sense of inadequacy, you know, feeling like, I\u0026rsquo;m not being more effective, and what does that mean? What does that say about me as a clinician? And, you know, how can I be better? So, sometimes there\u0026rsquo;s self-blame that comes up, and you want to push yourself harder, or you extend your limits, in a way that at some point might not be healthy? (Grace).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eIn one therapist\u0026rsquo;s account, a client once stated that \u0026ldquo;losing a child is the worst thing that can ever happen. There is nothing, there\u0026rsquo;s no other grief that is similar to it.\u0026rdquo; (Catherine). This sparked her own experience to be revisited \u0026ldquo;where I lost somebody that I loved very much under really difficult circumstances, I think it was hard to empathise with that person that almost minimised \u0026mdash; I felt unwittingly minimised how my experience was.\u0026rdquo; (Catherine). She offered her own interpretation of this interaction: \u0026ldquo;I think it\u0026rsquo;s transference really, and countertransference\u0026rdquo;. (Catherine). Three counsellors found that a combination of years spent in the profession and life experience proved beneficial in dealing with empathy fatigue: \u0026ldquo;I think as I gain more experience, and I think as I matured also in clinical work, [\u0026hellip;] that has happened much less.\u0026rdquo; (Grace).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003ch2\u003e3.2 Individual approaches to self-care\u003c/h2\u003e\n\u003cp\u003eAll interviewees mentioned that self-care served two purposes i.e., building one\u0026rsquo;s own resilience to remain healthy and enable better care for clients. \u0026ldquo;[\u0026hellip;] if you think of a full cup, and then you take away a bit at a time for different needs, then you have less in your cup for your ability to feel empathy.\u0026rdquo; (Anne). Without adequate self-care the ability to be a good counsellor declines: \u0026ldquo;[\u0026hellip;] using sort of analogy of the oxygen mask in an aeroplane, where they say, put yours on first because if you don\u0026rsquo;t find the oxygen, you can\u0026rsquo;t help somebody else.\u0026rdquo; (Carl). This theme was echoed by another practitioner who shared that one has to \u0026ldquo;take care of yourself first if you\u0026rsquo;re trying to take care of the others. My own well-being, I try to keep it as a priority so that I can be as good a psychologist I can.\u0026rdquo; (Elias). Measures taken to promote self-care covered a wide range of physical and mental activities, such as reflective or creative writing and journaling, meditation, yoga, needlework, music, gardening, and dog walking. Receiving support from spouse, family, and friends was reported as being beneficial. Practicing mindfulness was also seen as \u0026ldquo;good at really grounding me in the moment\u0026rdquo; (Justin), \u0026ldquo;tremendously helpful\u0026rdquo; (Grace), and practised frequently. One practitioner took a circular approach and remarked that \u0026ldquo;working with clients has been a joy. And I think that is a source of self-care, like allowing ourselves as clinicians to take to feel joy in the journeys of our clients.\u0026rdquo; (Grace). Further, Grace stated that \u0026ldquo;community care is self-care.\u0026rdquo;, and expanded on this by seeing the benefit of \u0026ldquo;intentionally nurturing a sense of community\u0026rdquo; (Grace).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003ch2\u003e3.3 Neglected and rediscovered self-care strategies\u003c/h2\u003e\n\u003cp\u003eParticipants were aware of the effects when they neglected self-care strategies. Feeling irritable or not getting enough sleep was identified as \u0026ldquo;one sign that there\u0026rsquo;s something going on.\u0026rdquo; (Elias). Participants observed that phenomena such as feeling depleted could also spill over from the professional to the private setting: \u0026ldquo;[\u0026hellip;] the times that I don\u0026rsquo;t have time for those activities, all other areas of my life feel more like a struggle.\u0026rdquo; (Anne). Time constraints kept counsellors from maintaining self-care strategies: \u0026ldquo;[\u0026hellip;] everyone has to be selective with their hobbies, because you don\u0026rsquo;t have endless time.\u0026rdquo; (Anne). There was, however, an awareness of the reasons and a resolution: \u0026ldquo;[\u0026hellip;] maybe I\u0026rsquo;m trying to fit too much in, you know, I don\u0026rsquo;t have time for meditation [\u0026hellip;] you have to find the time for self-care sometimes.\u0026rdquo; (Carl). Two participants realised that they were not tapping into the support network available to them: \u0026ldquo;And I think all of us probably miss out on asking each other for help or for advice on a regular basis.\u0026rdquo; (Justin). A participant in private practice remarked he wanted \u0026ldquo;to be more in touch with my colleagues here [\u0026hellip;] So that\u0026rsquo;s something that I know that I would benefit from, which I haven\u0026rsquo;t done that much yet.\u0026rdquo; (Elias). Being aware of neglecting this strategy, the participant was determined to address the situation: \u0026ldquo;But that\u0026rsquo;s exactly what I\u0026rsquo;m gonna do in the near future.