Burnout Compassion Fatigue, Secondary Traumatic Stress, Vital Exhaustion: Effects, Treatment, & Implications for COVID-19 (1 CE Credit)

Burnout Compassion Fatigue, Secondary Traumatic Stress, & Vital Exhaustion: Effects, Treatment, and Implications for COVID-19

(1 CE Credit)

Introduction By, Aaron Gubi, PhD

The special section this issue is intended to disseminate information regarding burnout as it pertains to psychologists, related health care workers, parents, and clients. In particular, the implications of COVID-19, as it pertains to compassion fatigue, secondary traumatic stress, and vital exhaustion and how they challenge healthy coping is assessed. The article concludes by examining psychological interventions and evidence-based practices that psychologists can utilize in their work with clients to prevent burnout and promote well-being. We thank Lorraine Gahles-Kildow, PhD, for her comprehensive examination of this topic in her article Burnout, Compassion Fatigue, Secondary Traumatic Stress, and Vital Exhaustion: Effects, Treatment, and Implications for COVID-19.

Aaron Gubi, PhD is a licensed psychologist and certified school psychologist. He is an assistant professor and serves as Clinic Director of Kean Psychological Services, the community training clinic for the Doctoral Program (PsyD) in Combined School-Clinical Psychology at Kean University. He also holds part-time positions with a private practice and an adolescent residential treatment facility, and currently serves as the editor of the NJ Psychologist.

Earn 1 CE credit when you read this article and complete the CE evaluation. Instructions for obtaining CE credit: Visit www.psychologynj. org and find the CE Homestudy Library link under the Learn Tab. What is Burnout?

“As a metaphor for the draining of energy, burnout refers to the smothering of a fire or the extinguishing of a candle.

It implies that once a fire was burning but the fire cannot continue burning brightly unless there are sufficient resources that keep being replenished.” (Schaufeli et al. 2009) Burnout as a concept has been around for several decades. In an overview of the concept of burnout, Schaufeli et al. 2009 trace the early history of this phenomenon. It was originally borrowed from a term used by drug addicts in the 1970s (Freudenberger, 1974) and was made more prominent when Maslach (1996) identified three distinct factors that comprised burnout. These factors were: 1) emotional exhaustion, 2) depersonalization, and 3) a reduced sense of personal accomplishment or efficacy (Maslach and Jackson, 1981; Maslach et al., 2008). At first, burnout was considered to occur only when working with people, especially in healthcare and human service occupations. Later, people began to realize that these three factors could occur in other occupations and research in organizations began to explore the concept that chronic stress on the job could result in burnout. The persistence of burnout as a phenomena was explained by Maslach et al. in

2009 as resulting from two prime factors. One, the progressive imbalance between work demands and the collateral lack of resources to meet the demands. The depletion of resources can occur at the external level, for example, lack of equipment, space, and or funding, and at an internal level, such as reduced opportunities to rest and replenish one’s energy and reserves. Another influencing factor suggested by Schaufeli et al. 2009, for the maintained experience of burnout, was a motivational one. As service fields became more corporate, a mismatch began to occur between provider ideals for themselves and their recipients and corporate values for the organization and its bottom line. Maslach and Leiter (2016) cite industrial psychology’s conceptualization as a form of job stress and use the term dimensions to explain the burnout experience. The exhaustion dimension produces behaviors like fatigue, lack of energy, and feeling debilitated. The cynicism dimension, originally called depersonalization, results in inappropriate behavior toward clients such as irritability, withdrawal, and negative attitude and loss of idealism. The inefficacy dimension replaces reduced sense of personal accomplishment and is measured by negative morale, an inability to cope, and low productivity. An additional aspect of this dimension seen in the healthcare field is medical error and malpractice lawsuits. One of the first measures of burnout, and one that is considered the standard assessment today, is the Maslach Burnout Inventory (MBI). It measures the three dimensions discussed above. A relatively recent development in the burnout area has been to design measures that capture the opposite experience of burnout, termed engagement. As stated by Maslach and Leiter (2016), engagement dimensions are reflected by high energy, involvement, and a sense of efficacy. Another measure, the Utrecht Work Engagement Scale assesses vigor, dedication, and absorption as a separate, positive experience at work.

