Healthy Leadership and the High Cost of Caring

How should we lead the church?

In this Pneuma Review conversation, Christian counselor, Dr. Eric Scalise answers this question by saying that ministry leaders need to recognize how pastoral ministry causes stress and how they need to develop a plan for self-care.

Pastors and ministry leaders, much like those who work in the caregiving professions, are often thought of as being compassionate people. Indeed, many of us who feel called into the ministry readily identify with the compassion of Christ as He related to those around Him. Webster’s Collegiate Dictionary defines the term compassion as a “sympathetic consciousness of others’ distress, together with a desire to alleviate it.” It comes from the Latin word, compat, which means to suffer with. Much of the research on this subject underscores the critical importance of the helping relationship and pastors are frequently in close proximity to the emotional suffering and resulting grief of those they minister to. Herein lies both a potential problem (increased stress and burnout), as well as a wonderful opportunity (to function as God’s ambassadors of reconciliation). Some leaders burn out. Some rust out. And some finish out. May God grant us the mindset of Paul when he said, “I have fought the good fight, I have finished the race, I have kept the faith” (2 Tim. 4:7) and, “…nor do I count my life dear to myself, so that I may finish my race with joy…” (Acts 20:24a).

How do you sustain joy along the way? When the unexplainable, the unpredictable, or traumatic event takes place, theological rulebooks are often inadequate when a response of compassion is required. This is because compassion, to be effective, must likewise be visible. The teaching of Scripture is to “Let your light so shine before men, that they may see your good works and glorify your Father in heaven” (Matt. 5:16). Yet, the goal is to remain “salt” and “light” in the face of alcoholism, drug use, grief and loss, depression, marital discord, separation and divorce, child abuse, sexual addiction, parenting struggles, unemployment, financial stress—and the list could go on. These are the day-to-day issues that people bring to us when seeking guidance and help. At times, the impact that accompanies the sheer level of pain we are confronted with can overwhelm even the most capable and mature leaders. A primary challenge for those who live and function in a ministry role, is the simple reality that self-care is something pastors tend to focus on when it pertains to their congregations and not necessarily to themselves. The question then becomes, not only how do I finish the race God has ordained for me, but how do I finish well?

The Lord gave me a wonderful life lesson a few years back while flying overseas to speak with over a thousand pastors at conference on, of all things, stress and burnout. It had been a particularly chaotic and hurried week leading up to my departure. On top of that, making difficult connections in multiple airports due to weather conditions was not what I had in mind. When I finally boarded my last international flight, I managed to grab a newspaper and was ready to slow down and relax. If you travel frequently as I do, you may tend to politely ignore the flight crew as they go over airplane rules, seatbelts, emergency exits, and the like.

Here I was perfectly content in “tuning out” when the voice of the stewardess came across the loudspeaker and said, “Ladies and gentlemen, I know many of you have already had a long day and that you are tired, but if you would be so kind as to set aside your reading materials for a few brief moments, we would like to cover some important safety information with you.”

This at least prompted me to pull the corner of the newspaper back a few inches and glance up into the aisle. To my surprise, there was a flight attendant standing just a few feet away smiling at me with that “look.” Here I was going to teach on ministry-oriented stress and I was swimming in it at the moment. Of course, I put down the paper, sighed, and smiled back.

In the middle of the preflight announcements, I heard the following—which I have heard many times before, but usually gloss over.

“If we should experience the sudden loss of cabin pressure, oxygen masks will deploy from the ceiling above you. If you are traveling with small children, please put the mask on yourself first and then assist the child.”

The Holy Spirit immediately began to shake me awake regarding this profound truth. Why should parents put on their mask first? One would tend to think it would be more humane, loving, and compassionate to help the children first. However, because children are probably more vulnerable and less able to take care of themselves in the moment, then the most responsible course of action is for parents to make sure they are in a position to help and facilitate care. To do that, they need to be stable and breathing in the oxygen themselves. The same is true for us as ministry leaders. When people bring their hurts or are in the middle of a crisis, they are typically less mobile, less resourced, more incapacitated and anxious, and perhaps less able to discern the voice of the Lord at the moment than we are (at least in theory). If we want to ensure that we are “available” to the Lord and to others, we must take care of ourselves first—appropriately and in a balanced way—or we risk becoming ineffective and at times, even a hindrance to what God is trying to accomplish.

