Marylayo: Welcome to Marylayo Talks, a podcast
that discusses mental health and spiritual
Before we jump in, there may be episodes that
are particularly sensitive for some listeners.
And if that applies, then I hope.
Marylayo: You'll be able to join me whenever.
Marylayo: You feel ready and able.
Today's episode is on caregivers, and I'm with
guest professor Dale Larson.
Professor Larson is professor of counseling
psychology at Santa Clara University in
He's also an award winning author, a national
expert on grief, burnout and resilience.
So I asked him about the challenges that
healthcare workers and other caregivers
experience and how they can stay well
Let's join in the conversation.
Marylayo: How prevalent is burnout among first
line healthcare workers?
How prevalent is it?
Professor Larson: It's very prevalent.
World Health Organization has now recognized
it as a phenomenon of great importance.
In a recent interview, the president of the
National Academy of Medicine said that before
COVID about 40%, maybe up to 50% of doctors
and nurses were reporting burnout, distress
Since COVID the figures have risen to 70% to
Now, it's hard to get exact figures on this,
but a high percentage of health professionals,
and I think helping professionals in general
experience significant amounts of burnout.
And this is a real issue for us in today's
world because we need helping professionals
who are not burned out to help everyone who is
So what are the unique challenges then, like
psychosocial risk factors?
What are the challenges that caregivers
encounter that actually impacts their mental
Professor Larson: Well, doing this kind of
work asks a lot of us.
It asks us to be present to suffering.
It asks us to be pretty vulnerable because we
are human beings doing this work.
There are extreme demands that are placed on
I'm thinking mainly doctors, nurses, social
workers, clergy who are working with people in
oncology hospice and general medicine.
And there's so many difficult experiences that
people have doing this work.
There was a survey of end of lifeprofessionals, over:
are your major stressors?
And they reported two things which I found
Number one was they thought overwork too many
Number one, stressor, which is not surprising
in COVID, things were absolutely outrageous.
And just recently there was a report in the
United States of 100,000 nurses leaving the
So that's a pretty good sign.
But their number two stressor, which I found
really intriguing because of my own background
and interest, is that they said we don't have
time to grieve.
So those professionals working with dying
patients, or with everyday patients who become
ill and die, they found the lack of
opportunity to grieve.
So that's why we have more emphasis now on how
do we address that need, how can we provide
opportunities for people to talk about their
experiences as caregivers in these situations?
We have Schwartz rounds in healthcare.
We have various efforts to kind of build in
opportunities to talk about our experiences.
If you're working in a high mortality
saturation environment, how do you take time
as a team or as an individual to grieve the
loss of this patient for whom you were in a
very intimate relationship?
Marylayo: So let's take it maybe back a little
bit in the sense of what are the signs that a
caregiver, whether they're professional or
even voluntary caregiver because they're
caring for a loved one, what are the signs
that they are actually facing burnout?
Professor Larson: Well, burnout there are
three things in addition to burnout.
We have secondary traumatization and we have
So let me talk about burnout, secondary
traumatization and moral distress.
So burnout, first of all, it's hard to
recognize in oneself.
So there are studies showing that people don't
recognize burnout in themselves, but their
colleagues do recognize it in them.
And it's really dramatic kind of finding.
But how do we recognize it?
Well, burnout has three major characteristics.
The first is demoralization, and that is that
inner experience of I'm not doing well at
I'm kind of beating myself up.
I'm not feeling good about myself, feel
It's like a learned helplessness experiment
that Martin Seligman did with the rats.
You just can't do what you want to do.
So the highly motivated person is more likely
to experience this because they're most
frustrated when they can't make a difference
in their work.
The second characteristic is a little bit of a
distancing that one experiences.
You develop a kind of cynicism, oh, I have the
cancer in room 238, and you start to find a
way to keep yourself emotionally distant
because you're burned out.
It's like a bright flame is more likely to
That's the idealism burnout relationship.
And you start to pull back and not be caring.
And then you really dislike yourself.