\u0026rdquo; (Elias). Another practitioner recognised the \u0026ldquo;necessity to switch off and not be constantly available\u0026rdquo; and acknowledged that this was \u0026ldquo;something that I would like to be better at doing, because I think it would be helpful.\u0026rdquo; (Anne). One counsellor was prompted by the question on potentially neglected self-care measures to reflect on the reason why yoga, once considered very helpful, was currently not actively pursued: \u0026ldquo;So, oddly enough, I was doing it at home, in the summertime last year, and then I stopped it. And then I did it again, once about two weeks ago, I thought I must keep doing this, and I haven\u0026rsquo;t done it again.\u0026rdquo; (Carl).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe aim of this study was to explore the definition and experience of empathy fatigue and how self-care is practised. The participants were unanimous in their view that empathy constitutes the core quality of a counsellor (Turgoose \u0026amp; Maddox, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). All therapists had an intrinsic motivation to help others. Unprompted, the majority thought it was the best job imaginable and felt a sense of personal and professional fulfilment, and shared happiness emerging directly from working with clients (Singer \u0026amp; Klimecki, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Some considered themselves in a dual role as carers in their relationships with their families indicating an empathic disposition for the profession. One participant made a noteworthy observation when stating that while experiencing empathy fatigue she felt her amygdala was being hijacked. Neuroscientific research shows how the amygdala is involved in the processing of emotions, perspective taking, and empathy (Ruby \u0026amp; Decety, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Other participants also remarked that a client\u0026rsquo;s story could stimulate their own material indicating vicarious trauma (Pirelli et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile reviewing the different terminology on professional fatigue, it was found that there was a lack of conceptual clarity (Baird \u0026amp; Kracen, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). In view of the absence of clearly measurable biomarkers there appears to be no valid diagnostic differentiation between syndromes or constructs (Deighton et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). This was mirrored by participants who reported that they were either unsure they were experiencing empathy fatigue or possibly a different type of fatigue, and in one case were unable to tell it apart from burnout. From a constructivist\u0026rsquo;s point of view, it would seem evident that there was a great deal of variation in defining symptoms of empathy fatigue since no two individuals would be able to gauge their experiences on a common scale. One practitioner argued that, because of the very ability to empathise, its corresponding lack should be termed empathy fatigue (Stebnicki, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). PTSD was also mentioned, which connects with the construct that PTSD is a common denominator of all types of professional fatigue (Bride et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). A number of participants agreed that empathy itself might cause empathy fatigue (Figley, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2002b\u003c/span\u003e). The account of another counsellor that the amplified frequency of sessions with a client would potentially relate to an increase in empathy fatigue shows a link to the concept of empathy being on a continuum: Emotional overinvolvement with subsequent exhaustion might result in professional fatigue (Jenkins \u0026amp; Baird, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFeeling depleted, weary, but also hopeless and helpless are typical symptoms associated with both compassion fatigue (Day \u0026amp; Anderson, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) and empathy fatigue (Stebnicki, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Other topics emerged while exploring empathy fatigue, namely anxiety, self-doubt, blame, a sense of inadequacy, and a detrimental effect on the therapeutic relationship. Doubting one\u0026rsquo;s own ability might be associated with the early stages of entering the profession and making mistakes in the counselling room (Merriman, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, p. 374) and not so much being an experienced therapist. Yet in view of the fact that two proficient practitioners were at the moment of facing empathy fatigue highly analytical of their general suitability, shows an ingrained ability to critically reflect and question all aspects of the client relationship, including themselves (Glennon et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). At times, counsellors tend to view their own actions or interventions as insufficient. Gentry (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2002\u003c/span\u003e) lists \u0026ldquo;inadequacy as a caregiver\u0026rdquo; (p. 43) as an intrusive symptom of compassion fatigue. In this same comparison table, increased anxiety, as mentioned by another participant, is classified as an arousal