Compassion Fatigue

One of the greatest gifts I receive in my work as an addictions therapist is to witness individuals and families surmount incredibly difficult challenges and embrace a life of recovery. Often the breakthrough occurs at the bitter end, when I’m scratching my head in disbelief that they can endure such intense levels of frustration and pain.

Witnessing the thrashing that occurs at addiction’s hands is grueling. I’ve spent countless sleepless nights wondering if a patient will “make it” or “get” the breakthrough they need to begin the healing process. Fortunately, as a professional I’ve been trained to deal with the frustrations that come with this work.

As a young clinician, I had wonderful mentors who taught me to never to give up on the human spirit. “You never know when the seed you planted will take hold,” was the steady advice of Dr. Stanly Evans, a man of enormous integrity and a pioneer in the field of addiction treatment. Another, Sid Goodman, creator of the highly effective Florida Model and Family Restructuring programs, constantly reminds me to be fearless and tenacious in challenging a family’s resistance to change. “You must think systemically,” he constantly instructs me when I’m baffled with what to do in a particular case. “The patient is the family and the family is the patient.” But even with this exceptional support, there are times when I get exhausted, crushed by the weight of a disease that diminishes the dignity and souls of my patients and their families.

What is Compassion Fatigue?

Compassion fatigue is a well-established concept in the realm of health care providers. First observed in nurses who worked in emergency rooms, it describes the sense of helplessness and hopelessness that can overtake a person providing care for someone whose suffering seems never-ending and insurmountable. It’s also a condition that I observe frequently in the families and loved ones of the patients I treat.

Marsha* is an example of a wife and mother whose emotional spirit and physical health were beaten down by the seemingly hopeless addictions that plagued her husband and daughter.

A once beautiful and vibrant woman, Marsha presented for treatment disheveled and profoundly depressed. Coffee stained her blouse, mud caked her shoes and silver roots defined the brittle locks of her auburn hair. Although she had a master’s degree in English and for years taught American literature at a local college, she could barely put together a coherent thought. “I’m just exhausted…tired…no energy.” It didn’t take long for me to realize why. Her 17-year-old, heroin-addicted daughter was expelled from school for selling OxyContin and had been in and out of five $30,000-per-month rehabs in the last three years. As if that wasn’t enough, Marsha’s husband of 27 years was on the verge of losing his middle management job at an insurance company for excessive absences due to his late stage alcoholism. “It seems he loves cheap vodka more than he loves me and our kids” Marsha sighed as she finished telling her story.

Exhaustion, frustration and an overwhelming sense of hopelessness: these are just a few of the symptoms described by people who suffer from compassion fatigue. The following is a more thorough list compiled by the American Academy of Family Physicians.

Common Symptoms of Compassion Fatigue

Abusing drugs, alcohol or food
Chronic lateness
Diminished sense of personal accomplishment
Exhaustion (physical or emotional)
Frequent headaches
Gastrointestinal complaints
High self-expectations
Inability to maintain balance of empathy and objectivity
Increased irritability
Less ability to feel joy
Low self-esteem
Sleep disturbances
You can determine if you are suffering from compassion fatigue by taking a self-assessment test. If you respond with a 1 (very true) to more than 15 questions, it’s critical that self-care is your first priority.

For Marsha, self-care meant finding something to anchor herself to when the gales of her daughter and husband’s addictions thrashed against her. Since she was a child, Marsha had internalized the belief that if she fixed those upon whose love she depended, then all would be well. It was a message she learned as an infant, completely reliant on the conditional love of a narcissistic and anorexic mother. But while her selflessness enabled her to survive her childhood, it trapped her in relationships that crushed her spirit and enabled those she loved to march uninterrupted down paths of self-destruction.

Fortunately, for Marsha and millions of other people like her, there is a way out of these devastating relational patterns. The key of liberation is to acknowledge that your unhealthy response to other peoples’ behavior is a habit – and most importantly – that it’s a habit you can break.

