Helper Syndrome and Pathological Altruism in nurses – a study in times of the COVID-19 pandemic

Background Pathological Altruism and the concept of Helper Syndrome are comparable. We focused on Schmidbauer’s description because it provides a comprehensive and testable definition. Nevertheless, this concept of Helper Syndrome has not yet been empirically investigated in a sample of helping professionals. Aim To investigate whether nurses working with covid-19 patients are more likely to have Helper Syndrome compared with individuals from non-helper professions. Methods The online survey took place between April 2021 and February 2022, in urban and rural regions of Salzburg, during the time of the COVID-19 pandemic. Nurses (n = 447) and controls (n = 295) were compared regarding Helper Syndrome characteristics. To measure characteristics of Helper Syndrome the following questionnaires were used: WHO-Five (WHO-5), selected scales of the Personality, Style and Disorder Inventory (PSSI) and the Freiburg Personality Inventory-Revised (FPI-R), the Alcohol Use Disorders Identification Test (AUDIT). Insecure gender identity and self-assessment of having a Helper Syndrome was measured by a Likert scale. Results In both groups, Helper Syndrome was detected (nurses 29.5%, controls 30.5%). Participants with Helper Syndrome showed significant differences in personality styles and traits, namely significantly higher scores for Foreboding-Schizotypical Personality Style, Spontaneous-Borderline Personality Style, Amiable-Histrionic Personality Style, Ambitious-Narcissistic Personality Style, Loyal-Dependent Personality Style, Helpful-Selfless Personality Style, Carefully-Obsessive Personality Style, Optimistic-Rhapsodic Personality Style, Social Orientation, Strain, Emotionality and lower well-being. The only difference between nurses and controls was that nurses were significantly less open aggressive. Conclusion For the first time, we were able to demonstrate Schmidbauer’s concept of Helper Syndrome. According to our data, we found a subgroup of individuals similar to Schmidbauer’s description of Helper Syndrome, but this sample was independent of helping or non-helping profession. These individuals seem to be at higher risk for psychiatric disorders.


Background Definition: Pathological Altruism and Helper Syndrome
This study deals with Pathological Altruism, more precisely with Helper Syndrome, which was introduced in 1977 by the German psychoanalyst Schmidbauer (2018).The concept of Schmidbauer is similar to Pathological Altruism, but it is more comprehensive.By definition, Pathological Altruism is a tendency to promote the welfare of another person, but with negative consequences for the other person or even for oneself (Oakley et al., 2012;Oakley, 2013;Kaufman and Jauk, 2020).Pathological Altruism is also defined by a compulsion to heal, save, and help others (Wong, 2020).Schmidbauer (2018) likewise describes Helper Syndrome also by an increased willingness to help other people and denying one's own limits.Helper Syndrome (Schmidbauer, 2018) and Pathological Altruism (Kaufman and Jauk, 2020; Wong, 2020) are related to narcissism.According to Schmidbauer, gratitude from the client/patient leads to narcissistic gain and self-esteem is stabilized by sacrificing energy and time for others in need (Schmidbauer, 2018).In addition, helpers with Helper Syndrome find it difficult to express negative feelings such as anger (Schmidbauer, 2018).They show inhibition of direct aggressive behavior.In addition, both Helper Syndrome and Pathological Altruism include dependent behavior toward others (Oakley et al., 2012;Schmidbauer, 2018).Thus, Helper Syndrome describes people who are attracted to helping professions because of a certain personality structure and who perform this profession in a way that leads to symptoms, namely depressive symptoms and pathological alcohol consumption (Schmidbauer, 2018).Also Pathological Altruism cause depressive symptoms (Kaufman and Jauk, 2020).
Figure 1 provides a detailed overview of the specific symptoms, personality traits and styles that define Helper Syndrome.

