Reframing compassion fatigue: Compassion as a tool for combating burnout


AMA STEPS Forward® podcast

Reframing Compassion Fatigue: Compassion as a Tool for Combating Burnout

Dec 7, 2023

Rola Hallam, MD, British-Syrian consultant anesthetist, humanitarian and founder of CanDo, a social enterprise that enables local, frontline health care workers to provide health care to their own war-affected communities, shares the story of her “valley of darkness” and how compassion can be a tool to combat burnout.


  • Rola Hallam, MD, consultant anesthetist, humanitarian, and founder of CanDo


  • Jill Jin, MD, MPH, senior physician advisor with AMA STEPS Forward®

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Dr. Jin: Hi everyone, and welcome. This is Dr. Jill Jin, Senior Physician Advisor at the AMA. Today on the podcast, we are joined by Dr. Rola Hallam, who is a British-Syrian physician, humanitarian, entrepreneur, and trauma-informed life coach. She is the first Syrian TED fellow and founder of CanDo, a humanitarian organization that supports frontline health and aid workers to save children's lives in war devastated communities. She has helped to build seven hospitals in Syria, including the first ever crowdfunded hospital. Dr. Hallam, however, started her career, like many of us, as a practicing clinician. She is an anesthesiologist by training and had her own journey with burnout as she was doing humanitarian work alongside her clinical work.

Today we will talk more about her personal experience with burnout, how she overcame it by practicing self-compassion, which led her to reframe the concept of compassion fatigue, and ultimately use compassion as a tool for combating burnout. Dr. Hallam, thank you so much for joining us today.

Dr. Hallam: Thank you for having me.

Dr. Jin: So let's start from the beginning. Tell us about your personal journey with burnout.

Dr. Hallam: So I always tell people that I think I was born a doctor, because I really remember being a six-year-old and playing with my siblings and as we grew up in Damascus and insisting on performing the lifesaving surgeries with our Barbies and Sindy's. And as I was training for anesthesia in the UK, global health and health development was really pulling me. I always had this sort of seeming innate belief that access to health care is a fundamental human right. And so I really had planned for a career in anesthesia in Sub-Saharan Africa, but of course life has other plans. And so in 2011, when peaceful protests turned to war and shattered millions of lives and created the epic war that we all know about, as a Syrian, I did the only thing that I knew I could and I joined the humanitarian effort.

Alongside my full-time work, I was a volunteer fundraising, collecting medical supplies, spending every evening, every weekend, every holiday on medical missions to Syria. To take equipment, to deliver supplies, to do needs assessment, as well as be a clinician, treating patients. And I guess I thought it was just going to last a few weeks. And so we went at it at this completely unsustainable rate. Of course, during every medical mission I went, there were war crimes and crimes against humanity that we witnessed.

But one particularly is etched on my heart, mind, and soul, where back in 2013, I had an influx of severely burned children who came into one of the hospitals I'd helped to burn after their school was bombed. And despite my efforts and the efforts of the few colleagues I was working with, we were totally overwhelmed. We didn't have access to all of the equipment, medication and supplies that we needed. And many died that day because I, the physician who had the skills and the ability to administer potentially lifesaving treatment, didn't have the tools and the resources that I needed.

And I didn't really know until many years later, until two years later, the profound, if you like, effect or consequences, that all this witnessing had taken on me. And that incident had spurred me on to create CanDo and to try and get all of these resources that were needed to frontline health workers, to local aid workers and people who were there on the front lines and able to provide that potentially life-saving treatment, but weren't accessing the resources that they needed. And as happens with most of us, we are so passionate and dedicated to what we do that we are driven.

And the more suffering that we see, the more that we want to do, the more that we take responsibility on. And so I guess I kept running and I kept doing. And then one day, 10 years later, on the 10th anniversary of the war, I was doing a BBC interview. We had just released a second documentary about our work and some of these war crimes that were happening, bombings of schools in Syria. And I had this outer body experience where I suddenly just saw myself giving the interview and I was just like, "What the F? I can't believe I'm still talking about this. I can't believe that we're still talking about hospitals being bombed and schools being bombed and children being bombed. It's been 10 years."