symptom. The observation of one practitioner that reduced empathy can have a disastrous effect on the client relationship is in line with the textbook definition of an empathic counsellor (Rothschild, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). One therapist absorbed a trauma survivor\u0026rsquo;s story, which when being connected to her own material of loss and grief ultimately led to a break in empathy. This transference describes part of the therapeutic process, yet also counts towards the cost of caring (Pirelli et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, p. 7). Although literature is ambivalent when it comes to assessing whether years spent in the profession aid resilience (Kabunga et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), the participants\u0026rsquo; accounts are in support of this hypothesis. Experiencing empathy fatigue correlates with lower life experience and fewer years spent in practice i.e., it occurs earlier on in the career. The more experience a counsellor has, the more effective their approach to dealing with empathy fatigue is seen. A study by Coetzee and Laschinger (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), which posits that a lack of resources leads to compassion fatigue and not empathy itself, found little support. Although some participants reported occasionally feeling frustrated in the line of work or experienced a lack of structural support, all dealt with this through coping strategies or self-care measures. There was no indication that comparatively low renumeration or the structure of the organisation was linked to experiencing empathy fatigue.\u003c/p\u003e \u003cp\u003eUnsurprisingly, clients are at the core of the phenomenon of empathy fatigue, especially when they repeat themselves and will not do the work. Time chips away at the willingness to listen to clients. The deeper a counsellor gets into a client\u0026rsquo;s story, the deeper the abyss may potentially become. What emerged was an understanding that most practitioners had experienced some type of professional fatigue, which in the context of this study they would readily define as empathy fatigue. There is a distinct possibility that had this term been replaced with empathic distress fatigue (Klimecki \u0026amp; Singer, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), the same observed phenomena might have been reported.\u003c/p\u003e \u003cp\u003e All participants felt that they needed to practise self-care to be present and at their best for their clients. They viewed self-care as a requisite foundation to deliver therapy work. It seemed that this construct was deeply embedded in their thinking; they did not question its necessity or efficacy. It was viewed as an ethical imperative by which the therapist needs to address the issues encountered in the counselling room to ensure the welfare of the client (Barnett et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). However, the activities the counsellors engaged in did not go against their nature, meaning they did not force themselves or step outside their comfort zone. None of the participants mentioned that they pursued measures that they did not enjoy yet knew that they were per se suitable to add to their resilience. In essence, self-care served two purposes: maintaining one\u0026rsquo;s own mental and physical fitness by leading a healthy lifestyle, and ensuring that engaging with a client remained on a professionally high level to work towards a favourable outcome (Simionato et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This implies that all participants had high ethical standards and would not compromise the therapeutic alliance by ignoring their own well-being. Self-care was in fact a self-mandated regimen.\u003c/p\u003e \u003cp\u003eTwo contrasting approaches to self-care emerged. Some participants explicitly stated that they required empathy-free zones to mentally remove themselves from the day spent in the counselling room. They specifically sought regenerating sanctuaries in areas that were free from fellow human beings. Meditating, enjoying nature, being creative, or writing poetry assured them an inner space which they needed to switch off from the office and regain resilience (Newell \u0026amp; MacNeil, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). A number of participants commented on highly beneficial effects of practising mindfulness remarking on its positive outcome (Richards et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Contrasting this, some interviewees stated that socialising with others after work hours or being with family and friends was their preferred way of switching off. There was a sense of feeling sprightlier when resuming work the next day, especially when they had stepped outside of both domestic and professional life. Singing in a choir or being in band would also involve doing things together with fellow humans. Interestingly, both approaches were present in the same counsellors suggesting the wish to satisfy both needs albeit at different times: the need for self-centred solace and the need for social engagement and support. Meeting these needs serves as a bolstering and protective measure (Norrman Harling et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) with a favourable outcome: It promotes higher levels of resilience.