When you entered into the ministry, you probably expected to be successful. Most people do not feel passionately called to something, only to fail. One common distortion is that many leaders define success primarily by quantitative measures (e.g. buildings, budgets, and baptisms) and not by qualitative measures such as those that make a difference in someone’s life by helping them become more Christ-like. There is a strong temptation to develop a comparative “bean-counting” mindset. We can set increasingly unrealistic standards that have less to do with trusting God and walking in faith, and more to do with how we compare to the church or ministry next door. If we evaluated Jesus using this paradigm as a sole criterion, some might deem His ministry to have been an abject failure.

Countless pastors and ministry leaders accept very difficult job descriptions and few other vocations have such a broad range of “plate spinning” demands. A good friend of mine was candidating at a new church and during the interview with the pastoral search committee (twenty-three individuals—some of you are smiling), he was first asked about his own vision for ministry if he were to be called. Following a dinner meeting, he went around the room and asked each person what they were expecting and looking for in a pastor, all the while, taking notes. As he flew home from the interview, he began to read over what he had written down and counted 106 different expectations from the group and yet, they all seemed somewhat reasonable in their own way. Here is an important principle when it comes to ministry: the individual expectations might be legitimate, but the composite expectations can be all encompassing and at times destructive.

Acceptance of these unrealistic job descriptions may mean that we have been put on a pedestal and we have to be very careful if we come to like the view from up there. It feels nice to be liked and wanted, but we cannot allow this to become our primary motivation for service or our sense of identity. Otherwise, in seeking the applause of men, we may allow others to define our calling and purpose. The Apostle Paul identified himself to the Corinthians as a “bondservant,” but note that it was for “Jesus’ sake” (2 Cor. 4:5). In other words, he was certainly there to serve the Corinthian church—not however, primarily for their sakes—but for and to his Lord. If we do not recognize this dynamic, it will catch us off guard whenever we experience the unwritten rule that we are not allowed to fail, hurt, or in essence, be human. Stress increases and so does our resistance to seeking counsel and help. The result can be a crisis of faith at both a personal level and within the ministry, because we have either not learned how to set reasonable boundaries with the people we lead, or we choose not to. Usually, the only one who really knows what is going on is the ministry leader’s spouse. Over time, the unrelenting stress can begin to erode the foundation of the marriage and family.

Several years ago, when my twin sons were still adolescents, I walked into our family room on a Saturday morning while they were lounging on the couch watching television. There, lying on the floor, was a dirty sock. It was obviously not Dad’s—I have normal feet, not landing strips. So, very nonchalantly I merely said, “Would one of you mind picking up the sock and tossing it into the laundry basket?” Thinking that the directive registered successfully and would be complied with, I proceeded to my office. Twenty minutes later, I came downstairs. No one had moved an inch. The television was still on. The sock was on the floor. If you are parent (which many ministry leaders function as in some respect), you understand what came next. I ratcheted things up into lecture mode and began to describe all the starving children in the world and how blessed they were to have a roof over their heads, food on the table, a bed to sleep in, etc., etc.—“Now please pick up the sock!” Certainly they understood now. I headed to the bedroom to shower and dress and thirty minutes later, walked back through the family room. The television was still on. The boys are nowhere to be found. A dirty sock…still sitting on the floor. What do we do? More often than not, we grumble, complain and then walk over and pick up the sock. The truth is that you and I have our own “dirty socks” and if we keep picking up everyone else’s, we become exhausted and they will never learn or grow. In time, we may become desperate for relief.

In my work with pastors and ministry leaders over the years, I have found several common outcomes that are frequently set into motion once they realize they may not be able to live up to the expectations that are set by others:

Developing a preoccupation with stress-producing people or situations. They remain in the intensity of the stress-filled environment and become adrenaline junkies—always moving, always busy, with the appearance of human doings rather than human beings—more on that later.

Indulging in escape behaviors for many of the same reasons other people do—they are tired of being discouraged, lonely, or in pain and their chosen path is a way to “self-medicate” via certain substances or behaviors, although usually in an unhealthy manner.

Avoiding intimate relationships with one’s spouse or close friends and substituting fantasy over reality. True relational intimacy requires time and effort and if a person is emotionally and spiritually drained, they are unable to make the necessary investment. Sexual addiction is now a national epidemic. It can be tempting to engage an image on a computer screen, because it is easy, there is an immediate emotional/physical reward, and there is little risk of failing or being rejected by that image.

