This post is part two of Nari Clemon's series on practitioner burnout, compassion fatigue, and the story of a pelvic rehab therapist who struggled to care for herself while caring for patients. Read part one here.

There is a point where caring so much and wanting to help becomes counter-productive to us, until we burn out. We can develop true compassion fatigue. Compassion fatigue makes us feel apathetic, spent, and sometimes even jaded or cranky. But, how do we turn that caring off in time? Our compassion is what led us to this field in the first place.

That day, I talked to my colleague and close friend, whom I was teaching with, Jen VandeVegte. Jen and I both felt that conversation was a wake-up call. We talked about seeing this same scenario at our courses: so many amazing therapists getting spent, and our best therapists getting burnt out. People were coming back with enhanced skills course after course, but many of them were looking weary and tired...

In the prior years, Jen and I were both trying to be mindful and intentional. But, it hadn’t been enough in our own lives. I remember thinking, “I’m mindful I’m getting drained and there is a creeping sensation of fatigue as I am working with this patient. Now what?” There seemed to be some pitfalls many of us were getting trapped in. We noticed there were certain patients who drained us more: when the role was therapist as hero and patient as victim. There were themes of not being able to leave the patient stories at work, finding ourselves laughing less, being less adventurous. There also seemed to be a link with empathy. Those of us who were more empathic carried burdens differently than our more concrete minded peers.

For myself, I had to hit bottom to learn how to climb back out. It got to the point where I didn’t honestly want to go to my thriving private practice and treat patients. I was treating more and more complex patients and leaving work drained, despite having a repertoire of advanced skills. I remember consulting with many people trying to understand how to stop this process of my patients’ illnesses and moods bleeding into my space and my body. People told me all kinds of things: “Imagine wearing gloves that are impenetrable”, “Picture a plexiglass box around yourself”, or “Just decide it is a one way flow.” None if it worked for me. I studied Reiki and worked with therapists. Still, I was so spent after treating patients. When I moved from Indiana to Portland, I took a whole year off of work with a singular mission: get healthy and figure out how to stay that way in my work. There was no book on this. There were some crazy stories and consults that made me realize I was heading in the wrong direction, and I finally learned the key concepts that changed my life.

And oddly enough, my great friend, Jen, also had to transform. We talked honestly and shared our failures, fears and successes as we learned. We committed to being real and honest about what parts of us were stuck in old, unhelpful paradigms. Some of these were playing the hero, feeling like there should not be limits on our compassion, not holding boundaries with what was ours to own, facing difficult things within ourselves, learning how to deeply own the space in our own bodies, and accepting that as intuitive, empathic women, we can’t expect ourselves to reproduce a very masculine, directive method of treating that denies so much of who we actually are. We also changed how we dialogued with patients from the outset. We read and researched and learned how to apply a shared responsibility model from the first contact with our patients and how to hold that model during the course of care. We then applied more pain theory and how to educate patients on those aspects of their own recovery to encourage a model of mind-body wellness and responsibility for their own reframing with our guidance. I created a mediation for pelvic health CD, so patients had a clear way to practice these home programs.

Jen and I both found that as we healed and re-framed there was a great freedom and honesty that emerged in our lives and our practices. We would get together to teach Capstone and were filled with gratitude for how much had shifted and that work no longer felt like a burden. Our lives were more balanced and we were physically, mentally and emotionally stronger. We felt like we had found the holy grail of balanced practices.

But, there we stood, teaching so many of our peers who were clearly in the same quicksand that had been plaguing us in the past. Where could our colleagues who were at our series courses go to learn how to do this job and navigate their days differently? How could they feel as good at the end of the day as they did before they saw patients? This was the training many pelvic therapists needed to thrive in this field AND their life, but it had taken us so many years. This was our call to action.

We all take courses on how to help our patients and how to reach those few difficult patients and help them. Yet, as medical professionals, we do not have enough training in how to care for ourselves. At some point, we all need to realize that our care is as important as our patients. Our wellness, physical, mental, and emotional also matter and may actually be necessary to keep helping patients. Enjoying our lives is no less important. It is an investment in your family, your future patients, and yourself to take a few days to peel back and deeply examine the root of why work is so taxing and come up with a clear, individualized plan to take your life, joy and passion back…without leaving pelvic rehab.

We need all of you in this field. We want to help you stay in this field and stay in it well! Please come join us in Boundaries, Self-Care and Meditation for a retreat-like weekend to change the framework of your practice and commit to your own wellness as a provider. Come learn how to shift dynamics from your first interaction with patients and how to hold that space. You are worth it!