And with that, my whole world just seemed to collapse and I entered what I now call, My Valley of Darkness, where I just in that moment felt like the world's biggest failure. I just felt like everything I was doing was useless. I was useless. I just felt utterly depleted. And that darkness carried on for quite a while. I just felt trapped, lost and broken. And everyone kept saying to me, "Well, this is burnout and compassion fatigue." And all I knew is that I felt terrible and I knew I couldn't go on anymore, not in that way.

Dr. Jin: So then what happened?

Dr. Hallam: Well, to be honest, I think for quite a while I was just drowning in this darkness because I think suddenly ... The bit that I did know I needed to do was that I finally needed to slow and to feel in order to heal. I knew that after 10 years of just acting my way out of everything, I hadn't dealt with any of the grief. I hadn't dealt with anything that I had witnessed, with anything that had happened to us. I'd lost over 30 members of my family, I'd become exiled from the country. And so there was just so much that had happened that well, like most of us, you suppress. You deny your feelings, you deny your emotions and you distract yourself through some helpful, some less helpful mechanisms. And so I just had to allow all the feelings. And so there were days when a rage would visit and all I could do was rage or sobs would come out and sobs that I just didn't know that I had and I thought I was losing my mind.

It's interesting because looking back, of course, the beauty of hindsight, such a magical thing, there was just so many warning signs that all was not well. But we normalize so much don't we? Because it's our job. Because it's what we do. Because it's how everyone else is around you as well. And so you kind of think, "Well, this is normal in it." And it took me getting into that valley of darkness to realize, "Oh God, no. This is in no way normal and in no way right." But there were so many warning signs.

So for example, for me, I had developed back pain of unknown cause. I had emotional inability. I'd become extremely self-critical. I was becoming more and more unsociable. I was becoming more forgetful and brain foggy. And I think two of the sneakiest signs or symptoms of this is the shame. That voice of shame that tells you to, "Shut up. Stop moping around. It's not your sister who was killed. It's not your brother who was raped. Just shut up and keep doing your work." That nasty voice of shame, I didn't know was trauma until I started to learn about trauma and I started to heal my wounds.

Dr. Jin: In a sense, was this inevitable? Did you feel like it was inevitably going to happen at some point?

Dr. Hallam: Well, I think when you're in a survival state, you are not projecting like that. You're not sitting there thinking in any kind of rational, sensible way, about your own health and wellness. In fact, this is the problem and why so many of us burn out because we think it is selfish to look after ourselves or at least a luxury. It becomes like, "Do everything else, look after everybody else, prioritize everything and everyone else. And then if there's any more time, money or energy left, then maybe I might get a look in." And even then we only kind of do tip of the iceberg kind of self-care. You throw a massage at it or whatever, rather than any kind of holistic wellness plan.

And so again, in hindsight, of course it was going to happen, but at the time you don't think that because you are just treading water, trying not to drown. You are shipwrecked at sea. You are not sitting there thinking, "I'm going to get exhausted." You're just like, "Okay, must keep going, must keep going, must keep going." This is why so many of us don't do the self-care and the healing is because you put out one fire and before that's even been put out, you've got another fire that you're dealing with. So it keeps you so engaged in the here and now. It stops you from really taking a step back at yourself unless you have either experienced it before, in which case you might learn from your mistake or you have someone who might point it out to you, someone who you know you can listen to. Or hopefully this is why I am talking about it, so that maybe someone listening might start to see their warning signs and see that. But I guess otherwise if we're just stuck in the thick of it, you just keep going.

Dr. Jin: Right. Until you have that out of body experience and everything shuts down.