Because I got into this work as a physician,
as a social worker, as a clergy member, as a
nurse, as a psychotherapist, because I'm a
caring person, and now I'm not caring.
So that is a downward spiral.
The final characteristic, which is almost a
defining characteristic, burnout, is
Emotional, physical, psychological exhaustion.
It's not because you're doing more physically,
it's that it's emotionally demanding.
So this is what burnout looks like from the
Then you have vicarious or secondary
traumatization that you experience because
you're talking to people who are traumatized.
If you're talking to someone whose child has
died, they're traumatized.
And this trauma can be transmitted to you.
And that's where empathy is challenging,
because empathy is a double edged sword.
It's the thing that makes you a little bit
more vulnerable, but also can make you a great
And you have to find a way to be an emotional
relationship emotionally balanced in order to
do this work without burning out.
I call that the challenge of caring.
And then we have moral distress.
So in COVID, we had so many examples of this
where people were triaging.
When you have to make a decision about who to
attend to in an emergency room, who to give
this life support to, some very difficult
decisions were being made.
And in general, when we feel like we're not
doing enough, or our organization is not
providing the kind of care we want, or our
team isn't doing very well with our patients,
that leads to moral distress, and that can
lead to what I call helper secrets.
All these experiences, this trifecta
troubling, trifecta burnout, secondary
traumatization and moral distress can lead to
people concealing their experience.
Because I don't want others to know that I'm
You're looking over at the other professional
across the table and you say, they're doing so
They seem like they're in control and managing
this so well, and yet I'm feeling terrible.
And that's what leads to many people leaving
And undoubtedly those 100,000 nurses, many of
them were feeling the same thing.
It's just not right for me.
But if they had gotten the support they needed
in those difficult moments, if they had an
organization in which they felt like their
mission division process was in alignment with
the mission division process of their
organization team and they got the support
they needed, I don't think they'd be burning
Marylayo: Very true.
So I want to come on to your book.
You've written a book called The Helper's
Journey empathy, Compassion, and the Challenge
of Caring, and that was written for
caregivers, and it won a Book of the Year
award from the American Journal of Nursing.
Can you tell me about that?
Professor Larson: Yeah, it goes from the
inside out, if you will.
It begins with the inner experiences, like
some of those we're talking about, what's our
mission in the work?
How did we get here in the first place?
Call those emission moments when we discover,
well, this is why I'm here.
We don't have them every day necessarily, but
we learn from them.
Well, this is what really brought me in.
This is what can keep me in.
This is what can nourish me and make me
realize why I'm here in the first place.
And then talk about stress management, because
we need to find a way to manage our stress.
We need to find a way to be emotionally
involved without burning out.
We need to learn about self care and
reappraisal of stressful situations and
mindfulness and self compassion.
So I write about all these new ideas that we
have in psychology, a lot of them coming from
And that's kind of exciting because to realize
we can do something about our stress is very
important to realize the fact we can make a
Resilience is not a trait, really.
It's an outcome.
We can affect that outcome.
Maya Angelo said, you cannot control all the
events that happen to you, but you can decide
not to be reduced by them.
Albert Vander was sitting in this office with
me that I'm in right now, and he's the person
who developed the idea of self efficacy, I
think one of the foremost psychologists of the
And I said, what would you tell all the
doctors, nurses, therapists who are struggling
He'd say, don't let them wear you down.
And he quoted this.
It's not really Latin, but illegitima known
carborundum, which means essentially, don't
let the B-A-S-T-A-R wear you down.
So it's important to realize we can do
something about it.
Then I talk about self concealment, and that's
a big research area.
Now, my scale has been used in 15 countries
and there are 220 studies now looking at the
tendency to self conceal and how that causes
us problems, especially as helping
professionals, and leads to helper secrets.
I write about helper secrets, which is another
thing I focused on a lot in my career.
All these troubling experiences we have that
we don't disclose to others, but then can kind
of corrode from within.