Seeking to control everything and everyone as a means of coping. Many times, control is a survival tool we picked up along the way rather than a characterological disorder. If we have come to believe somewhere in life that we are powerless or have been hurt from repeated traumatic experiences, we may erroneously conclude that if we can just figure out how to control our environment and the people in it, we will somehow be safer. Unfortunately, this is rarely the case as most people do not respond well to excessive control.

Justifying actions by blaming other things and/or other people. Blame-shifting is an attempt, albeit with unintended negative consequences, to avoid responsibility and accountability. If I can make the issue(s) primarily about someone or something else, then I can more easily separate myself from the emotional and practical aftermath.

Choosing to simply quit or leave the ministry. The enemy of our souls would like nothing better than to notch another battlefield casualty. Sadly, the Body of Christ is the only army I know of that will shoot its own wounded, often burying them before they die. Sometimes, we do our firing squads in circles—everyone gets shot and this grieves the Holy Spirit deeply. So what are the consequences of stress overload? Dr. Hans Selye, a Canadian endocrinologist who is considered as the “father” of stress research, began to define the phenomenon during the mid 1930’s in terms of what he called the General Adaptation Syndrome. The normal pattern is for the body to cycle through a three-step process: alarm, resistance, and exhaustion. He went on to define stress as the “non-specific response of the body to any demand.”¹ Think about that statement for a moment. The implication here is that almost any demand placed on the body (including the mind and spirit in my opinion), has the potential to create a stress response.

Stress can have both a psychosocial (within the environment) and a biogenic (within the body) orientation. Eustress, which is a normal part of every-day-life, is necessary for keeping us alert and active. It enables us to be productive, creative, and assists with decision-making activities. However, a chronically high level of stress becomes distress and exacerbates a rapidly downward spiral in day-to-day functioning. The two primary stress hormones that begin this rollercoaster ride are adrenaline and cortisol.

The stress cycle starts in the brain. When a stressor is detected as a threat, the amygdala, hypothalamus, and pituitary glands trigger the fight-or-flight stress response. The sympathetic nervous system activates several different physical responses to mobilize for action. The adrenal glands increase the output of adrenaline (also called epinephrine), cortisol and other glucocorticoids, which tightens and contracts the muscles and sharpens the senses. Five main systems respond to stress and can be compromised by prolonged stress: the cardiovascular system, immune system, nervous system, endocrine or glandular system, and metabolic system. The body also forms free radicals that are associated with degenerative diseases, illnesses, and an acceleration of the aging process.²

While the fight-or-flight response is instinctive, it tends to compromise rational and balanced thinking. This is because adrenaline signals the body to move blood out of the brain and into the major muscle groups where it may be needed more (to prompt swift action and/or reaction). What happens is that a small gland called the amygdala, hijacks the messages from the neo-cortex (the thinking part of the brain), directs them into the limbic system (the feeling part of the brain) and makes calm responses vastly more difficult—think of road rage when someone cuts you off in traffic after an already grueling day at the office. As you contemplate the myriad of situations, decisions, and stressors most ministry leaders constantly face, is it any wonder that making wise, healthy, and balanced decisions can become a challenge after one’s resources (emotionally, cognitively, physically, and spiritually) are taxed to the very limit?

When excessive amounts of adrenaline and cortisol enter the bloodstream, the cumulative effects over time can be harmful. These include: a narrowing of the capillaries and other blood vessels leading into and out of the heart, a decrease in the flexibility and dilation properties of blood vessels and their linings, a decrease in the body’s ability to flush harmful (LDL) cholesterol out of its system, an increase in the overall production of blood cholesterol, an increase in the blood’s tendency to clot, and increased deposits of plaque on arterial walls. Although the research is still emerging, there is also some evidence that increased cortisol levels result in unwanted weight gain and the accumulation of fat cells around one’s midsection. This is why a number of dietary and weight control supplements currently available are designed to reduce these levels (e.g. CortiSlim, CortiStress, Cortistat-PS, Cort-Aid, etc.).