\u003c/p\u003e \u003cp\u003eThe study participants were very much aware of when a tipping point between managing the cost of caring and feeling overwhelmed was imminent. One counsellor noticed she was on \u0026ldquo;autopilot\u0026rdquo; (Anne) with others reporting a reduced capacity to reflect in and out of session. A disruption to their normal sleep pattern also emerged when they felt that levels of resilience were becoming increasingly depleted. Identifying these signs as an alarm bell would help to make time to re-engage in activities in the domain of self-care. Being able to assess risk factors and put alleviating measures in place is an essential quality of a counsellor (Norcross, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). None of the participants mentioned that things had gone beyond a tipping point resulting in prolonged absence, illness, or burnout. Long weekends and holidays served as sufficient breaks to ensure that meaningful client relationships could be maintained. Self-monitoring helped to identify tipping points.\u003c/p\u003e \u003cp\u003eAll participants were clear about potential insufficiencies in the domain of self-care and were able to name their previously pursued activities. By reflecting they became aware of measures that were currently not in place. A number of the underused strategies were the result of government-imposed regulations in light of the SARS-Cov-2 situation. Some counsellors realised that they had fallen short of adequately tapping into support networks available to them, preferably by engaging with colleagues. Others noticed that they lacked the capacity to disengage after sessions, particularly at the end of a working day or week. Being able to disconnect will help to define a border between professional and personal life (Norcross \u0026amp; VandenBos, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Leaving distress at the office should be a priority.\u003c/p\u003e \u003cp\u003eFindings show that some counsellors consciously neglect self-care measures indicating that practitioners do not display an inherent exceptional ability or superiority to observe strategies. Anecdotal evidence suggests that strictly adhering to self-care measures is not per se their forte and does not set therapists apart from the rest of the population (Norcross \u0026amp; VandenBos, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Counsellors do not always practise what they preach.\u003c/p\u003e \u003cp\u003eThe data collected did not reveal niche or novel ways of practising self-care with one noteworthy exception: viewing client work itself as self-care. Serving as a reflective statement (Finlay, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), the author noted this as a \u0026ldquo;busman\u0026rsquo;s holiday\u0026rdquo; where one seeks change or relief from the daytime job by repeating it in one\u0026rsquo;s own spare time. Spirituality might be an aspect of this concept as caring for the community and its reciprocal effect is promoted in many a world religion. Culturally, there seemed to be little variance in what counsellors counted towards their self-care measures. If cooking helped a practitioner mentally leave therapy work at the office, then this would work for counsellors in England and the Philippines alike. Solution-focussed questions are important when assessing personal effectivity and relevance of self-care measures (Miller, 2005; as cited by Stebnicki, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), and thus aid rediscovery of self-care measures. These questions can be self-directed in a type of stocktaking exercise to ensure that helpful strategies remain in place and are not neglected.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Significance, limitations, and future research\u003c/h2\u003e \u003cp\u003eThe degree of empathy fatigue and how a practitioner is experiencing this phenomenon will influence the counselling relationship. To help others, therapists need to help themselves first. Adding underused or rediscovered strategies to the domain of self-care brings a further dimension to the scientific discussion of professional fatigue among therapists. Specifically using the term empathy fatigue positively broadens the spectrum both on experiencing and reporting.\u003c/p\u003e \u003cp\u003eA potential inherent weakness of this research lies in the design of a qualitative study since findings cannot be generalised. The purposive non-randomised sample of such a low number cannot claim to be representative or replicable.\u003c/p\u003e \u003cp\u003eFuture quantitative studies on the perception of all terms of professional fatigue, including empathy fatigue and empathic distress fatigue, would provide valuable insights into whether the use of particular terms yielded different results. Conducting randomised studies in a number of populations would show whether significant differences emerged when identifying and reporting professional fatigue symptoms. If dissimilarities between the various concepts were negligible, contesting all professional fatigue syndromes in favour of an integrative model as posited by neuroscientists has a practical side to it. A new umbrella term would integrate all types of fatigue syndromes, making professional fatigue easier to identify and act upon with suitable interventions.