Then I go to the interpersonal realm and look
at, well, how can we communicate more
How can we develop a person centered
What makes that work?
What's at the heart of that to put our
compassion to work and with the patients we're
And then team issues.
So focus on what makes for a healthy team.
What do we know about team functioning and how
can we get our mission division process
working within the team and increase
effectiveness and the compassion that we're
providing in our care?
And then finally, I end with a bigger
statement about compassion in the world and
how do all these ideas relate to what's
happening in our society and in the world?
Largely looking at all the developments that
have happened recently and how we can take
some of the ideas from psychology and put them
to work and creating a more compassionate
It was an exciting thing to write.
I was really glad that it got recognition.
Marylayo: It certainly sounds comprehensive in
terms of what it covers.
You mentioned healthcare workers, how they
need to find that balance in terms of still
being emotionally involved, but without
getting burnt out.
And when you were talking about that, it
brought a picture to my mind.
And so when my mum passed away, for example,
who broke the news was a nurse in the
So I was in the hospital with a nurse and it
was obvious that she'd been crying and she was
in the room with me.
And I had to tease out of her what happened
because maybe she'd been sent there to keep me
company or to hold the fall until the doctor
came to share the news.
And so it was basically when the nurse shared
the news, I knew because of her reaction,
because she'd been crying and because she
dared not even look me in the face.
And I felt she was very emotionally involved
and it had upset her.
However, when the doctor came to share the
news, it was all very mechanical, very
And so there was a big difference between
those two healthcare workers and basically how
they expressed themselves or how involved they
were when it came to empathy and being
And there's a part of me that actually really
valued or appreciated the nurse because she
It was my mom.
She cared and it bothered her.
Just oh, it concerned her and it showed in
terms of how she was.
So back to the point that you raised about
being emotionally involved.
How can a healthcare worker be emotionally
involved and protect themselves?
They're there to care.
And if something traumatic has happened, it
can impact them.
So how can they remain healthy?
Professor Larson: Yeah. Mary Loud this is
really a great illustration.
Your personal experience really illustrates so
So how can we do that?
First of all, people don't care what you know
till they know that you care.
The nurse with tears is an interesting
And then the doctor coming in and being more
And it's highly likely that the nurse had a
much deeper relationship with your mom.
Nurses are on the front lines.
They're caring for patients day to day.
Your mother was obviously special to her in
some way and she had real feelings.
And this is something that the idea that we
know that helping professionals when they
report, especially end of life professionals,
say that the number one stressor is
The number two stressor is no time to grieve.
So that nurse was grieving there.
Now the question is, okay, how can she do that
in a way that she's not feeling shame and that
she's able to still be helpful to you?
I have a metaphor that been used a lot by
people over the years because I think it just
makes sense in a way, the helper's pit, that
we don't want to fall into the helper's pit as
helpers because we don't want to identify with
the losses of people we're caring for.
And we have to find a way to keep our
So when Mary Leo walks in the room, I'm able
to communicate with her.
And you saw the grief that she was
It was for you.
It meant something that's special.
She was caring for my mother, and that's
I've asked, like, one time I was lecturing to
5000 oncology nurses all at once.
And I said, how many of you have had a tear in
your eye when you're working with patients?
Every single person in the room raised their
I couldn't see maybe every single but it was
the whole yeah, it seemed like I said, for how
many of you?
Did the patient or family member run out of
the room saying, my nurse is having a feeling
I can't deal with it.
No one raised their hand.
We are human beings working with other human
But the trick is we don't want to fall into
the helper's pit and then have all the focus
shift to ourselves.
That's self focused, and that's not helpful to
the people we're caring for.
We have to maintain that empathic
So she had to also be there for you, and
So we've got to find a way to be emotionally
And I've devoted a lot of my career to trying
to understand this experience I write about
How can we be emotionally involved?
How can we nurture our compassion and find a
way to express that without burning out and to
help people live with hope in a world in which
loss is inescapable?
That's kind of the challenge of caring.
That is the challenge, caring.