Work Related Quality and Safety Cost in Healthcare Burnout

In a discussion paper by Dyrbye et al. (2017), they cite cross sectional studies done with US surgeons where error and malpractice claims were independently related to burnout. They further suggest that burnout and medical errors have a bidirectional, cyclical relationship. As burnout levels increase, the likelihood that errors are reported also increase. Additionally, when errors are reported, burnout tends to become worse. The level of burnout in nurses has been associated with more infections in patients especially in the ICU environment and both doctors’ and nurses’ burnout levels are associated with mortality ratios and teamwork reductions. Job dissatisfaction, turnover rates, and reduced work effort are all other aspects of the efficacy dimension that have been impacted by the burnout experience in healthcare workers.

The Personal Cost of Burnout

The personal cost of burnout is that it produces “real suffering among people dedicated to preventing and relieving the suffering of others” (Dyrbye et al., 2017). Studies have shown a 25% increased risk of alcohol abuse and a 200% increased risk of suicidal ideation in physicians compared to the general US population. Specifically, the suicide rate is 40% higher for male physicians and 130% higher for female physicians in the US compared to other workers.

Gender and Racial Diversity Issues

Templeton et al., 2019 found that there were genderbased differences in burnout, for example, female physicians reported more emotional exhaustion while men reported more depersonalization. Some of the gender-based issues faced by women included lack of role models, challenges of dual career couples, a finite number of years to bear a child, lack of parity in salaries, lower number of promotions, conscious and unconscious biases, and higher rates of experienced sexual harassment. Women physicians earned less money consistently throughout their careers and across specialties. In addition, women who became mothers experienced discrimination when pregnant and during breastfeeding resulting in limited opportunities for advancement and higher self-reported burnout. This study cites that 70% of women reported experiencing gender discrimination and they postulate that women in racial and ethnic minority groups may experience additional discrimination leading to feeling marginalized with a consequential decrease in self-confidence (inefficacy).

The prevalence of racial/ethnic differences in physician burnout has not been investigated as widely. Garcia, Shanafelt, West et al., 2020, sought to investigate this in a second analysis of a cross sectional study of US physicians from 2017 to 2018. Burnout was seen in 44.7% of Non-Hispanic White physicians, 41.7% in NonHispanic Asian physicians, 38.5% in Non-Hispanic Black physicians and 37.4% in Hispanic/Latinx physicians as compared to general workers in the population. The minority racial/ethnic groups of physicians were less likely to experience burnout as compared to the White physicians. This pattern seemed to be associated with less reporting of emotional exhaustion for the minority racial/ethnic groups. There were no reported differences with the depersonalization dimension of burnout. In addition, Black physicians reported more work life integration than White physicians. Depression and career satisfaction showed no significant differences along race or ethnic dimensions. Possible explanations suggested by these authors were: 1) stigma attached to selfdisclosure of burnout for minority/racial/ethnic groups, 2) inability to retain medical students from minority racial/ethnic groups, 3) a difference in resilience factors associated with being from a minority racial/ethnic group and a selection bias that favors those with resilience from these groups. One multi-institutional study reported that minority students showed resilience and recovered from burnout more than their White contemporaries. The authors suggest that there is a dearth of information about minority racial/ethnic differences and that further research will help to elucidate these possible explanations.

Cultural Diversity

When resources fail to keep pace with demands and when workers do not have the opportunity to rest and replenish depleted energy, organizational values create a conflict with individual values and one sees a motivational depletion in the individual in addition to energy depletion or exhaustion (Shanafelt et al., 2009). Even though work environments and national values differ across different countries and cultures, studies show that burnout occurs in Western and Eastern Europe, Asia, the Middle East, Latin America, Australia, New Zealand, Africa, China, and the Indian subcontinent. It seems that as countries develop with increasing work, productivity, and time pressure demands, burnout increases accordingly. Often, the term exhaustion is used and in some European countries, like Sweden and the Netherlands, burnout has become an “established medical diagnosis” (Shanafelt et al., 2009).