In his best selling book, The Power of Habit, Charles Duhigg, an investigative reporter for The New York Times, distilled habits into three key components. The first of these components consists of a cue. This is the cause of your reaction. The second is a routine. This is the effect. It’s the behavior you engage in or the reaction you have in response to the cause. The third is the reward. This is the benefit you derive or the instantaneous relief you feel once you’ve had your reaction.

In Marsha’s case, the cue for her reaction to save and protect others was the unmanageability of her life, caused by the insanity and chaos of her family’s addictions. The routine she fell into was to become a caretaker extraordinaire. When a crisis struck (and there always was a crisis), Marsha became super mom and super wife. Like a caped crusader she swooped in and solved their problems. The reward she got from her behavior was having a moment, if only fleeting, of mastery and control – and perhaps most importantly – of being validated as a person who mattered.

Unfortunately her habit, while enabling her to survive as child, had outgrown its usefulness. Now instead of adding value, it became deeply rooted in her family’s disease.

How Can We Overcome Compassion Fatigue?

Fortunately, Marsha possessed within her the tools to change. To recover, she needed to become hyper conscious of when her cue arose and implement different routines to address it. So instead of looking to control the externals of her life, she needed to enhance the mastery of her internal, emotional state.

Central to accomplishing this skill was her coming into therapy and talking about what was going on in her life with a person who was completely present for her. Second, she needed to find and cultivate a life outside the stagnate confines of her family. In Marsha’s case, this expansion occurred slowly. Initially and reluctantly she started attending Sunday mass at her community church. A month later she was back at work, teaching English as a second language to families in need. Finally, she was able to get her daughter into a treatment program that had a robust family therapy component as a central part of its curriculum. The work that she and her family were able to do in this program broke the strangle hold of their addictions and liberated them in a spirit of mutual respect, love of self and each other. They were finally able to hear each other out and set boundaries that were clear, consistent and enforceable.

Six months have passed, and is Marsha’s life perfect? No. But, it’s infinitely better than the life she found herself in upon entering treatment. Although her husband did lose his job, he was attending AA meetings and was cobbling together periods of sobriety. Her daughter was clean and living in a half way house in Florida and had just started a part time job in a coffee shop in Delray – a wonderfully robust recovery community. The greatest transformation, however, was that which occurred in Marsha. No longer were her eyes flat orbs surrounded by craters of darkness. In them shown a light of recovery and hope –evidence that her compassion fatigue had been replaced by compassionate strength for her self and others.

*The name and identifying details have been changed for patient confidentiality.

Trauma and Compulsive Spending

How trauma leads to destructive financial choices:
By Erica Sandberg

Child abuse. Warfare. Assault. A devastating accident. If you have endured one or more life-threatening events, you may be more likely to make destructive money decisions.

Researchers discovered that post-traumatic stress alters the way a person thinks and reacts to situations, including financial behavior. A 2012 Cornell University study of veterans, “Do Psychological Shocks Affect Financial Risk Taking Behavior?,” found that service members who lived through combat are more cautious in their financial investments, thereby forfeiting capital gains that could benefit them in their retirement years. The study states that just as unpredictable macroeconomic shocks (such as a stock market crash or a rapid currency devaluation) makes investors risk-averse, profound psychological shocks impact survivors in much the same way.

How trauma can wreck your finances
If you are making negative money choices, especially those hurling you into arrears, and you believe it might be due to past trauma, there are ways you can change course.

Trauma’s neurological impact
According to Paul Hokemeyer, a Manhattan therapist, traumatic events can lead to compulsive and destructive economic behaviors. The root of this phenomenon, he says, is the impact that trauma has on the brain.

These are not conscious, deliberate actions, says Hokemeyer. “Traumatic experiences cause our brain to overreact. They force us into a stress mode where we are compelled to take action as a protective measure.