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis piece of research brought together the experiences of empathy fatigue of six therapists from three continents. There was both overlap and uniqueness in the reporting of their strategies in the domain of self-care. Commonly, self-care was viewed as a self-mandated regimen satisfying both needs for empathy-free zones and social engagement. Five out of six practitioners had experienced professional fatigue, yet were unclear where the syndrome sat within the academic framework. There was much support favouring the counselling-specific term empathy fatigue over the more widespread compassion fatigue.\u003c/p\u003e \u003cp\u003eA recommendation for practitioners would be to regularly take stock of one\u0026rsquo;s personal wellbeing, connect with one\u0026rsquo;s inner self, and assess the effectiveness of self-care strategies. By doing so, any early warning signs would become noticeable and one could react accordingly through improving on personal self-care strategies. Increasing measures in this detection period would make achieving equilibrium in both professional and personal life easier and faster as one\u0026rsquo;s personal baseline would remain in sight. Additionally, highlighting the importance of self-care in training would help prospective counsellors to adopt the ethical imperative: Look after yourself first so that you can look after others.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgement and affiliation: This work is self-funded with no conflict of interest. Source data is available upon request.\u003c/p\u003e\n\u003cp\u003eThis study has been reviewed and approved by the Research Ethics Committee, Leeds Beckett University.\u003c/p\u003e\n\u003cp\u003eAll participants gave their written consent to being interviewed as well as the anonymised publication of this piece of research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAllsbrook, K., Atzinger, C., He, H., Engelhard, C., Yager, G., \u0026amp; Wusik, K. (2016). The relationship between the supervision role and compassion fatigue and burnout in genetic counseling. \u003cem\u003eJournal of Genetic Counseling\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(6), 1286\u0026ndash;1297. https://doi.org/10.1007/s10897-016-9970-9\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association. (2013). \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition\u003c/em\u003e. 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Improving the effects of psychotherapy: The use of early identification of treatment failure and problem-solving strategies in routine practice. \u003cem\u003eJournal of Counseling Psychology\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(1), 59\u0026ndash;68. https://doi.org/10.1037/0022-0167.50.1.59\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Leeds Beckett University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"counsellor, empathy fatigue, self-care, compassion fatigue, empathy","lastPublishedDoi":"10.21203/rs.3.rs-4258196/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4258196/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe ability to join a client on a collaborative, non-expert level is based on a counsellor\u0026rsquo;s empathy. Yet the very capacity to show empathy and deep understanding of a client\u0026rsquo;s problems may make counsellors vulnerable to professional fatigue. Experiencing this phenomenon will negatively influence the therapeutic relationship. Self-care measures are at the core of bolstering a therapist\u0026rsquo;s resilience to ensure a high standard of working with clients. Instead of the more frequently researched compassion fatigue, this qualitative study uses the term empathy fatigue to broaden the scope of reported experiences. It examines the effects of empathy fatigue and self-care strategies reported by six counsellors from Asia-Pacific and Europe. While the lack of conceptual clarity on the different constructs of professional fatigue became apparent, rich data helped to interpret how the individual made sense of this phenomenon. Findings showed that self-care was commonly viewed as a self-mandated regimen satisfying both needs for empathy-free zones and social engagement. To help others, therapists need to help themselves first. Self-directed solution-focussed questions to gauge how effectively self-care measures in place are working prove useful for counsellors in managing and maintaining equilibrium in both professional and private settings.\u003c/p\u003e","manuscriptTitle":"An exploration of empathy fatigue in counsellors and their use of self-care strategies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-17 20:20:07","doi":"10.21203/rs.3.rs-4258196/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"246c4541-b32c-40a4-92e9-71368d9cb3ae","owner":[],"postedDate":"April 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30608359,"name":"Psychology"}],"tags":[],"updatedAt":"2024-04-17T20:20:07+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-17 20:20:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4258196","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4258196","identity":"rs-4258196","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}