According to the American Institute on Stress, 80-90% of all doctor’s visits today are stress-related.³ The American Heart Association further states that more than 50 million Americans suffer from high blood pressure and nearly 60 million suffer from some form of cardiovascular disease, resulting in over 1 million deaths each year (2 out of every 5 that die or 1 every 32 seconds).⁴ Heart disease has been the leading cause of death every year since 1900 (except 1918 during the great flu pandemic) and crosses all racial, gender, socioeconomic, and age barriers. Finally, the U.S. Dept. of Health and Human Services recently reported that 25% of all prescriptions written in the United States are for tranquilizers, sleep aides, antidepressants, and anti-anxiety medication.⁵

We have seen that pastors and ministry leaders are not only susceptible to increased levels of stress, but when combined with a call to love and serve others, the result is what is commonly referred to as compassion fatigue. Compassion fatigue can be understood as a comprehensive exhaustion that takes place over time when one is constantly in the “giving” position and as a result, loses his/her ability and motivation to experience joy, satisfaction, or to feel and care for others.⁶ Pastors now join the ranks of other caregivers (e.g. doctors, nurses, counselors, social workers, teachers, disaster relief workers, crisis responders, EMT personnel, etc.) in being among the most vulnerable of groups in this regard. It is sometimes referred to as secondary or vicarious traumatic stress associated with the emotional residue related to the cause of caring. The traumatic event or crisis did not happen to you directly, but you were close enough to those it did impact, so that its detrimental effects can still have a causal effect (much like secondhand smoke).

Perhaps by now, just reading this article feels a bit disheartening. However, we must consider a proactive strategy in addressing the realities of being in the ministry. Before doing so, it is essential that we likewise understand the two primary categories of stress. First, there is the stress of the ministry. Would you agree with me that just working and being around people (sheep can also bite as some of you know), is stressful? Second, there is the stress we bring into the ministry (e.g. unresolved hurts of our own, patterns of besetting sin, unhealthy relationships, unforgiveness, an insecure leadership style, extreme control needs, etc.). Pastors and ministry leaders who have successfully addressed the second category of stress (what we bring), will do a much better job in handling the first category.

Here is a potentially difficult, but important question we must all ask ourselves from time-to-time: Is my ministry causing the problems in my life; or, is my ministry revealing the problems in my life? Stress and pressure have a way of squeezing things out of us. The good news is that cause-and-effect dynamics can be improved or resolved and revelation can be used by the Holy Spirit to promote needed adjustments and change. Our role is to have “ears to hear”, “eyes to see”, and a heart that is willing and open before the Lord.

You might wonder, what goes into a good stress prevention or self-care plan? The following are a number of principles you may find helpful in your own journey. Take them and prayerfully develop a personalized approach tailored to your needs and/or situation. Write the plan down and review it at least once every week. Start by being honest with yourself and be open to what the Holy Spirit is speaking.

Learn how to recognize the stress-producing areas in your life that might need attention and take ownership of what needs to be done. “Let us search out and examine our ways, and turn back to the Lord” (Lam. 3:40). You cannot extinguish a problem until you can distinguish a problem. Things that remain a secret usually continue to have power over us and may be sources of fear, guilt, and shame. Here is my definition of fear: it is the “darkroom” that develops all our negatives. Fear is a dark place where negative thoughts, emotions, and behaviors emerge. The only thing I know of that will stop a developing photograph in its tracks is light. This is because light penetrates and darkness does not. Ephesians 5:13 says, “But all things that are exposed are made manifest by the light, for whatever makes manifest is light.”

Learn how to renew your mind. We need to reject the lies of Satan and replace them with the truth of God’s Word. It is like taking an antibiotic to fight off an infection. However, the “medicine” will never do us any good unless and until we take it in—so to with the Word. The process is like weeding in a garden. If the ground is dry and hard, it can be very difficult to remove the weeds. God’s Word washes our minds and softens our “heart ground”, thereby allowing Him to root out the things in our life that have become detrimental to spiritual, emotional, and relational health. Paul encourages us in Romans to “Not be conformed to this world, but be transformed by the renewing of your mind, that you may prove what is that good and acceptable and perfect will of God” (12:2).

Learn to depersonalize some of what you do in the ministry and limit your time around negative people. People frequently bring a host of complaints and problems to ministry leaders where they may not necessarily be encouraged, positive in their outlook, or full of faith in the midst of the pain. This can be draining after awhile—remember Jethro’s observation of Moses in the wilderness that he was “wearing himself out” while trying to counsel everyone (Exodus 18). Criticism is a frequent companion of any leader, but sometimes, it is an adult form of crying or throwing a tantrum. Leaders can become a lightening rod of sorts simply because they are in an authority position at the moment by virtue of their title or position. This can be especially true if a person has unresolved issues arising from their family of origin, so it is important to remember that strong negative reactions may not really be about you or your leadership.