Last year, I was teaching our Pelvic Floor Series Capstone course. It was the end of day three of the course. Most, students were thanking us for a course that filled in so many gaps in their practice and taught them a whole new way to use their hands. They were feeling energized and excited to bring all the new information back to their patients who had plateaued, so this was a surprising and atypical comment. To those of you who are unfamiliar with Capstone, it is a course for experienced pelvic therapist who have already taken three of the series courses, and it was written to address truly challenging patients, to learn to problem solve with manual therapies, to address all the things that my co-authors and I wished we had known five years into our field. It teaches complex problem solving and more receptive and dynamic use of their hands. So, usually, by this course, therapists are fully committed to this field and geeked-out to get so many more pearls. They are usually on board and looking for more sophisticated tools.

As one student, Soniya (name changed) was walking out, she said, “I took this course to figure out if I want to treat pelvic patients, and I definitely don’t. It confirmed what I already knew about pelvic rehab being wrong for me.” I was so confused at that point. All I could say in that moment was, “Can you please tell me more about that? I’m interested.”

Soniya went on to explain that she used to be a pelvic therapist. She said she loved it at first. But, she got so enmeshed with her patients and found she stopped having energy for the rest of her life: her kids, her health, her own enjoyment. She said she would go into her “dark cave” treatment room with her patients, isolated with them one at a time, and come out spent and depleted at the end of the day. She clarified that it was rewarding helping people so profoundly, but there came a point when she had to choose between helping others and saving herself. She changed back to outpatient ortho, choosing to treat in the gym, dynamically interacting with other PT’s all day and not being one-on-one in a room with patients and her problems. She also changed to part time, stating she just couldn’t be around patients five days a week anymore.

I understood. I totally got it. I hear this all the time at courses from other pelvic PT’s: that they love what they are doing, and they feel called to this line of help, but ultimately, they are depleted. I have been there. Pelvic rehab can get to be a little confusing with all the blurred lines. There are so many boundaries that are different. We ask our patients questions normal PT’s don’t. We do treatments in areas that other therapists don’t normally touch or see. We are one on one in a private room with our clients. We know more private details about our patients than most of their friends and family. And…we care deeply and listen intently….sometimes many hours a day to stories of other people’s pain, fears, and stress. Often, we are a lone pelvic practitioner in a practice with other kinds of PT’s. Let’s face it, our colleagues who don’t do pelvic rehab think we are a little weird! With HIPPAA, we can’t talk to our coworkers about our heart wrenching stories. We are also not trained psychologists, and our training in PT school really didn’t address how to deal with all we face in a day, especially the psychological aspects.

A recent study found nursing students show compassion fatigue before they even graduate and that “Therefore, knowledge of compassion fatigue and burnout and the coping strategies should be part of nursing training”. Yet, as pelvic therapists we are taught to recognize signs of trauma in our patients, but we are not yet taught how to stop ourselves from being traumatized.

I asked “Soniya” if it had worked for her: changing back to outpatient ortho and going part time. She said it had for the most part. She felt she had her life and energy back for the most part.

So, I asked “Soniya” how she landed at Capstone? What brought her here? It turns out her boss had asked her to come to Capstone and consider going back to pelvic rehab. So, she came and heard about all kinds of problem solving and new research with very complex patients at Capstone: cancer, multiple surgeries, systemic inflammation, endometriosis, and even gender affirming/change surgeries. She learned about complex hormonal issues, pharmacology and anatomy she hadn’t ever considered as an experienced pelvic therapist. She spent around 10 hours that weekend in lab, learning new ways to use her hands to make change. At the end, she said the thought of going “back in the cave” with such complex patients and having her hands on them all day long was draining to her. She just couldn’t go back.

There is a point where caring so much and wanting to help becomes counter-productive to us, until we burn out. We can develop true compassion fatigue. Compassion fatigue makes us feel apathetic, spent, and sometimes even jaded or cranky. But, how do we turn that caring off in time? Our compassion is what led us to this field in the first place.

This post is a two-part series on practitioner burnout and compassion fatigue from faculty member Nari Clemons, PT, PRPC. Nari helped to create the advanced Pelvic Floor Series Capstone course, which is available several times each year. Nari is also the author and instructor for Boundaries, Self-Care, and Meditation, Lumbar Nerve Manual Assessment and Treatment, and Sacral Nerve Manual Assessment and Treatment. Stay tuned for part two in an upcoming post on The Pelvic Rehab Report!

Mathias CT, Wentzel DL. Descriptive study of burnout, compassion fatigue and compassionsatisfaction in undergraduate nursing students at a tertiary education institution in KwaZulu-Natal. Curationis. 2017 Sep 22;40(1):e1-e6. doi: 10.4102/curationis.v40i1.1784. PMID: 2904178