So I think we need technical expertise and we
need relational expertise from our caregivers.
And that's across the board, whether it's
psychotherapist, a social worker, nurse,
doctor, chiropractor, whoever it is, we need
both and to have really truly compassionate,
person centered care.
Marylayo: And Dale, a lot of what you've
mentioned or certainly touched on and
referenced from your book was just about like,
teamwork and even having that space for
grieving, for professionals.
So I see that there are a lot of challenges
for the healthcare sector when it comes to
ensuring that the healthcare worker is able to
get back to being well or staying well
mentally, because a lot of those issues could
be systematic or cultural within the
So, yes, they may try, but the fact of in
terms of the number of hours that they're
doing or maybe the scheduling or what they're
encountering in terms of patients and it's
probably not a response you're able to give
because it's going to be so detailed.
And it's probably in your book that are there
ways you can share?
What the key things someone would be able to
Professor Larson: Well, first, one of the key
findings in the burnout field, chris Manslack
at Berkeley had this understanding of burnout,
which is, it's not bad apples, it's bad kegs
that the apples are in.
It's the system we're in.
I don't think those 100,000 nurses who left
the field recently left because there was
something wrong with them.
We couldn't have predicted them leaving the
field by giving them a personality measure
before they entered the field.
We could predict them leaving the field by
looking at the organizations they're in and
the lack of support that they've received.
Healthcare has become brutal in so many ways
in terms of not providing enough support for
And that's a reality.
And we are struggling, at least here in the
United States, I'm sure true in England as
I have spent quite a bit of time in England at
the various hospice programs at St.
Christopher's Lecturing, and I know that these
are universal kinds of situations.
But in our system, which is very often for
profit and driven by bottom line.
Bottom line is not taking care of our health
So the bottom line is making more money.
And we've seen that with hospice care becoming
more and more for profit here in the United
States, it's coming a little bit of an issue.
Not that all for profit organizations are bad
or all non profit good, but whenever your
mission is to make more money versus you're
making more money to fulfill your mission, you
have problems because you think, well, should
we provide this extra service for our patients
or the community?
No, we're not going to do that because that
would cost us money.
We don't have to do it.
I'm not an expert on all that, but I just have
But I do have expert knowledge about the
stressors that health professionals and
caregivers generally are dealing with.
And we need to provide for family caregivers
In the United States, we're trying to get some
mobilization of a national policies that would
be supporting family caregivers.
We would provide tens of billions of dollars
of support for their loved ones.
I mean 50 just huge numbers of people
supporting their loved ones who have
Alzheimer's and different infirmities.
So we need to do more to support those who are
helping us with our conditions, our
situations, our suffering.
And I hope that the future holds more promise
in that regard.
Marylayo: Sure. Like you mentioned about COVID
how that made a significant increase in terms
of healthcare workers leaving the profession
pre COVID and post COVID, there's that
So actually, are there any specific signs that
as a caregiver it shows that it's because
they've been traumatized by COVID?
Is there anything in particular that shows
that it's because of that traumatic period?
Professor Larson: Well, actually we have now a
We always develop measures.
So the first thing we do is we say can we
And then we try to develop a scale.
There's actually a COVID Stress Syndrome
And here are the items fear of Contamination.
So think about people who are really high on
I'm really afraid of being contaminated.
This is true in general.
I mean, COVID has not gone away and it's still
a reality in our lives and will be, it seems,
I have an acronym that people will find
humorous probably Scared situational
coronavirus Activated Relational Disorder.
But it's this fear that we have when you're
encountering anybody who's new in your life,
have they tested?
This is a little barrier between us and
So I call it scared but fear of contamination.
Worry about finances because you're worried
about losing money.
These are the items from the scale xenophobic
fear that foreigners are spreading the virus.
Traumatic stress symptoms associated with
direct or vicarious traumatic exposure.
Compulsive checking and reassurance seeking
profound and pervasive experiences of grief,
loss and trauma are I think really reshaping
how we live, die and grieve now in the future.