Learn how to not lose sight of your first love because “you” are not your ministry. Before your identity as a pastor or ministry leader…before your identity as a husband, wife, father, mother, or a number of other roles, you and I are first and foremost, the adopted sons and daughters of our Heavenly Father. We must not allow the “ministry” to become the “mistress” in our walk with God because it becomes like chasing the wind and is a formula for discouragement and burnout. When Jesus prayed in selecting His Apostles, the Scripture says that “He appointed twelve, that they might be with Him and that He might send them out to preach, and to have power to heal sicknesses and to cast out demons” (Mark 3:14-15). It is a blessing and privilege to be given opportunities to preach the Gospel, move in the miraculous, and engage in frontline spiritual warfare, but this is not the first reason that God has called or appointed you either. It is that you and I “might be with Him,” our first love.

Learn to rest because the nature of God has much to do with rest. Rest, true God-given rest, does not automatically imply inactivity, but trust and dependency. God has so ordained our bodies that about every sixteen hours, it needs to shut down for awhile. If you live to the normal life expectancy in the United States, you will sleep approximately 25 years of that life. Speaker/author, Steven Covey, tells a story about two men who chopped wood side-by-side all day together. One man stopped every hour and rested, while the other worked straight through the day. When they finished, the man who rested actually chopped more wood. Why—because when he stopped, he also sharpened his axe. Resting allows us to stay sharp. We sharpen our physical axes, our emotional and relational axes, and especially our spiritual axes.

Learn to be silent and learn to be still. What is it about the ministry that often compels us to try and accomplish more than Jesus did? I cannot imagine anyone busier and more in demand than Christ was during His life on the earth. Yet, He clearly understood the value of being alone with the Father. Luke records this for us: “However, the report went around concerning Him all the more; and great multitudes came together to hear, and to be healed by Him of their infirmities. So He Himself often withdrew into the wilderness and prayed” (5:15-16). The busier we are, the more we need to strategically withdraw, wait on the Lord,  and allow the Holy Spirit to “renew our strength so that we can mount up with wings like eagles, run and not be weary, walk and not faint” (Isaiah 40:31).

Learn to give your burdens to God each day. We were not designed to be ministry pack mules. We are sheep. The only burden sheep carry is their wool and they lose that twice a year. In Matthew 11, Jesus admonishes us by saying, “Come to Me, all you who labor and are heavy laden, and I will give you rest. Take My yoke upon you and learn from Me, for I am gentle and lowly in heart, and you will find rest for your souls. For my yoke is easy and My burden is light” (vs. 28-30). In Colonial Williamsburg (VA), where I have lived, there are a pair of oxen that pull a cart throughout the restored area. Usually, one ox is a wise, seasoned animal and the other, new, young, and untrained, Whenever, they bring a new ox in like this, a special training yoke is often used. The neck hole for the wise seasoned old ox fits his neck almost perfectly, but the yoke for the young ox is much larger. The reason—the young ox is not supposed to feel the burden of the cart, but only learn what it means to walk alongside the other. It is an easier yoke. Jesus told us His yoke is easy. Yet, it remains a yoke which means that we cannot simply go anywhere we choose. However, God does want us to learn to walk alongside Him. If you are constantly feeling the burden of the ministry yoke—and I say this in Christian love—it means that you are in the lead and not the Lord.

Learn to triage your daily and life events. Emergency personnel have been trained to come into a situation, assess the genuine priorities, and begin making decisions regarding the most critical things first. Sometimes it can literally make the difference between life or death. The same is true in the ministry. Spiritual triage—discerning what God is doing in the moment, having the wisdom to know how to respond, and being led by the Holy Spirit—is a critical, stress-reducing leadership skill. Not everything that is important is urgent and not everything that is urgent is important. David cried out to God saying, “Show me Your ways, O Lord; Lead me in Your truth and teach me, for you are the God of my salvation; On You I wait all the day” (Psalm 25:4-5).