Helper Syndrome, mental health problems, nursing staff
In addition to Schmidbauer, other studies between 1977 and the present also addressed the mental health of healthcare workers, particularly nurses: One study found that a significant proportion of nurses suffered from symptoms of post-traumatic stress disorder (Cavanaugh et al., 2014).Another study showed that 81 of 561 nurses were in an incipient or advanced burnout process (Schramm, 2016).Other studies have shown an increased risk of burnout among nurses (Cañadas-De la Fuente et al., 2015) and a higher percentage of risky alcohol use among healthcare workers compared to the average population (Romero-Rodríguez et al., 2019).Study results have also shown that a significant proportion of healthcare workers who were responsible for patients with COVID-19 and SARS reported mental health problems, depression, anxiety, and insomnia (Maunder et al., 2006;Lancee et al., 2008;Lai et al., 2020;Muller et al., 2020;Chen et al., 2022).While working conditions undoubtedly affect mental health care professionals (Lancee et al., 2008), mental health problems of health care workers have also been associated with specific personality traits (Pérez-Fuentes et al., 2019).We assumed that during the COVID-19 pandemic, Helper Syndrome would be an additional risk factor for mental health.According to Schmidbauer, Helper Syndrome is more common among health care professionals, triggering depressive symptoms and pathological alcohol consumption.

Hypotheses and aim of the study
The central question of the study was whether there was a significant difference between nurses and control subjects in terms of certain personality styles and traits as well as symptoms (pathological alcohol consumption, low well-being, insecure gender identity).It is important to emphasize that Schmidbauer first described Helper Syndrome in 1977, and since then more than twenty editions of his book Helpless Helpers have been published in German (Schmidbauer, 2018), indicating that many people are interested in this concept.We hypothesized that there are significant differences in Helper Syndrome characteristics between nurses and controls.In his work Helper Syndrome and Burnout Danger, published in 2002, Schmidbauer focuses primarily on nursing staff as a typical helping profession, which is why we have chosen the nursing profession as the main group (Schmidbauer, 2002).

Data collection
The survey was conducted using LimeSurvey (2020) and took place between April 2021 and February 2022, in and around Salzburg, during the time of the COVID-19 pandemic.This study was approved by the local ethics committee.Participants received an online link and completed the questionnaires after they had provided written informed consent.

Participant characteristics
The health care professionals sample (n = 447) consisted of graduate frontline nurses with COVID-19 patient contact aged between 20 and 62.The mean age was 39.49 (SD 10.89).Managers or nursing staff who were exclusively in teaching positions were excluded.The control group (n = 295) consisted of people from other professions (e.g., architects, craftsmen, hairdressers, salesmen, IT, cook, service/ waiters and others), aged between 20 and 64 years, without COVID-19 patient contact.The mean age was 39.91 (SD 10.94).From this group other "helping professions, " namely teachers, psychotherapists, psychologists, doctors, priests, nuns, educators, secretaries, speech therapists, journalists, and nursing staff were excluded.People in training or retired people were excluded from both groups.The mean age of the health care professionals group and control group did not differ significantly (p = 0.61).The following participants were excluded from the sample: 40 participants who did not fit into a category, 42 nursing assistants, 14 nursing staff who did not work with patients, 8 participants who were either too old or too young, 3 nurses who were in training, and 70 participants who worked in other helpingprofessions.Since we were looking at occupational groups, it was important to us that all participants in the study were employed.No psychiatric disorders were recorded or whether anyone was receiving