Burnout and its Relation to Secondary Traumatic Stress, Compassion Fatigue, and Vital Exhaustion

Much research has focused on the exhaustion dimension of burnout. Schaufeli et al. (2009) and Cieslak et al. (2014) note the overlapping definitions and measurement of the burnout experience as well as the evolving conceptualizations of exhaustion. Researchers have included physical exhaustion and mental and emotional exhaustion. Others add physical and psychological fatigue to exhaustion. Melamed et al., (2006) added vital exhaustion and cognitive exhaustion to the conceptual framework. These authors consider burnout the “depletion of individual energetic resources as represented by feelings of physical fatigue, emotional exhaustion, and cognitive weariness. This depletes coping resources and can result in physical illnesses, especially cardiovascular events. They propose that vital exhaustion is like burnout in that it is associated with work stress and it influences many other detrimental outcomes, such as increased irritability, sleep disturbances, and health impairments and disorders such as inflammation, immune, and metabolic disorders. They reason that chronic stress activates the hypothalamic pituitary adrenal (HPA) axis on an excessive basis. This then causes dysregulation of the HPA and therefore a dysregulated allostatic response which affects glucocorticoids (mainly cortisol) that has a regulatory role in whole body homeostasis, basal activity, and termination of the stress response. A dysregulated HPA tends to influence hypocortisolism (lack of cortisol availability) that can result in increased risk for autoimmune disorders, inflammation, chronic pain, asthma, and allergies (Heim et al., 2000 and Raison and Miller, 2003 as cited by Melamed et al. 2006). Thus, stress influences burnout and vital exhaustion that influences health disorders that serve as risk factors for cardiovascular events. Segerstrom and Miller, 2004 as cited by Melamed et al. 2006, found that chronic stressors were associated with suppression of cellular and humoral immunity, thus exhausted people were more at risk for reduced immunocompetence and prone to infectious diseases, such as upper respiratory and viral infections. Hobfoll (2000,) as cited by Melamed et al., (2006), suggests that in the early stages of burnout when active coping is still being used to replenish loss of energetic resources, anxiety often accompanies burnout, whereas, in later stages of burnout

depression is noted. This is based on the notion that one’s energetic resources like vitality and vigor can be used rapidly and are difficult to replenish. The authors suggest that organizational and individual psychological interventions are best in the early stages of burnout and vital exhaustion before physical health impairments set in. Within the context of direct and indirect exposure to trauma, the burnout construct is related to compassion fatigue and secondary traumatic stress. An overlapping conceptual framework allows one to address exhaustion and other factors related. Compassion fatigue is considered a type of burnout associated with caregiving. It captures the emotional components of caring, empathy, and emotional investment, which are beneficial to those who provide care, but can also have a cost (Figley, 2002). In particular, according to Figley (2002), compassion fatigue can limit our desire to care about and “bear the suffering of others.” Figley states that compassion fatigue is a “secondary traumatic stress reaction” that results in symptoms similar to Post Traumatic Stress Disorder: re-experiencing the trauma material, avoidance of trauma triggers or numbing of emotions, and heightened arousal such as anxiety. Cieslak et al. (2014), in a meta-analysis, found that there was a strong correlation between burnout and secondary traumatic stress with indirect trauma exposure, especially when it was measured within the framework of compassion fatigue. Other researchers questioned whether burnout led to secondary traumatic stress or vice versa (Shoji et al., 2015). These authors used a longitudinal design across two countries, the United States and Poland. They found that job burnout may predict secondary traumatic stress, but secondary traumatic stress does not predict burnout. The pattern was in one direction and thus burnout may be considered a “gateway” outcome that makes the risk of developing secondary traumatic stress more likely. These findings are related to conservation of resources theory (COR) (Hobfoll,1989, Shoji, 2015) that posits we only have a limited amount of resources to cope with ongoing stress and continual exposure to stressors lowers our reserve, resulting in secondary traumatic stress symptoms.