Learn to resolve those things that can be attended to easily and quickly. I frequently talk with leaders who spend 90% of their time, energy, and resources on the 10% that they may be able to do very little about. Reversing those numbers could help immensely in how we go about our day. Have you ever had a pebble in your shoe? A splinter? An eyelash in your eye? These are not life threatening events, but they can be extremely irritating nonetheless. A simple adjustment (i.e. taking the shoe off and shaking it out) can provide immediate relief. Ask God to show you the things in your life that represent the pebbles, splinters, and eyelashes, that with a little attention, you might experience relief and even freedom—in other words the “little foxes that spoil the vine” (Song of Sol. 2:15). Perhaps it means getting at least one more hour of sleep each night. Or actually taking your day off and relaxing. It could be any number of minor adjustments having significant payoffs. We only have to be off course by a little to miss the mark by a lot.

Learn to manage you time by saying “No,” or your time will control you. Time does not manage us, it tends to take over. We must be active—and at times brutal—in our self-examination and intentional in correction when it comes to this issue. I have learned than cemeteries are full of indispensible people. The fact of the matter is that life usually goes on with or without us. If the Lord was to literally call you home today, would someone still preach the sermon this Sunday? Counsel the parishioner? Finish the committee work? Write the report? Visit the hospital? Perform the wedding? Meet with the deacons or elders? Finalize the budget or the architectural plans for the new sanctuary? The answer is a resounding, “Yes.” Ministry leaders too often move their spouses, families, and their own self-care, out of their schedules when something else comes up and crowds the calendar. We rationalize that we will make it up later and yet, we never seem to have the time.

Learn to delegate to others whenever, wherever, and however it is appropriate. Some of the most secure leaders I know are the ones who can let their ministry go and who are comfortable having strong, anointed  people around them. Moses heeded his father-in-law’s advice (Exodus 18) and surrounded himself with able leaders. Does it really matter if someone else can preach a better sermon, teach a better Sunday school class, write a better book, lead better worship, do a better job counseling a parishioner? Hopefully not! Good leaders produce followers. Great leaders produce other leaders. But, the greatest of leaders understand what it means to become a follower again. The important thing is that the Kingdom of God wins.

Learn the value of authentic relationship and find one or two key people in your life to be accountable to. Someone once told me that accountability was the breakfast of champions, but that too many people skipped the most important meal of the day. Isolation and the lack of accountability is, in my opinion, the primary strategy that Satan uses to take down a leader—“walking about like a roaring lion, seeking whom he may devour” (1 Peter 5:8). Whenever we are alone (in reality or perception) and cut off from supportive relationships, we are the most vulnerable. We do not necessarily need more “yes men.” Most leaders already have their share of them—good people, prayer warriors, faithful, and loyal to be sure—but we also need “truth-tellers” in our life. These are individuals who also love us, are safe, and we can count on them to give honest, direct, and transparent feedback. However, we must give these individuals permission and an open invitation to do so. The spiritual landscape is littered with leaders who have failed to embrace this truth. Look at the foresight of the wisest man who lived. In 1 Kings 4:1-19, we see a wide-ranging list of Solomon’s officials (priests, scribes, recorders, military commanders, projects managers, governors, and the like). Yet, imbedded in this list, is a priest named Zabud, who is also described as the “King’s friend” (vs. 5). Here was Solomon, apparently with the wisdom to have at least one person on his staff who also served in the capacity of friend. Who is your Zabud? If you do not have one, may I encourage you to find one. Better yet, consider being a Zabud to another leader.

Christian leadership is a high and sacred calling—to humbly, yet transparently represent Christ as His ambassadors to a lost and hurting world. This is the ministry of reconciliation and from the perspective of the Apostle Paul, “…as though God were pleading through us [emphasis mine]: we implore you on Christ’s behalf, be reconciled to God” (2 Cor. 5:20). In order to “run with endurance the race that is set before us” (Heb. 12:1), we must be deliberate when it comes to our own self-care. Only then can we put on the compassion of Christ and consistently manifest His grace, truth, and love to all who so desperately need His touch. May you have true joy in the journey.

PR

Notes

¹ Hans Selye, The Stress of Life, (New York: McGraw-Hill, 1956).

² Archibald Hart and Catherine Hart Weber, Caring for People God’s Way: Personal and Emotional Issues, Addictions, Grief, and Trauma (Nashville, TN: Thomas Nelson Publishers, 2005), p. 164-165.

³ American Institute on Stress http://www.stress.org/

⁴ American Heart Association http://www.americanheart.org

⁵ U.S. Department of Health and Human Services http://www.hhs.gov/

⁶ Charles Figley, Treating Compassion Fatigue, (New York: Brunner-Routledge, 2002).