“In my work as an addictions and family therapist, I see too often how people utilize money and the objects it buys to self-medicate away the emotional pain that is left in the wake of their trauma,” says Hokemeyer. “Oppressive credit card debt is very frequently one of the destructive consequences of their unfortunate legacy.”

So while soldiers who have been through battle tend to shun risk, others who have suffered through different kinds of trauma may respond by being spendthrifts.

As an example, Hokemeyer describes a female patient who, as a teenager, had been exposed to domestic violence. “When she was 15, she heard her parents always screaming and fighting. To medicate, she would go online and look at clothes. That was the way she felt soothed.”

I see too often how people utilize money and the objects it buys to self-medicate away the emotional pain that is left in the wake of their trauma.
— Paul Hokemeyer
Marriage and family therapist
Initially, the girl would calm herself by looking at images. Then she bought something and felt good. As problems at home continued, she bought more. “So here’s a direct relationship between the trauma and the activity,” says Hokemeyer. “But as an adult she didn’t see the connection right away.”

Michelle Black, a credit expert at, a credit education and restoration program in Charlotte, North Carolina, says she comes across people on almost a weekly basis who have financial problems due to traumatic circumstances.

“A couple years ago, I was helping a man to rebuild his credit after his wife was killed in a car accident,” says Black. “Naturally, he had unexpected financial expenses from the funeral and decreased income from missing work while he was grieving. However, he also began to use shopping and overspending as a way to temporarily cover up his grief. There is a reason that it is called ‘retail therapy.’ ”

Negative reactions to trauma
What financial decisions might you be making as a reaction to trauma? Responses vary among individuals, says Hokemeyer, but the most common include:

Excess spending. Shopping makes you feel in control and centered. When the trauma is triggered, you shop to self-medicate.
Excess saving. The opposite side of the coin is hyper-vigilance. You consider the world to be an unsafe place, so protect yourself by hoarding possessions or money.
Under-earning. You may be highly educated, talented and capable, yet do not pursue or keep positions for which you are worthy because you feel undeserving.
Over-working. You can’t stop working because the only way you can feel of value is by bringing in as much money as you can. Satisfaction is elusive, though.
Perpetual debt. Owning tangible consumer items is proof of worth (when you may not feel it). Therefore, you reach for things outside yourself and your means. You might also believe, deep down, that you do not deserve wealth, so sabotage it with overcharging.
Of these responses, Pandora MacLean-Hoover, co-founder of the Think-diff Institute counseling center, says uncontrolled shopping is the most typical — and most damaging.

“While spending may provide relief from the emotional injury of trauma, it often creates unmanageable debt,” says MacLean-Hoover. “Therefore, the relief may be short-lived. The burden of debt eventually reinforces negative beliefs that the spending diminished, creating a vicious cycle.”

Black agrees, explaining that the abuse and mistreatment of money after a trauma is a common coping mechanism: “When a consumer’s world gets turned upside down, especially by a sudden illness or accident, financial and credit problems are usually not far behind.”
When a consumer’s world gets turned upside down, especially by a sudden illness or accident, financial and credit problems are usually not far behind.
— Michelle Black
Hope4USA credit expert
Stephen Lesavich, a Chicago attorney and co-author of “The Plastic Effect: How Urban Legends Influence the Use and Misuse of Credit Cards,” also believes that traumatic life events often lead to impulse purchases. “The products and services are used for easing the feelings associated with the negative emotions and may be used to fill an emotional void,” says Lesavich.

Connecting trauma, financial behavior
Can you stop such negative, compulsive responses? Yes, insists Hokemeyer. Crucial to getting your dignity and esteem back is realizing and accepting that a traumatic event has changed the way you deal with money. Yet pinpointing deep-seated issues can be elusive.

“Neurologically, we defend against uncomfortable truths,” says Hokemeyer. Knee-jerk denial is normal. After all, you might not want to accept that you keep yourself in debt or unemployed because something terrible happened to you. Instead, you want to believe that it’s all due to separate, outside factors, he says.