Burnout in parents

“The fact is that child rearing is a long, hard job, the rewards are not always immediately obvious, the work is undervalued, and parents are just as human and almost as vulnerable as their children. ---Benjamin Spock (2011, p. 5)” (Spock, 2011 as cited by Mikolajczak et al. 2019) Parental burnout has the same features of burnout, but the three dimensions are related to the parenting role. Parents can feel overwhelming stress about their parenting role and feel that they lack the resources to deal with it (Mikolajczak et al. 2019). This outcome coincides with the job-demand resources theory of stress (JD-R model) originally proposed by Demerouti, Bakker, Nachreiner, & Schaufeli, 2001, as cited by Schaufeli and Taris, (2014). The JD-R model suggests that high job demands with low resources leads to burnout and its consequent health impairments. The revised version of the JD-R by Schaufeli and Baker in 2004, added work engagement and vigor, dedication, and absorption as the positive counterparts to burnout (Schaufeli and Taris, 2014). In a study with French-speaking parents from Belgium, Europe, and outside of Europe, with at least one child at home, data showed that there are

three types of stressors that parents may experience: daily hassles, acute stressors, and chronic stressors. Daily hassles included things like homework, work schedules, school, and after school activity schedules. Acute stressors were family conflicts, angry reactions, and sudden emergencies. Chronic stressors were any emotional, physical, and learning disabilities in children (Mikolajczak et al. 2018). It is when the demand placed by risk factors outweighs the resources, parents have to cope with them, that parents are more likely to experience burnout. According to Mikolajezak et al. 2019, when this imbalance occurs, one sees extreme exhaustion and detachment (emotional and possibly physical) from one’s children and an insecurity (inefficacy) about whether one is able to be a good parent or not. Just the fact that you are experiencing stress does not mean that you are experiencing burnout. It is chronic, overwhelming stress that influences the definition of parent burnout (Mikolajezak et al. 2018, Mikolajezak et al. 2019). Parental burnout and job burnout can be separate experiences. One can be burned out from the job, but not have burnout with their children (Mikolajczak et al. 2019). Mikolajezak et al. (2018) found that there were three important risk factors that correlated with burnout. These were: 1) stable traits of the parent, 2) parenting, and 3) family “(dys)functioning.” The authors obtained weighted estimates associated with each risk factor. In the stable trait of the parent, they found a strong negative correlation between burnout and emotional intelligence (-.79) suggesting that as emotional intelligence increases parental burnout may decrease. Neuroticism (a personality trait measure) showed a positive correlation with burnout (.53) while an avoidant attachment pattern also showed a strong positive correlation (.42). One’s parenting style also has an effect. Positive parenting and self-efficacy beliefs showed a strong negative correlation -.62 and -.82, respectively. This suggests that interventions in self efficacy and promoting positive parenting styles may protect against parent burnout. In the family functioning factor, four variables were measured: exposure to conflict (.56), co-parental agreement (-.59), marital satisfaction (-.73), and family disorganization (.87). These correlations show that treatment targeting families in reducing conflict and disorganization while increasing agreement between parents on parenting practices may help in mitigating against parent burnout. An interesting original finding about their research in risk factors was that sociodemographics, for example, being a single parent, having very young children, being in an inadequate living space, or having financial difficulties, did not show any significant correlations in their preliminary studies. The upside of this finding is that the significant correlations found were with variables that can be changed through psychological intervention. The authors suggest that intervention studies should focus on “improving emotional competencies, improving adult attachment, improving marital satisfaction, enhancing coparenting agreement, and promoting positive parenting practices.” Mikolajczak et al. 2019 investigated “escape ideation (ideas of running away or committing suicide), child neglect, and parental violence” as consequences of parental burnout. They used two cross-lagged longitudinal studies, one in a French cultural context and the other in an English cultural context to determine a relationship. The results showed that parental burnout had strong associations with escape ideations, neglect, and violence at all the times measured and across the two cultures. The authors suggest that more research is needed and that parental burnout may be a risk factor for child abuse and neglect. Identifying parent factors may pave the way for early intervention so that these adverse outcomes can be prevented. With regard to parent factor characteristics, a study was done by Hubert and Aujoulat (2018) investigating parent exhaustion from five different mothers in five different cities in Belgium. Although the method was phenomenological interpretative analysis, it is included here to provide some additional insight into the parenting risk factor for burnout along the exhaustion dimension. Two in-depth interviews were performed at two separate times for each subject and the following themes emerged: overinvestment with perfectionistic standards and self-pressure, along with a fear that they were not good parents. They also reported a fear that everything they did now would affect their child’s future (projection). These overarching fears led to exhaustion that seemed to lead to emotional distancing and were described as robotic like behavior towards their children. They then began to lose control with their children verbally but, in this group, they did not physically hit their children. This led to a change in their self-identity comprised of selfhate, shame, guilt, and loneliness. These mothers did not ask for help, but, once they were able to identify,