Dr. Hallam: Yeah, exactly. Until your body in its wisdom, moves out of fight and flight and into freeze, into shut down. Into disconnection. Into, "We are no longer dealing with anything. We are no longer doing anything. We are going into absolute shutdown mode." And then you know about it.

Dr. Jin: And then how long did you stay in that valley of darkness?

Dr. Hallam: Several months. And the breakthrough in the middle of that breakdown, was when I started to finally practice self-compassion. It was finally acknowledging my own pain and suffering and sacrifice, that enabled me to finally take that shames' handhold over my neck and start to help me to breathe again. It started to help me to commit to my healing. When I finally was able to be kinder towards myself and acknowledge myself and more of a friend towards myself. That really was a huge catalyst to saying, "Okay, we're going to do this. Time to prioritize you, baby. Let's put that oxygen mask on first." And it was key. And this is what I work with with all my clients now. I say like, "You having self-compassion is really so key to that."

After that, as I started to read more and more about trauma, I realized this isn't burnout. This is trauma. And actually what so many of us are labeling in health care or in frontline work of any sort as burnout is actually trauma, that is being unrecognized and therefore unmanaged and untreated. So that was one of my profound learnings. And so I started to trial different things to try and bring my nervous system into a state of regulation. And I remember the moment when a few months later I kind of suddenly was like, whoop, "Oh, I'm not in fight and flight anymore." It was so interesting. It was so palpable, the difference in my body, from basically the 10 years before to where I then was in that moment in a state of calm connection, connected to my creativity, connected to my problem solving. Just a completely different internal environment to where I had been for months before that.

Dr. Jin: And how specifically did you get there? When you say you practiced self-compassion and self-care, what kinds of things did that include and did you have professional guidance? Tell me more about that.

Dr. Hallam: I tried quite a few different things, some of which were more effective than others, so others were so profound and important in my journey. So sharing with my loved ones, but also with my dear friends. And I think this is something that is an issue for so many of us health workers and front liners in general. We have such a vulnerability aversion. Where we are, we've put the superhero cape on ourselves or someone else has put it on us and we're the savior who is off we're going into the universe to save it. And it means that we can't admit when we are struggling and we need help and support.

When I was able to finally do that, it was so profoundly important because I was able to then regulate my nervous system through other people's regulated nervous systems. Other people's calm and love, kind of helped me to come back into the fold and into that state of connection. And my daughter, who was two at the time, was of particular importance. And as a spiritual person, prayer and meditation was profoundly important for me. So I don't believe that there is a specific recipe for everybody, but I think that there are certain categories that we all need to have each bit of it in our toolbox, if you like. That holistic approach, trying to tackle it in just a uni-dimensional way, isn't going to work. We are multi-dimensional beings and therefore we need that holistic way of tackling it so that we can be brought back into that wholeness.

Dr. Jin: Yeah, absolutely. So tell me more about this idea of trauma versus burnout and then this compassion fatigue. You've referred to it as a myth in the past, and whether that is real or not or just a part of the trauma picture. Tell me more about that.

Dr. Hallam: For me, when I was talking about burnout or when I was really looking into it for myself, I thought it cannot be that the same thing that an IT programmer feels from overwork is the same thing that I am feeling. We have had entirely different experiences that have got us to that point. I was curious, what is that difference? And so when I started to look into nervous system and the physiology of it, because I think the other problem is we kind of label it as a mental health problem when actually it's really rooted in our physiology and the state of our nervous system, that then impacts our cognition, mental health, emotional health. Everything essentially. But the more that I started to learn about that nervous system dysregulation, and the more that I started to look into the risk factors for trauma, the more that I realized, "My God, we're sitting ducks for it."