Several psychotherapy methods can help you differentiate between conscious, healthy financial behaviors and harmful ones triggered by the event. The standard approach is cognitive therapy, which is based on the assumption that thoughts, feelings and behaviors are interconnected. With a therapist, you isolate the origin of your inaccurate thinking, determine the emotional response, then work to form new, positive behaviors.

Less widely known techniques are also effective, says MacLean-Hoover. She uses a combination of therapies, including Eye Movement Desensitization Reprocessing (EMDR), which was originally developed to help relieve trauma-induced stress, as well as gestalt and cognitive therapies. In aggregate, these therapies “help people identify why the spending makes them feel better,” she says. “Once people understand why they do what they do, they may embrace alternatives.”

With professional guidance or even with just a mighty will to change, you can switch gears. Black recalls a client whose wife died. “A couple of years later, he was ready to deal with the financial fallout of the trauma,” says Black. “He wanted to put himself in better position so he could buy a home for himself and his child. We were able to help him, but it took about six months of hard work to correct the mistakes of his past.”

Ultimately, “You must train your brain to believe in you. If you sense you have a problem, there is a 99 percent chance it’s true. Trust that feeling and seek proper care to address the issues,” says Hokemeyer.

What to do now
In the absence of formal therapy — or before seeking it — you can try to redirect the feelings of powerlessness into other activities. Do things that “restore a sense of importance,” says MacLean-Hoover, who suggests physical exercise, reading, artwork or socializing with friends as examples of positive ways to redirect spending urges.

Even the process of budgeting can restore a sense of power, says Hokemeyer. It’s a simple defense against irrational, destructive economic choices.

If you suspect a traumatic event is behind your consistently poor financial decisions, Lesavich suggests a process of “checking in” on your emotional state. Awareness breeds strength and the opportunity to make better decisions, he says. “When emotional triggers cause you to make purchases you don’t need or can’t afford, you give your power away to someone or something else.”

Prior to shopping or charging, Lesavich recommends asking yourself the following questions:

How do I feel right now?
What is causing me to react this way?
Why do I feel the need to buy this?
Do I really need it?
How will I feel after I buy it?
How will I feel when I have to pay for it?
It’s self-generated cognitive therapy, helping you connect the cause-to-action dots. Frequently asking and then answering them will guide you to make deliberate, healthy actions not based on past hurts, but on present needs and sensibilities.

You don’t have to let a traumatic event continue to haunt you or harm your economic security, says Lesavich: “By making a choice to not react to them, you will help yourself to create a prosperous financial future for you and your loved ones.”

Sex Addiction: Diagnosable and Treatable

In the following article that I wrote for, I discuss the phenomenon of sexual addiction and sexual compulsivity:

“I don’t know how it got this far out of control,” Matt practically whispered during our first session.

“It all started so innocently. I went on Ashley Madison (a website that connects men and women interested in engaging in infidelities) after reading about it in the Wall Street Journal. The next thing I knew, Marsha and I were deep into this S&M thing. Now, I obsess about her all the time. It’s taken over my life.”

While Matt claimed his wife knew nothing about his infidelity or the sexual pleasure he derived from binding and gagging his mistress, he knew his life was spinning out of control and racing towards a disastrous ending.

“Tell me what to do?” he pleaded. “I can’t sleep and it’s affecting my work. I don’t spend time with my son and my wife’s got to sense something’s going on. We’ve been married for 23 years and I love her…I just can’t break it off with Marsha.”

As a marriage and family therapist who works in the realm of addictions, I’ve successfully treated a host of “Matts” and a few “Marshas” too. These are smart, successful and dedicated family men and women who find themselves trapped in one of the most insidious, gripping and controversial addictive disorders.

