Taking Care of Others (Without Exploding into a Thousand Bits)

“For as long as a single being remains stuck in the cycle of suffering, I will continue to do everything in my power to rescue and benefit others.” This, in a nutshell, is the vow of the bodhisattva, the individual whose entire focus is the happiness and, ultimately, liberation of all. Quite the commitment.

In my tradition, Tibetan Buddhism, inspiration may be found in the example of Avalokiteshvara, the Bodhisattva of Great Compassion. One of his many incarnations has 11 heads and 1,000 arms with an eye in the palm of each hand. Why? Well, while manifesting in a more moderate form, he takes the bodhisattva vow (“…and if I ever break my oath, may my head and my body break into a thousand pieces…”), guides countless beings to liberation, and, according to one account, has just succeeded in emptying the realms of great suffering of their inhabitants and is feeling pretty good about life. Until, that is, he happens to have another look and sees that those realms have already repopulated. There’s just as much suffering as ever.

Disheartened, he thinks, “There’s no point. I might as well go have a holiday in nirvana,” whereupon his head and body explode into a thousand bits. In his moment of doubt he broke his vow: he considered leaving all those beings to their fate. Fortunately, his master, Buddha Amitabha, patches him back up into a higher-octane bodhisattva form and he goes on helping all who need him and always will. Now, with his myriad arms he can grace all beings with his touch; with those many eyes he sees exactly what they need.

But before he became super-bodhisattva, he had a burnout moment. Or maybe, because he had a burnout moment and had to drop his expectations about actually succeeding in alleviating the totality of suffering in the universe, he deconstructed and, with help, reappeared as a super-bodhisattva.

Avalokiteshvara’s burnout is easy to relate to. In psychology, burnout is most often defined as a three-phase depletion that unfolds as emotional exhaustion, or not feeling up to caring for others; depersonalization of those one is committed to helping; and a reduced sense of personal accomplishment or agency. According to social psychologists Christina Maslach and Michael Leiter, “Burnout is the index of dislocation between what people are and what they have to do. It represents an erosion in values, dignity, spirit, and will—an erosion of the human soul.”

Burnout is especially prevalent in the helping professions—think health care providers, teachers, therapists and counselors, case workers, keepers of the peace, clergy, attorneys (immigration law, for example), nannies and elder-care companions, and everyone else whose calling is to nurture, protect, cure, solace, or guide. Our deep commitment to others requires that we put their needs before our own, and this is precisely what gets many of us out of bed in the morning.

But the current social and political context seems designed to thwart our best bodhisattva intentions, adding an extra layer of stress to already-challenging vocations. Avalokiteshvara may have had to alleviate the entire mass of suffering of the six realms, but at least he didn’t have to deal with tone-deaf administrations, hours of documentation, endless meetings, the threat of litigation, insufficient resources, or office politics.

Take health care. According to a recent article in the New England Journal of Medicine, the majority of physicians burn out at some point during their careers, and numbers are high for other clinicians as well. “The health professions are at a critical inflection point. The health system cannot sustain current rates of clinician burnout and continue to deliver safe, high-quality care,” the authors write. Characterized by practitioner dissatisfaction, high staff turnover, exhaustion, increased risk of error, and personal distress, burnout is now considered a public health epidemic.

So how can we answer our callings as caregivers, protectors, and guides while retaining our capacity to give of ourselves? How do we maintain our resilience: our ability to adapt to challenges and bounce back? To reassemble those shattered bodhisattva pieces and keep going?

Understandably, most institutional programs that address burnout-resilience issues focus on self-awareness and self-care. But as my niece Izzy, a pediatric resident at a top children’s hospital, puts it, “Out of ten hours here, we generally spend one doing direct patient care, which we love, and six documenting, which no one likes, then we’re offered workshops that are supposed to boost resilience. The onus is on us to make the most of a dysfunctional health care system and feel good about being doctors.” Touché. As a chaplain, the deepest feelings of stress, inadequacy, and frustration I’ve experienced have not been linked with the job, which I love, but with unsupportive—even soul-sapping—work environments. It’s an all-too-common story across the helping professions.

To my mind, the most effective path to resilience might include a better understanding of how burnout happens, training in on-the-spot awareness, learning when and how to take care of oneself, and a long-overdue organizational wake-up. Although the last point may not be, the first three are generally within our reach.

Thankfully, some organizations are looking at all aspects of the question, including systemic dysfunction. I spoke with the University of Virginia School of Nursing’s dean emerita, Dorrie Fontaine, about resilience and the helping professions, particularly in healthcare. In 2008, during her first year as dean, Fontaine attended Roshi Joan Halifax’s Being with Dying training program for health care professionals at Upaya Zen Center in New Mexico. “It was life-changing, and it shaped how I led the school. It was about dying, but it was really about stopping your life and thinking about how you could make the most meaningful contribution,” she said.  

Fontaine agrees that changes at the structural level have become imperative, and she firmly believes that resilient, compassionate people can be empowered to lead beyond organizational barriers. She has worked with other innovators in the field to explore compassionate care within a design thinking approach. “We’re advocating and demanding, ‘What is a compassionate organization? What does it mean to be a mindful leader? How should we do things differently? But there’s a lot of acknowledgement that the issues are the same and we’ve been talking about it forever.”