express, and manage their emotions, they had a better understanding of the burnout experience and were more open to talk about it. The authors suggest that interventions that facilitate emotional competence and emotional intelligence may help mitigate against this type of inefficacy dimension of parental burnout.

Implications of COVID-19

COVID-19 has certainly taken a toll on healthcare workers, and, presumably their levels of burnout, compassion fatigue, secondary traumatic stress and vital exhaustion have been affected.

Previous research on burnout suggests that US physicians were already experiencing burnout before COVID-19. Shanafelt et al. 2015 found that more than half of US physicians compared to US workers in general reported experiencing at least one burnout symptom and dissatisfaction with their work life balance. This was an increase seen from their research in 2011 that showed that less than half of the US physicians reported burnout. A significant percentage (about 46%) reported high emotional exhaustion, while about 34% had high depersonalization, and 16% showed low personal accomplishment scores on the Maslach Burnout Inventory (MBI). The rates of depression 39% in 2014 vs. 38 % in 2011 and suicidal ideation 6.4 % in 2014 vs. 6.4% in 2011 stayed the same. Physician specialties reported different percentages of burnout with the highest burnout occurring in the Emergency Medicine field. In a review done by Balasubramanian et al. (2020), they found that workers in the healthcare field in Wuhan, China, were overwhelmed by being thrust into an unfamiliar situation with high risk. This resulted in high levels of distress and depression. Research done on healthcare workers on the frontlines in Wuhan, reported anxiety, stress disorders, and depression. Further, mental health impairments were prevalent across all participants, but in different degrees, for example “subthreshold 36%, mild 34% moderate 22% and severe 6%.” These healthcare workers used different coping strategies “perusing psychological resources (36.3%), accessing digital psychological recommendations (50.4%), and participating in therapeutic support (17.5%).” It was hypothesized that workers who were severely distressed were less likely to obtain resources to cope. Of note here is that the largest percentage of use of coping resources were from digital psychological recommendations as opposed to therapeutic support. In a recent study of frontline healthcare workers in the United States, it was found that physician trainees who were exposed to COVID-19 patients reported more stress and burnout than a non-exposed group. In addition, they reported moderate to extreme stress with regard to childcare and a lower work life family balance. Females were more likely to be stressed while unmarried trainees were more likely to be depressed and anxious. (Kannampallil, T.G. et al., 2020) Despite being a vulnerable group, very few trainees took advantage of the mental health support services that were available to them at the workplace. A brief article by Liang, Zhu, and Fang (2020) gives us some information about the post-traumatic stress response and COVID-19 that may inform us about the possible secondary traumatic stress responses. The authors from Wuxi and Shanghai, China, hypothesize that there is a circular relationship between PTSD from the stress of COVID-19 influencing immunosuppression that, in turn, influences one’s susceptibility to COVID-19. They suggest that PTSD shows two phases with regard to the stress response. In its early stages, there is acute stress and a subsequent increase in the immune response, however, when the stress becomes chronic, one sees a suppression of the immune response that then can lead to increased susceptibility to infections, particularly respiratory viral infections, like influenza and pneumonia (Song H, Fang F, Tomasson et al. 2018; Yang et al. 2020 as cited by Liang, Zhu and Fang 2020). This research corroborates with the physical pathways and outcomes stated in the Melamed et al. (2006) study. Parents also have been impacted by the quarantine that made them take on multiple roles all at once, making sure their children were attending Internet-based classes, doing their school work plus homework, all the while performing their own full-time work at home, along with their usual parenting duties. The American Psychological Association’s Stress in America Report pertaining to stress in the time of Coronavirus states that “American parents are, on average, feeling significantly higher levels of stress than adults without children.” About 71% of American parents say that managing online learning for their children is a major stressor, while 67% of American parents state that the government’s response to COVID-19 is a source of stress (Mental Health Weekly, 2020). Additionally, parents also labeled inadequate access to healthcare, change in routines, food and housing access, and self-isolation as significant stressors. People of color have also reported that they feel “constant” stress about “getting the virus,” as well as “getting their basic needs met and having adequate access to healthcare.” Fontanesi et al. (2020) examined the effects of the lockdown of COVID-19 on parents in Italy. The outcomes they describe may be generalized to US parents. The lockdown has increased parent stressors, such as managing frequency, duration, and outcomes of children’s schooling, financial worries, anxiety about social isolation of themselves and their children due to lack of peer and teacher support, and concerns about physical health and how to present accurate information of COVID-19