I mean, at one point I was really angry that no one throughout my medical training, none of my seniors, at no point in my training did anyone say, "You are high risk for trauma. These are the signs of trauma. This is how you would recognize it, and this is what you would do about it." Nothing. And I think it is still grossly unknown and grossly under recognized and therefore under managed. And I think that, and we can talk about that later when we're talking about policy, but that has a huge ramifications for how do we deal with burnout. Because as long as we remain focused solely on the external factors of bureaucracy and workloads and things like that, which are important, but if we don't tackle the fact that we are a traumatized profession working in a traumatizing profession, then I think we are never going to come out of this vicious cycle that we are in.

And I guess everyone kept telling me, "Oh, you've got compassion fatigue." And I was like, "Okay. Right. Well, I definitely feel fatigued." But being a spiritual person, I'm a Sufi, and I was like, "Okay, well," and I'd studied Buddhism and I was like, "well, how come Buddhist call Buddha nature compassion, and one of the limitless qualities? And how come in Sufism we call compassion is one of the other names of God? Compassion is infinite. So what's going on here? How can it possibly fatigue?"

And so I started to look into the neuroscience of it and realized that actually most of us don't understand what compassion is, let alone practice it. What we refer to as compassion fatigue is actually empathetic distress. And they have entirely different neurocircuitry in our brains as well as different experiential templates if you like, within us. So when they have scanned the brains of those who have empathetic distress, and that is, "I see you in pain and I feel your pain." Then it is literally the pain centers of our minds that light up.

But when they then studied another group of people who were also witnessing the pain, but were given compassion instructions of keeping the pain focused on that person and just feeling with them and instead of for them, they had a sense of wellbeing and a drive to want to alleviate their suffering. And so in empathetic distress, because we're activating our pain, we contract. No one wants pain, right? Pain is aversive to most of us. And so they have entirely different, like I said, experiential templates as well as neuroscience backgrounds. And so I think what we are referring to as compassion fatigue is empathetic distress. And actually, therefore, the significance of it is what I discovered is because the answer is compassion. It is not the problem. The antidote to burnout is compassion. The antidote to trauma is compassion. It is not the problem, it is the solution.

Dr. Jin: Yeah, that's fascinating the way that you frame that, because you're right. I think the natural response is to draw yourself in and say, "No, I have to put a wall between myself and the patients in order to protect myself." How do you do that? How do you practice compassion in a way that is not harming to yourself?

Dr. Hallam: I'm going to give you an example if I may. So I'd spent few months practicing self compassion, that is the first thing. The root to any of us being compassionate with our patients, with our loved ones, with anybody is being self-compassionate. I hundred percent believe you cannot practice it on anyone else until you have got it within you. And that means befriending yourself and bringing that kindness and acceptance to yourself. So that is the first critical thing.

So having practiced that for several months, I was like, "Oh, I'm ready to look at the news now." Because I had ditched it for months. I was like, "I'm too overwhelmed. I can't look at anything anymore." And that's I'm sure something that so many of us experience. You're just like, "I'm not watching the news." And so I turn on the news and of course I'm tested immediately. There was a bombing that had gone off in northern Syria and they bombed a school and three children were killed. And my immediate reaction was like, "Oh God, that could have been Naya," my daughter.

And I literally went to put my phone away, empathetic distress response, and I remembered my compassion training, and I stopped mid-movement and I took a deep breath in and I conjured up the three mothers of the three children. And I just said to them, "I'm sorry, I cannot take your pain away, but I will just sit here with you as you grieve your children." And I just sat there. And before I knew it, tears were rolling down my face. But actually bizarrely, they were happy tears, because I was able to stay in an open-hearted connection to that suffering, to that pain, and in a way that didn't feel overwhelming. In a way that made it feel like I had acted, I had connected with them and their suffering, but in a way that really totally absolved me of the responsibility, because I didn't translate that pain onto mine, or at least I let it go as soon as I was made aware of it. Did that make sense?

Dr. Jin: Yeah. I mean, it took you months of training yourself, but I think that that is a key point, that we got to start with ourselves.