Measures
Figure 1 shows which psychological methods and scales were used to measure symptoms and personality of Helper Syndrome.Results of two groups (nurses and controls) were compared using the following psychological tests: Selected scales of the Personality, Style and Disorder Inventory (PSSI) and the Freiburg Personality Inventory, Revised (FPI-R) were used to measure the specific personality structure of Helper Syndrome.The PSSI is a self-assessment instrument which measures personality styles.The PSSI comprises 140 items assigned to 14 scales (Kuhl and Kazén, 2009).Three personality styles (Helpful-Selfless Style, Loyal-Dependent Style, Ambitious-Narcissistic Style) were assigned to Helper Syndrome.The FPI-R measures traits of personality.It comprises 138 items and consists of 12 scales (Fahrenberg et al., 2010).Four scales (Aggressiveness, Social Orientation, Strain, Achievement Orientation) were used to assess Helper Syndrome.The internal consistency (Cronbach's alpha) of the scales of the FPI-R ranges from α = 0.73 to α = 0.83.The consistency coefficients (Cronbach's alpha) of the PSSI scales vary from α = 0.73 to 0.85.Table 2 shows the descriptions of styles and traits that were important for measuring Helper Syndrome.
The WHO-Five Well-Being Index (WHO-5) is a screening questionnaire used to assess psychological well-being.Advantages of the WHO-5 are its brevity and validity as a screening tool for depression (Topp et al., 2015).Brähler et al. (2007) demonstrated that the German version of the WHO-5 index has a very good psychometric accuracy.Scores range from 0 to 25, with 0 denoting the lowest wellbeing and 25 denoting the highest well-being.A score below 13 indicates depression (World Health Organisation-5, 2022).
The Alcohol Use Disorders Identification Test (AUDIT) is a screening questionnaire to measure unhealthy alcohol consumption.It consists of 10 items (World Health Organisation, 2020).The AUDIT is a reliable and valid screening tool for the identification of pathological alcohol consumption (Dybek et al., 2006).Alcoholrelated disorder is diagnosed at scores above 7 (Suchtforschungsverbund Baden Württemberg, UKL Freiburg, 2022).
Participants were also asked to assess their gender identity on an adapted Likert scale from zero to five (How masculine do you feel/How feminine do you feel?) A second self-assessment on an adapted Likert Scale addressed Helper Syndrome itself ("I have Helper syndrome.On a scale of 0-5, answer how much this statement applies to you").This self-assessment was included to capture how strongly someone assesses themselves as having a Helper Syndrome.This self-assessment does not necessarily have to agree with Schmidbauer's definition of Helper Syndrome.We were primarily interested in the self-description of the participants.

Statistical analysis
All analyses were conducted using SPSS v.27 (IBM Corp, 2021).In order to reassess the claims of Schmidbauer, a t-test for independent samples was calculated.For the t-test (two-sided significance) the Levene test of equal variance was used to check for homogeneity of variance.In total, of 31 variables were tested: all personality styles, all personality traits, alcohol consumption, wellbeing, self-assessments (12 scales of the FPI-R, 14 scales of the PSSI scales, 1 scale of the Audit, 1 scale of the WHO-5, 3 self-assessment scales).Hence, the level of statistical significance was adjusted to p = 0.002 (0.05/31) using the Bonferroni correction for multiple hypothesis testing (Bühner and Ziegler, 2009).In order to not ignore the two potential influencing factors of age and sex, a multiple linear regression was carried out.Two artificial groups were created: participants of "Helper Syndrome group" rated 4 or 5 on the selfdesigned scale "I have Helper Syndrome." The participants of the "Non-Helper Syndrome group" rated 0, 1, 2 or 3. Group differences between "Helper Syndrome group" and "Non-Helper Syndrome group" regarding personality styles, personality traits, femininity, masculinity, well-being, alcohol consumption were also investigated by calculating t-tests (for independent samples).Group differences "Helper Syndrome group" and "Non-Helper Syndrome group" There were no differences in demographic characteristics (gender, occupation, relationship status, extent of employment), except for age (see Table 3).The age of the groups differed significantly (t(740) = 3.44, p = 0.001)."Helper Syndrome group" (M = 37.57, SD = 11.15,95% CI [36.09, 39.04]) had a significantly lower mean age than "Non-Helper Syndrome group" (M = 40.55,SD = 10.68,95% CI [39.63,41.47]).