And this COVID stress syndrome, not sure what
that'll look like when it's administered to
tens of thousands of people if it is.
But some of those elements we can all relate
I think this COVID has affected us all.
It's changed our relationships.
I know I'm always thinking am I safe?
It's really taken away a sense of security.
I never thought about going into a crowded
room as any kind of threatening situation.
I'm going to a conference soon where I'll be
with hundreds of people.
I don't know how comfortable I feel standing
at the boot know with a bunch of people I
don't know they tested.
So this is the kind of anxiety that I know
people go oh no, I'm not worried about that
But I don't know.
In my own life I've had six friends all
actually coming back from Europe on long term
flights who've developed COVID and a couple of
them have long COVID now so it's not gone
Marylayo: So those items that you mentioned in
the scale, if there's an increase in them then
there's a chance that it's because the
individual has been traumatized by COVID.
So how could they then cope with that or deal
with that, address it effectively?
Professor Larson: Well I think we have to have
exposure whenever we have any kind of anxiety
So I think it is good that we find ways to
begin segwaying back to normal but we're in a
new normal, but segwaying to this new normal
reality that we're in.
So I think exposure is good to find safe
contexts where you can be without a mask.
Most people now I know on airlines are not
wearing masks so there's a way that that's
There's another way that it's a little bit
brazen because I know people listening might
be saying oh my gosh, he's so stuck in this
It's a reality still and it's something we
have to pay attention to but we don't want to
be overwhelmed by it, we don't want to be
panic stricken, we don't want to score super
high on the COVID stress syndrome.
We have to find a way to adjust.
So it's going to be part of our future that we
find a way to be overcoming these anxieties.
And I think we do that through exposure
principle in psychotherapy.
So we find ways to reappraise, we check out
the realities of how prevalent is the COVID
Right now, what's going on in my area and
what's going on generally and I think then we
find a way through this.
Marylayo: And specifically talking about those
caregivers that focus on end of life, there
will be some that are in positions of
So it could be for example, the load is on one
particular caregiver rather than others in the
family and there could be resentment that's
felt by that caregiver.
It could be self doubt, maybe in terms of the
fact that they feel that they haven't given
perhaps the level of quality care that they
could have, or maybe they've made a mistake.
So perhaps there's some secrets that the
caregiver may be harboring when in an end of
life support scenario, what can they do to
Professor Larson: Well, I think you've
outlined some really important ones.
What about me?
Is one of the categories.
When I do research on helper secrets or
caregiver secrets, it's a very common one.
What about me?
I'm caring for others.
Also feeling these self doubts, like I'm not
good enough or I'm not caring enough.
So it can go both ways.
And it's very important to recognize these,
which I term helper secrets.
And you get stuck in the fallacy of
The belief that I alone am having trouble with
And there are some secrets that we possess,
there are other secrets that possess us.
So some of these can really drive you out of
the helping professions if you're not sharing
them with others, if you're not normalizing
those experiences, you're not finding a way to
share them with somebody and also to get
feedback from others who are experiencing the
same kinds of things.
So I think the key thing they can do, any of
us can do with these kinds of inner
experiences where they get kind of stuck in
our echo chamber and we end up feeling bad
about ourselves and we have shame because, oh
my gosh, nobody else would feel this way.
The fallacy of uniqueness.
It's my failure.
It's something about who I am.
No, it's about the situation.
It's about this environment that I'm in, these
demands that are placed on me, this lack of
support, et cetera.
And so they need to find a way.
I think your question is what can they do?
They can find a way to explore these inner
experiences, to have self compassion.
I'll Let Kristen Neff has written extensively
about this, but what Carl Rogers also wrote
about and taught about beautifully, as one of
my teachers and inspirations, how to accept
When we can accept ourselves, we can change.
We have to accept these inner experiences.
Listen, to know burnout is in general, it's a
badge of honor.
You don't burn out unless you're on fire.
So one of the idealistic people are more
likely to burn out because they're on fire.