Dr. Hallam: A hundred percent. And we know this, right? That all the science now shows compassion is trainable and it takes just a few weeks. It took me months because I was in a terrible state and I was floundering and I was sort of trying to help myself and whilst trying to still work, whilst trying to et cetera, et cetera. But actually even within six to seven weeks, the neuroscientists have shown distinct difference in that. And I think it is critical in us and in the future of health care that we train and teach compassion and compassionate leadership.

Dr. Jin: Yeah, absolutely, that is. And in terms of, we can maybe pivot to the things that we can change upstream, like you said. That is the ultimate goal is to make changes preventatively, prophylactically, if you will, to prevent people from getting to the point where you got to. So from the system level, from the health care organizations, from the medical education, what do you envision needing to be changed?

Dr. Hallam: Two things. We absolutely must be teaching students and all health care workers about trauma, how to recognize it and how to manage it. We need to identify within each health facility, there needs to be a trauma assigned person for whom can be the contact point for when you do see, feel any of these symptoms and signs. Someone who will be trained in First Aid, if you like, of knowing how to deal with it and therefore what that onward referral mechanism is, which starts with nervous system regulation.

And again, we know this stuff. So this isn't like, "Okay, now you need to be sent to a shrink and a padded room." No, it's really all about how do we regulate our nervous system so that after each emergency, we can bring ourselves back to a sense of safety, right? Because what happens right now is you go into emergency mode, you go into survival mode, and you get stuck in it. And then we meet everything that happens to us with that same level of urgency. So our nervous systems are completely dysregulated. So it's really rooted in nervous system regulation. So that's the first thing. And then the second thing is like we just said compassion and compassionate leadership training. I think it's only when we learn to accept ourselves that we can accept others, we can be open to ourselves, we can be open to others.

I, now, don't feel like...I now with my clients tell them, "You're not broken. I'm not here to fix you. You are wounded and you have your innate wisdom and your innate healing." And so compassion is empowering because it's saying to you, "You have the answers." Plus it feels good. Instead of draining us, it's actually recharging. So those are the two things that I would, when I'm president of the world, that we would bring into health care.

Dr. Jin: I find it most fascinating and enlightening how you refer to burnout as trauma. Everything you just described, identifying a person at the high level to spearhead these efforts in recognizing trauma and training. I mean we say the exact same things except for we use the term burnout. But like you said, that almost minimizes it. "Oh, you're burnt out. Anyone can get burnt out." But I think that reframing it as trauma helps to identify one, the physiology like you said, but also to point out that it's a different phenomenon that we have to address a little bit differently.

Dr. Hallam: A hundred percent. When clients come to me and they are in that similar state to how I was, I say, "Look," and they want to figure out what to do about work and all these other kind of higher level things. And I'm always like, "Okay, you are right now shipwrecked out at sea in survival mode. Let's get you to shore. Let's get you out of survival mode and into safety. Let's get you regulated first. Then we can build some foundations and then we can go for great." But it really anchors it in that embodied experience as opposed to what often happens, which is dealing with the external without sufficiently dealing with the internal. And so that's why sometimes going on the vacation or just reducing workload doesn't really end up with the results you would hope. Because if you haven't actually done the internal work you need, you're going to stay in overwhelm.

Dr. Jin: You just come back to more work once you're done with vacation. One more thing I wanted to ask, any other pearls of wisdom? You've already offered so many, but anything, any final thought to end on?

Dr. Hallam: I love what the mystic and poet Rumi says. He said, "Yesterday, I was clever, so I tried to change the world. Today, I am wise, so I am changing myself." It's really a plea to all of us. We cannot heal the world if we are deeply wounded. We really must put that oxygen mask on ourselves first, prioritize our health, our wellness as our highest expression of our care and compassion towards ourselves and towards all our patients and our loved ones. And if there is anything that I can do on your journey of healing, I'd be honored to support you on it. So reach out.

Dr. Jin: Wow. Thank you so much, Dr. Hallam.

Dr. Hallam: Thank you so much. I've been honored to have this conversation.

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