A Controversial Diagnosis

While the recovery community has embraced the phrase “sexual addiction” to describe a very real and very destructive phenomenon, it has not been officially acknowledged by the American Psychiatric Association (APA). This failure to grant it diagnostic status has led to increased stigmatization of the people who suffer from it, a misunderstanding as to its root causes and a refusal to move the disorder out of the realm of morality and into science.

Fortunately, this failure of the bureaucratic and academic elites to officially recognize a very treatable condition has not prevented a handful of clinicians and recovery centers from formulating treatment approaches that liberate individuals and families from the degradation, despair and destruction inherent in it.

Sexual addiction first attained the public’s attention in 1983 with the publication of Dr. Patrick Carnes’ Out of the Shadows: Understanding Sexual Addiction. In this groundbreaking book, Dr. Carnes outlined five central features.

Five Central Features of Sexual Addiction

The use of sex to manage uncomfortable emotions (self soothing)
An escalation of sexual behaviors (tolerance)
A loss of control (impulsivity and compulsivity)
Significant negative consequences
Physical and emotional distress when the ability to sexually act out is limited (withdraw)
The National Council on Sexual Addiction and Compulsivity defines sex addiction as “a persistent and escalating pattern of sexual behavior acted out despite increasing negative consequences to self and others.” Put in more accessible terms, a person who suffers from a sexual addiction will continue to act out in sexually destructive ways in spite of escalating risks to their:

Finances and career
Significant relationships with spouses, lovers, friends and family
Personal freedoms
Four-Pronged Approach to Treatment

In contrast to those seeking treatment for drug and alcohol addictions, people who suffer from sexual addictions face more obstacles to getting effective care. These include the controversy surrounding the disorder’s existence that prevents treatment from being covered by insurance, the shame and guilt that keeps the people who suffer from asking for help and the scarcity of competent clinicians who can treat it.

In my own practice, I utilize a treatment approach that addresses the disorder in its four dimensions. These consist of the following:

The patients’ genetic predisposition and neuropsychology
Existing mood disorders that frequently include anxiety and depression
Personality traits that frequently include narcissistic and borderline features
The interpersonal systems in which the patient operates including their romantic and professional relationships, their religion, and their cultural and economic background

This approach is based on solid empirical research indicating the overwhelming majority of patients who suffer from sexual addictions also suffer from biological disruptions in their brain chemistry that cause them to act impulsively. In addition, research shows that people who suffer from sexual addictions also suffer from anxiety and depressive disorders at much higher rates than those found in the general population and have a history of trauma. Finally, several studies as well as my own clinical impressions support my conclusion that life’s stresses and the social, cultural, religious and influences of the patient’s family profoundly impact the patient’s vulnerability to sexual addictions; and, they evidence personality traits that cause them to objectify people as sex objects.

Treatment in Action

Patients who suffer from sexual addictions enter treatment paralyzed by shame and humiliation. They describe themselves as “evil” and “defective.” They desperately want to be liberated from the crush of their destructive behavior, but can’t get out from under it’s demoralizing weight.

They feel profoundly alone in the world and terrified of the vulnerability that comes from authentic intimate relationships. Most often they come to treatment not through their own volition, but rather through the demands of a betrayed and furious spouse or partner who’s unearthed the details of their salacious behaviors. Their world is chaotic and out of control.

It’s important that their treatment be methodically and holistically addressed in a structured and safe frame. They need to be understood rather than judged, heard rather than preached at. They must be able to lay the overwhelming weight of their world in the clinician’s hands and trust that he or she won’t drop it.

The clinician in turn must have specific and concrete interventions to address the four prongs of the patient’s addiction. These should include psychiatric evaluations to assess the need for appropriate medications, clearly articulated behavioral plans to address the patient’s high-risk behaviors, relational work to give them insight into their personality disorders and when appropriate, family and couples therapy. In addition, patients must be given specific tools to address their traumatic histories and responses. These tools should be designed to change the way their brain reacts in the present to the trauma that occurred in their past. Last but not least, patients must be encouraged to partake in recovery communities where they can learn new ways of managing their uncomfortable emotions and the stresses inherent in leading the full and emotionally rich lives they desperately desire.

