Self-care and vicarious resilience as buffers to secondary traumatization
Vol 9 #1
Caroline Giroux, MD, FRCPC
Associate Clinical Professor, Psychiatrist, UCD Trauma Recovery Center Director, Department of Psychiatry and Behavioral Sciences, UC Davis Health System, Sacramento, CA, USA, [email protected]
Helping professionals and those doing humanitarian work all around the world, such as physicians, nurses, social workers, psychologists, attorneys, police officers, and correctional staff, are at risk of developing post-traumatic stress disorder (PTSD) symptoms because of the very nature of their work.
For instance, a police officer arriving at a crime scene orhealthcare a physician witnessing death from COVID-19 in the intensive care unit might both experience significant symptoms in the aftermath. This type of trauma involves direct exposure and is therefore primary. It is just like for patients we serve who have suffered trauma (domestic abuse, car accident, war-related trauma, natural disaster…). Secondary traumatic stress refers to the development of symptoms while helping people who have been traumatized and who share their traumatic stories.
A Child Protective Services worker might develop symptoms from hearing child abuse stories. Secondary traumatization also occurs in family members or close confidants of a person who has experienced direct trauma (such as a parent hearing about his or her own child’s history of bullying or sexual abuse). Secondary traumatic stress can happen to a person who bears witness (such as a professional worker) and who ends up developing subclinical or clinical signs and symptoms of PTSD that mirror the trauma-related experience of the patients. Even though the trauma has not been experienced directly by the professional or family member, it is easy to understand that physicians’ innate or nurtured ability to experience empathy might make them feel with the patient and experience very acutely this trauma, as if it had happened to themselves. I will address the concept of empathy in a section below.
The experience of trauma by the professional prior to the job exposure and the way these situations were addressed or not could determine how a professional will cope with new trauma. If past trauma has been repressed and the physician has not fully healed, a patient encounter can reactivate traumatic responses by reminding the physician of his or her own trauma stories. The patient might then act as a “trigger”. This is almost unavoidable in our field, as we will meet so many people with whom we can easily identify or who might remind us of painful life experiences. Hence the importance of being aware of our own triggers, otherwise, the doctor is at risk of using avoidance strategies (such as not screening adequately), or of being more reactive (irritated, dismissive) than responsive (attentive listening). This could put the patient at risk of retraumatization.
Not surprisingly, self-care (including effective self-regulation of painful affects) is the foundation of trauma-informed care because it implies self-awareness of our own limitations and offers balanced ways to cope with them. This makes us more attuned to other people’s reactions and manifestations of distress.
Vicarious trauma and secondary traumatization have been used interchangeably in the research literature . However, the former has a more positive connotation in the sense that we may be able to derive inspiration and insight for ourselves by listening to the patient’s account of trauma. It can feel like suddenly becoming enlightened by the fragility of life, leading to the need to look at the big picture, to revise one’s priorities, or for the first time to experience gratitude feelings towards our own parents. So in that case, the patient’s own trauma brings something important to our awareness that makes us grow and become more present to ourselves and others. This can enhance our capacity to experience joy and do good.
A derivative of vicarious trauma is vicarious resilience. This is the ability to find strength and inspiration from experiencing the patient’s own resilience. This is a very positive aspect of the interaction and can be seen as one of the rewards of working in an emotionally demanding career.
Just think about a recent patient who had been through a lot and who left a strong impression on you, giving you hope for the future.
Conversely, secondary traumatization can be disabling as it might trigger deep feelings of horror, anger, and helplessness. The physician or professional might even present various PTSD symptoms such as flashbacks (of the patient’s own stories), nightmares, mood dysregulation with irritability or frequent crying spells, dissociation (feeling detached from one’s body, losing sense of time), and avoidance behaviours such as isolation, absenteeism, suicidal crisis or substance misuse. A deep sense of meaninglessness or demoralization may dominate the picture. This new, indirect traumatic experience can be superimposed on the professional’s own trauma stories that are reactivated.
To minimize the impact of secondary traumatization or PTSD in general, each physician should be aware of their specific adverse childhood experiences (ACEs). Medical students are highly likely to have experienced ACEs. The “wounded healer” paradigm might explain this, and generally it makes sense to be drawn towards career choices that have familiar aspects such as attempts to alleviate suffering.