They want to make a difference.
And when I can't make a difference, I feel so
We found that high commitment nurses are
really not bothered by the stupid things that
other people are bothered by.
Like the paper is not in the right place, et
It doesn't really bother them.
But it's when the quality of care is
compromised that they really are suffering.
So that's an important point, I think.
So we have to realize that it's not just me,
it's not all about me, it's situation I'm in.
And then when we get that new perspective,
we've got to see what we can do to change that
situation in this organization or in our
personal lives, helping lives.
We have to find a way to find balance
emotionally in the moment.
We have to find a way to take care of
ourselves and set limits and do things for
ourselves outside of our helping work.
Like how about vacations?
And about taking time for yourself to do
things that are nourishing.
And increasing that self compassion and
increasing your ability to have the resources
that you need when you are going into these
helping contexts so that you can really give
what is demanded of you.
And there's a lot that's asked of you that
these helping situations ask a lot of us.
They ask us to be present suffering.
They ask us to be vulnerable.
They ask us to be teammates with people.
When we're used to being Lone Rangers solo
kind of helpers.
Now I've got to work on a team and work
There are a lot of issues that I've talked
about and written about about these things
that are so central in helping.
Marylayo: And lastly, there may be someone
listening who is a caregiver that's
Would you like to share anything with them
Professor Larson: Well, first I'd like to
thank you for your work and I really hope that
that is experienced is really taken in because
I've dedicated my life to supporting people
I have a tiny clinical practice, but most of
my work has been researching and trying to
understand what's going on here.
And how can the things that we're learning in
psychology help you do what you're doing?
What matters to you?
I would say take time to understand how you
What matters to you?
What is your mission in the work?
One of the things we know now is that
compassion could be one of the best buffers
I know that sounds not right because we think,
oh no, the more compassionate person is more
likely to burnout.
No, actually compassion balanced emotional
And compassion is an antidote to burnout.
Empathy is an antidote to shame.
Compassion is an antidote to stress because it
enlivens you and you find a deeper sense of
There's a term that is very old.
It's a Greek term, eudemonia.
And eudemonia is a deeper kind of happiness.
It comes when we live our lives with our
values and the meanings that really matter to
Activated Actuated and I would like you just
to reflect on that, on your helping journey,
that what you're doing has meaning.
It's going to reverberate far into the future
long after you're gone and I'm gone.
In the families that follow, the patients
you're caring for, they will be sharing this
goodness that you're sharing with them.
Those children will share it with the next
So all this goes on far into the future.
And so feel that for yourself and also
recognize, hey, this situation is challenging.
It's not all about me.
It's not my failure.
It's that I have to find a way to navigate a
difficult world of helping, but one that is
deeply meaningful and can have so much
significance and such a legacy for you and
So thank you for your work from the bottom of
Marylayo: Well, Professor Dale Larson, thank
you for those words of encouragement to
caregivers, particularly those that may be
Thanks for joining me on Mary lyre Talks.
And for those that are listening, stay well
and hope you join me next time.
Being a caregiver can be overwhelming at.
Marylayo: Times, so here are a few spiritual
wellness tips you can meditate on.
The first is Matthew, chapter 25, verse 40,
which reads, and the king will answer them.
Marylayo: Don't you know when you cared for.
Marylayo: One of the least of these, my little
ones, my true brothers and sisters, you
demonstrated love for me.
Another is Psalm 23, verses one to four, which
reads the Lord is my shepherd, I shall lack
Marylayo: He makes me lie down in green
Marylayo: He leads me beside still waters.
He restores my soul.
He guides me in paths of righteousness for his
Marylayo: Even though I walk through the
Marylayo: Of the shadow of death, I will fear
no evil, for you are with me.
Your rod and your staff, they comfort me.
We'll end with first Peter, chapter five,
verse seven, which reads give all your worries
and cares to God, for he cares about you.
Thank you for listening.
Marylayo: Do follow and join me again.
Marylayo: Next time on Marylayo Talks Beyond