Personality styles and traits of Helper Syndrome by Schmidbauer
With exception of Aggressiveness (see below), there was no significant difference in Helper Syndrome characteristics between nursing staff and controls.Table 6 shows the group differences between nurses and controls regarding personality characteristics of Helper Syndrome.

Conclusion
Some of the personality styles and traits defined as characteristic for Helper Syndrome were significantly more expressed in individuals who described themselves as having Helper Syndrome.Especially Ambitious-Narcissistic Personality Style, Loyal-Dependent Personality Style, Helpful-Selfless Personality Style, Social Orientation, and Strain were prominent.Furthermore, participants who believe they have Helper Syndrome showed a significant lower well-being, possibly because of their combination of personality styles and traits.Nearly twice as many participants in "Helper Syndrome group" scored lower than the critical score of 13 for wellbeing, indicating depression in individuals who believe they have Helper Syndrome.
Our results indicate that the helper syndrome theory has flaws.First there was no significant difference in prevalence of Helper Syndrome in nurses and controls.Furthermore, nurses did not show lower well-being and did not consume more alcohol than control subjects.Similarly, there was no evidence of insecure gender identity among nurses of either sex.However, the nurses showed a significantly lower score for Aggressiveness, which is consistent with Schmidbauer (2018).This is confirmed by the finding that nurses suppress the open, direct expression of anger and instead choose forms of passive aggression, such as procrastination, apathy, unresponsiveness, forgetfulness, lack of understanding, or intellectualization (Carol, 1975).Thus, passive aggression is a potential characteristic of nurses, but not people who self-assessed them as having Helper Syndrome.However, we found that individuals who self-assessed themselves as having Helper Syndrome do not have a significantly lower aggression score.
For the first time, we were able to evaluate Schmidbauer's concept of Helper Syndrome.In synopsis of the studies and the concept of Schmidbauer and the concept of Pathological Altruism, a new clear definition can be derived.According to this, the "new" Helper Syndrome is an occupation-independent personality structure that is narcissistic, schizotypical, Borderline-like, histrionic, carefully-obsessive, rhapsodic, impulsive, somatizing, neurotic, dependent, selfless, socially oriented, and prone to stress and depression.In comparison to the concept of Pathological Altruism, which is defined as behavioral tendency to promote welfare of others with negative consequences for oneself and the other person, our new definition is superior because of its clear correlation to specific personality traits.Future studies should not focus certain profession but on personality traits and styles as potential predictors of mental health problems.
More empirical research is needed to verify these preliminary data.

Limitations
The voluntary participation of the participants, the one-time testing, the inhomogeneity of the control group, the gender-specific FIGURE 1The appearance of Helper Syndrome -described bySchmidbauer (2018)  -and the survey methods [PSSI, Personality Styles and Disorder Inventory; FPI-R, Freiburg Personality Inventory; AUDIT, Alcohol Use Disorders Identification Test; WHO-5, The World Health Organization -Five Well-Being Index (WHO-5)].

TABLE 1
Sociodemographic characteristic of participants.

TABLE 2
Description of styles and traits that were important to measure Helper Syndrome.

TABLE 4
*Statistical significance level of p = 0.002.The values with ** are significant values and because of this it is important that they are in bold.d, Cohen's d (effect size); n, Sample size; M, Mean; SD, Standard deviation.

TABLE 5
Group differences between "Helper Syndrome group" and "Non-Helper Syndrome group" regarding personality styles and traits.

TABLE 5 (
Continued) Statistical significance level of p = 0.002.The values with ** are significant values and because of this it is important that they are in bold.d, Cohen's d (effect size); n, Sample size; M, Mean; SD, Standard deviation. *

TABLE 6
Group differences between nurses and controls regarding personality characteristics of Helper Syndrome (t-test for independent samples).
*Statistical significance level of p = 0.002.The values with ** are significant values and because of this it is important that they are in bold.d, Cohen's d (effect size); n, Sample size; M, Mean; SD, Standard deviation.