On a more or less conscious level, people who have suffered trauma might be drawn to situations where they will finally act as “rescuers” instead of helpless victims. Unconsciously, they may be attracted to that profession as a possibility for repair or triumph over past traumatic experiences. I believe that people with lived experience enrich our field by broadening perspective and enhancing sensitivity through a quality of presence as healer. But when the commitment occurs without a full awareness of one’s own wounds or vulnerabilities, this becomes a double edged sword and might increase the risk of PTSD from clinical situations that resonate with the physician’s past.
If the stress experienced at work becomes overwhelming and severe, it will affect the physician’s functioning and ability to experience joy. Sometimes, PTSD presents as depression (in fact, 5 criteria for depression overlap with PTSD criteria; hence, screening for depression only might make one miss underlying PTSD). Conversely, depression can be the equivalent of residual PTSD. A thorough assessment of the physician’s childhood including attachment history can shed light on the underlying mechanisms leading to mood changes, feelings of worthlessness, hopelessness or helplessness. With the help of a psychotherapist , the physician can find a safe space to process painful emotions associated with the trauma exposure at work and also with the remote traumatic experiences. A therapist can assist the physician to identify and work through the specific triggers allowing the physician to reconnect with his or her resiliency. Within the therapeutic relationship, there is also an opportunity for repair of interpersonal trauma or insecure attachment.
There are numerous evidence-based interventions for PTSD, such as narrative exposure therapy, trauma-focused CBT, Cognitive Processing Therapy, Prolonged Exposure, Experiential Psychodynamic Psychotherapy, EMDR. At times, it is necessary to add a medication to alleviate severe symptoms of depression or PTSD, including avoidance, suicidal ideation, intense neurovegetative symptoms etc. Evidence-based pharmacotherapy can help recalibrate the stress response systems that have been overly sensitized by the traumatic experiences.
Socrates’ words resonate with our daily work:
“The only life worth living is the examined life”.
Insight into one’s past provides an advantage and the possibility to be empowered. Self-awareness will help us all to access our own resiliency. Once we know how past situations have affected us throughout our life, how they have influenced our choices or relationship dynamics, we are more likely to take measures to engage in extra self-care activities, which will buffer the occupational stress.
Having a healthy lifestyle, including restorative sleep, nutritious diet, exercise, mindfulness and socialization will increase our emotional reserves and make us providers more able to approach a patient’s painful story with compassion. Compassion is the byproduct of mindfulness. Its ultimate expression can be viewed as an unconditional love for all creatures; it is a form of altruistic love that is not based on dependency but takes place with detachment, without expectation, which is distinct from empathy.
Any emotion (anxiety or sadness) is a signal that we need to attend to a situation to restore balance and makes us mindful (see figure).This in turn can lead to compassion towards self and others. It helps us connect with people while not being overwhelmed by their problems. It is about looking at a situation with curiosity, without judgment. By being compassionate, we are subsequently more apt to mentalize, to think about others’ thinking (see figure).
Empathy is closer to a raw emotion (a signal: see above) and if we stay stuck at that stage without being able to move to a position of mindfulness and compassion, it can be draining and even lead to burnout (perhaps we should talk about “empathy fatigue” in medicine, rather than “compassion fatigue”, because once accessed, compassion stores are unlimited). Being compassionate allows us to see more clearly and makes us all more effective in approaching life challenges. By being mindful, we also maximize our chances of experiencing joy, by being attentive and catching it as it occurs, and when we learn to cultivate it, it boosts our compassion.
Trauma is ubiquitous. Even though we cannot erase trauma stories, we can heal from them and also better prepare for secondary trauma at work by boosting our resilience and maintaining connections with supportive colleagues.
If you think you are experiencing trauma-related or depressive symptoms, please know that you are not alone, and help is available. Acknowledge your patients’ own resilience, since witnessing it can revitalize you. Make room for your emotional experience after a traumatizing situation. It will help you plant a vast garden of mindfulness on which joy can rain, making the flowers of compassion grow, thrive and brighten up the world.