Dean Fontaine’s vision is behind the School of Nursing’s Compassionate Care Initiative (CCI), which she started a decade ago “to cultivate a resilient and compassionate healthcare workforce—locally, regionally, and nationally—through innovative educational and experiential programs.” They offer mindfulness (now on pre-retirement sabbatical, Fontaine attended 6:00 a.m. meditation weekly for ten years), yoga, writing retreats, and a variety of other programs dedicated to helping students be their best, most resilient selves. Given the breadth of CCI’s offerings, I wondered what Fontaine found most beneficial. The first thing she said was, “Connection. Connecting people, listening, being present.” Then she added, “These days I’m distilling all of this work down to paying attention, and pausing. Just two things, and it’s really helping. Nobody is saying it’s too simple. Instead of having people meditate for whatever length of time, I’m telling them, well, what about one breath? One deep breath.”

To understand something about the mechanics of burnout, I spoke with Dr. John Schorling, who heads the Mindfulness Center at the University of Virginia’s School of Medicine. He said that students in medical school and other health professions tend to start out with a lot of empathy. Physiologically speaking, Schorling explained, empathy has its roots in mirror neurons that allow us to experience and understand others’ emotions, which is how empathy is defined. But for those of us who are constantly working with people who are suffering, especially emotionally, the blurring of self and other can snowball into empathic distress, secondary traumatic stress, and burnout: the helper’s “cost of caring.”

Mirror neurons are bound to be activated when we work with emotionally difficult situations. Mindfulness, especially of what’s going on in the body, allows us to be aware of the impact that these situations are having on us. “Two things arise out of that,” Schorling said. “One is that as soon as we notice it, there are explicit choices we can make. Instead of ‘I’m having an emotion I don’t like and I’m going to leave,’ the dynamic changes to ‘Oh wow! This is difficult! What’s the most skillful thing to do in this moment?’ It might actually be to recognize, ‘This is overwhelming. I don’t think I can be of much use if I stay, so I’m going to step outside and take a few breaths.’ The second thing is that we can acknowledge that this is hard work, and it’s okay to have compassion for ourselves too.

Instead of beating ourselves up about it, he said, we can recognize our need to take care of ourselves, and meditating regularly helps. “It’s with mindfulness practice that we learn to really stabilize attention, to be aware of what’s arising in the moment, and stay open to it. Mindfulness lays a foundation and builds our capacity to tolerate suffering and stress. And compassion practices—tonglen and lovingkindness practices, for example—enhance our capacity to be with others who are in distress. The more we practice compassion [on the cushion, the more our practice] increases our resilience and capacity to be with suffering without burning out.”

I appreciated Dr. Schorling’s reminder that it was acceptable—even critical—for helpers to take care of themselves, too. When I was a chaplain resident, I knew that if I didn’t, I was going to fizzle out. Whenever possible, I gave myself time for lunch in a space that was as quiet and as far from the office as I could find, preferably outdoors. And I sought out a wonderful masseuse and warned her that during treatment I probably wouldn’t want to talk, and might need to cry. She understood perfectly—it so happened that her father had been a military chaplain.

Taking care of ourselves gives us the juice we need to keep caring for others without exploding into a thousand bits. Happily, we two-armed mortals don’t have to be super-bodhisattvas—when we’re able to keep our balance and muscle our resilience, everyday bodhisattvas like us bring plenty of light into the world.

Tips for Avoiding Burnout

In addition to regular spiritual practice, healthy eating, spending time in nature, and other self-care fundamentals, here are a few ideas that helpers might find helpful:

• Before seeing the next patient or client or entering the next over-populated, chaotic classroom, make a habit of taking a few deep breaths, focusing, and recalling your purpose. Give yourself a minute to fully arrive.
• Check in with your body. Note tension, observe it with kindness and/or invite it to dissolve. (Personally, this plus a moment of compassion practice really helps me center and be present for patients dealing with illnesses that might trigger a repulsion response.)
• On the job, find your ritual, recite a short poem, practice your mantra, pray. An inspiring palliative care physician I know says that taking extra time to wash his hands deliberately and with mindful awareness between patient visits allows him to put one situation aside so he can enter the next one with freshness and goodwill.
• Keep a gratitude notebook or simply count your blessings when greeting the morning and/or turning in at night. Find something to be grateful for even when times are rough. You might take an extra step and mentally (heartfully) share the blessings with others.
• Decide to spend some of your free time unplugged, and actually do it. Work as usual; deal with emails, phone calls, exercise, food, and errands as needed—and spend the rest of your time meditating or reading something that supports your practice. No non-essential internet, no social networking, no news, no entertainment for a full day or (much) longer. Ah, bliss!
• Use low points to reflect and reassess. Can anything be done to make this situation more supportable? Sometimes the answer is no. If your ability to stay sane and healthy is on the line, remember that there are lots of ways to brighten up others’ lives. When a doctor friend whose take-a-breather passion was chocolate confection had truly had enough of the hospital, she left medicine and started a successful artisan chocolate business.
• And yes, connect—even bodhisattvas network. It may be a debriefing with trusted colleagues or dedicated time with a community, a counselor, a friend, or a mentor. Just think, if it hadn’t been for Amitabha, Avalokiteshvara may well have stayed shattered forever.

♦

This article was originally published on August 20, 2019.