If you or a loved one suffers from sexual addiction, know that there is a clearly defined course of treatment. Know too that the hardest part in connecting with it is reaching out for help.

Sex and the cloud of moral, cultural and religious judgments that surround it obscures the hard and real fact that you are vulnerable and in pain. Leave these judgments on the curb where they belong and connect to the healing force of science and established psychotherapeutic interventions.

Walk through the door and sit down with a trained clinician who can help you. The only way out is through. The only way up to the light is by digging deep into the darkness.

Narcissism: Defining and Treating it


Narcissism: What is it and how do you treat it? 

Narcissism Defined

Narcissism is a character trait that defines a person’s self view and view of others.

Like the narrow lens in a microscope, it causes a person to focus on the world in a very self-centered way. It causes them to lose sight of notions like we, us and compassion for others. It’s a trait that takes hold early in a person’s life – typically as the result of a major breach of trust by a primary caregiver. Through this breach of trust, the person vows never to be vulnerable again and sets out to be a self-sustaining, autonomous entity.

Although narcissism is resistant to change, it can be “softened” through a variety of clinical interventions to a point where it no longer has a negative impact on the quality of the person’s life and relationships. Through this softening, the person can then embrace a comprehensive program of recovery for life, rather than feeling distant and detached from the healing force of others.

Recently, the diagnostic criterion for what constitutes narcissism was revised in the DSM-V. In looking for pathological narcissism, clinicians look for people who evidence the following traits:

They are what they possess: The person defines himself or herself from the outside in. They find their self worth in objects, external recognition, and adoration from others.
They are emotionally volatile: The person is only happy when they are being praised and acknowledged as special. They can’t tolerate being criticized and react with anger when they’re questioned.

They are externally driven: The person lacks a moral or intuitive compass. They are driven by commercial notions of success rather than spiritual principles.
They are emotionally shut off: The person lacks empathy and compassion. They only concern themselves with others when they feel their concern will advance their own narcissistic agenda.
They are manipulative: The person can be highly charming and charismatic, but only to manipulate and exploit others for their own gain.
They are grandiose: The person feels they are unique and special. Their condescending and critical attitude towards others is a tool they use to build themselves up.
They are entitled: The person feels they are deserving of special treatment and rewards without having to pay dues or earn them.
They need constant attention: The person is constantly seeking external validation and needs to be the center of attention.

Effective Treatment Modalities for Narcissism

The most effective forms of psychotherapy for the treatment of narcissistic personality disorder include the following psychotherapeutic approaches:

Interpersonal psychoanalysis: Through the patient and therapist relationship, the patient begins to explore his or her significant relationships and gains insight into how they perceive and are perceived by people.
Family therapy: An extremely effective form of therapy that involves the patient’s family. As a team, the family works to resolve conflicts and relationship problems.
Cognitive behavioral therapy: Gives the patient tools to change their thought distortions and negative beliefs. Through these tools, the patient replaces unhealthy and negative beliefs with healthy, positive ones.
Group therapy: Occurs in a group of other patients who share the same emotional and personality issues. Provides the patients with insights into how they relate to other people and as a member of a group.
Ideally, these treatment interventions will occur simultaneously and continue for as long as clinically indicated. In my experience, it takes at least one year for patients receiving treatment in a private office setting and at least 60 days in an intensive and comprehensive in-patient setting before they will begin to experience an improvement in their personalities and their relationships.

Is it worth the time and effort? Absolutely. Narcissism fuels the addictions that destroy lives and families. Are narcissists lost causes? Absolutely not. They are human beings who in spite of their external bravado are incredibly sensitive and terrified of being hurt. With the proper clinical care they can transform into loving partners and parents, sober men and women, who add great value to the lives of others and the world around them.


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