in an age-appropriate manner. Loss of security, predictability of the lockdown and disease course, and immobility are all factors that can contributed to detachment and distancing by parents. For those with pre-existing mental health problems, these conditions can be exacerbated. Not all parents are able to address their children’s educational needs, especially for those children with disabilities. Research has shown associations between parents’ mental health and their parenting practices, for example, parents’ “lack of confidence in their parental role, high stress, too much or too little discipline, more frequent use of punishments, and verbal hostility.” The authors suggest family interventions should address certain key issues: safety, distress, dysfunctional coping strategies, and negative parenting behaviors. In addition, therapists should promote and enhance hope, social connectedness, self-efficacy, and psychological well-being.

Possible Interventions for Burnout, Compassion Fatigue, Secondary Traumatic Stress, and Vital Exhaustion Positive Lifestyle

Balasubramanian et al. (2020) suggest that coping strategies can include positive lifestyle interventions, such as regular quality sleep patterns, eating healthy meals, and getting physical exercise. Research has shown that having a positive attitude and seeking family and peer support are healthy coping mechanisms.

Mindfulness

A before and after design study by Krasner et al. 2009 provided an intensive education program to primary care physicians that included mindfulness, communication, and self-awareness training for eight weeks with 10 months of maintenance. They found that improved mindfulness decreased emotional exhaustion and depersonalization, but increased personal accomplishment. They also saw an increase in empathy, conscientiousness, and emotional stability. Luken and Sammons (2016), in a systematic review of mindfulness practice and job burnout, found that job burnout was decreased in six of the eight studies investigated following mindfulness training.

Cognitive Processing Therapy For PTSD

An article by Moring et al. (2020) cites practical applications of delivering cognitive processing therapy through telehealth modalities. Previous research had established that cognitive processing therapy delivered via telehealth was equally as effective as in-person therapy. Cognitive processing therapy is a subtype of cognitive behavior therapy where one uses psychoeducation about trauma, focusing on one’s “stuck point” in cognitions or “problematic beliefs,” and examining the impact of their view of the world, themselves, and others as a result of the trauma. Cognitive strategies are then

used with common themes related to trauma, such as “safety, trust, power and control, esteem, and intimacy” (Moring et al. 2020).

Progressive Muscle Relaxation

Research conducted by Liu et al. 2020 in patients with COVID-19 in social isolation in Haikou, China, showed that practicing progressive muscle relaxation 30 minutes a day reduced anxiety and improved sleep quality. This was a randomized controlled clinical trial. It was performed as an alternative to using benzodiazepine-type drugs for sleep and anxiety reduction that have the potential to create respiratory depression in already compromised patients.

Possible Positive Psychology Interventions for Vital Exhaustion Cardiac Events, Immune System Issues and to Increase Vigor, Vitality, and Engagement

Fredrickson et al. (2000) showed experimentally that inducing positive emotions following a stressful event can bring cardiac reactivity back to normal faster than if one experiences a negative emotion or a neutral emotion. The authors called this the “undoing effect” of positive emotions. Another positive effect of inducing positive emotions for mental, emotional, and physical health is that positive emotions serve a “broaden and build” function in providing cognitive, psychological, and biological resources to us. Specifically, positive emotions can broaden our cognitions so that we can perceive in an expanded way, seeing broader and more divergent alternatives “pathways thinking” thus being able to problem-solve and cope more effectively “broad minded coping.” The build aspect of positive emotions results in gaining more ego resilience and having more social connections “bonding” that enhances more “purpose” in living. Finally, we also build biological resources by increasing cardiac vagal tone that increases the regulation of the cardiovascular system, and positive emotions have shown decreases in inflammatory cytokines involved in inflammation (Fredrickson, 1998; Kok et al. 2013; Fredrickson et al. 2008; Stellar et al. 2015). In a comprehensive review article done by Fredrickson (2018) called the Biological Underpinnings of Positive Emotions and Purpose, she cites research studies that show that negative conditions or stressors can increase the expression of genes involved with inflammation and decrease gene expression of antiviral responses and IgG synthesis. Positive emotions and a sense of purpose can create an inverse to that gene expression profile, that is: lower inflammation and increase antiviral response possibilities. Similarly, in a study done using a lovingkindness meditation (LKM) group versus wait list controls, the LKM group showed increases in cardiac vagal tone (CVT) a prognostic indicator of good heart health. Oxytocin (produced by such positive emotions as love) has been associated with reduced inflammation, increased pro-inflammatory cytokines, increased CVT, and decreased hypertension. Fredrickson calls this a “vantage resource” because it enhances the emotional rewards of meditation and makes us more responsive with positive emotions to social connections. Intranasal oxytocin vs placebo showed an increase in reports of spirituality (same day and 1 week later) and a boost in positive emotions when engaged in LKM and mindfulness meditation. This was pronounced especially with awe, gratitude, inspiration, and love. Positive well-being that incorporates positive emotion, positive affect, and optimism, has beneficial effects on mental health and flourishing and physical health. There are two types of positive well-being: hedonia, a pleasure in attainment of happiness or satisfaction, and eudaimonia, a deeper well-being due to meaning & purpose in life. In a review on well-being and its relations to physical health, Sin (2018) found that positive well-being was protective against incident cardiovascular disease, secondary cardiac events, and mortality. These were partially mediated by better health behaviors such as physical activity, medication adherence, sleep, diet, and non-smoking. However, positive well-being was also associated with better immune, neuroendocrine, and cardiovascular functioning, in addition to less stress reactivity and healthier coping skills. Sin concludes that “Interventions to enhance positive well-being or to sustain well-being in the face of stress may have the potential to promote favorable physiological functioning, optimal health behaviors, and downstream cardiovascular outcomes.” In conclusion, burnout, compassion fatigue, secondary traumatic stress, and vital exhaustion share overlapping effects on our mental, emotional, and physical well-being. COVID-19 has tested us in many ways and has exacerbated the above conditions, especially healthcare worker burnout and parent burnout. It is important to recognize these conditions and realize that there are interventions that can help us overcome these adversities and even enhance our ability to flourish in these trying times. ** some of the original sources used were presented with Dr. Nancy Gahles at the Integrated Healthcare Symposium in NYC February 2018 “Burnout Syndrome” and in 2019 “Compassion Fatigue Vital Exhaustion: a matter of the heart.”

References Furnished Upon Request About the Author

Lorraine Gahles-Kildow, PhD, is a licensed psychologist in NJ, in private practice for 21 years as a cognitive behavior therapist treating adults, teens, and children with issues related to Trauma, PTSD, Compassion Fatigue, Burnout, Anxiety, OCD, Depression and other disorders. Former adjunct professor and adjunct instructor at Raritan Valley Community College and Union County College and former Instructor at Princeton Center for Teacher Education for 20 years.