How to prevent rescuer syndrome from going on overdrive

Vol 10 #5

Caroline Giroux 1, Magi Aurora 2

Author information:

1 Associate Clinical Professor, Psychiatrist, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. [email protected]

2 Family Medicine and Psychiatry 4th-year resident, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. [email protected]

Carl Jung suggested that disease was sometimes the best training for a physician. Thus, only a wounded physician could treat effectively [1]. He coined the term “wounded healer” to describe this phenomenon in which a provider is compelled to treat patients because he is himself “wounded.” This paradigm is no myth. A proportion of people having suffered from childhood adversity gravitate towards helping professions such as nursing, medicine, psychology, law, social work.  

ACE and Exposure to Catastrophic Situations

Conversely, many physicians are ACEs survivors [2]. As physicians involved in wellbeing initiatives in academia, we [authors] are too familiar with the psychological toll undergraduate and graduate medical education has on trainees, affecting wellbeing, performance, and even professionalism. Micro- (and macro) aggressions from sexism, ableism, racism, etc. in a profession with a historically patriarchal structure can revictimize clinicians, trigger past traumas, and expose vulnerabilities.  

Routine exposure to catastrophic situations and bearing witness to devastating stories leaves us susceptible to secondary traumatization, i.e. experiencing psychological symptoms that mimic post-traumatic disorder from working with trauma survivors. Additionally, perpetual sleep deprivation, financial debt, isolation, and constant demands from various stakeholders (e.g. insurers, hospitals, healthcare systems) precipitate vicarious traumatization and moral injury. Meanwhile, institutions tout wellness programming on topics such as yoga, mindfulness, and sleep hygiene, adding insult to injury by implying distress stems from a broken individual without acknowledging or addressing the environmental context of a broken system.

Could physicians who suffered abuse or neglect in childhood be predisposed to the insidious effect of medical training? Could an upbringing that devalued the child—thereby failing to develop a deep sense of self-worth disentangled from external validation or the need to earn the caregiver’s love—leave the provider more vulnerable? Experiences during early development and formative years have a deep and often lifelong impact on a person’s self-concept. Certain providers who derive their value or self-worth from a need to be productive or do something good may be more susceptible to victimization by a system and culture that glorifies long duty hours, steadfast obedience, and stoic diligence. Meanwhile, high throughput of patients to maximize revenue might be veiled as “learning opportunities.”  

Those who aren’t gluttons for work might be corralled in more covert ways: shaming, gaslighting and weaponizing professionalism to name a few [3]. It’s no surprise there is an epidemic of physician suicide, fueled by depression, toxic stress, and self-medicating behaviors. With 28% of residents experiencing a major depressive episode during training (vs up to 8% of similarly aged adults in the general population), ACGME has mandated wellness programming [4]. The pandemic, with its stringent restrictions regarding social contact and other activities, has added fuel to the fire. Zoom-based didactics, remote work, and efforts to observe social distancing have shored walls within the silos of medicine.  

Craving Social Contact 

Developmental trauma often begets a certain level of insecure attachment. Isolation from the pandemic and increased demands of healthcare workers can fuel the fire of shame that chars empathy and drains emotional resources necessary for clinical care. In contrast, healing from traumatic or chaotic attachment requires the creation of new, healthier templates of relations with peers or loved ones with whom we can be ourselves and share our vulnerabilities. Doctors, like anyone, need and crave social contact. Support from supervisors and colleagues is the most important factor strongly and negatively associated with burnout, emotional exhaustion, depersonalization, and secondary traumatic stress [5]. Processing emotions, challenging cases, shared experiences with peers can promote perspective-taking, validate emotional responses, and distribute the burden of secondary stress. In essence, support from peers can reinforce the boundary between clinic and home, enabling the clinician to leave work at work.   

Medical culture and our healthcare system need a paradigm shift. As trainees routinely bear witness to racial and social inequities by working on the frontlines of the healthcare system, institutions and training programs must adopt a trauma-informed lens to patients and providers alike. We need to approach “professionalism lapses” with a similar framework and respond (rather than react) empathetically in a manner that reduces the likelihood of retraumatization of the wounded healer.  

Once the resident is offered appropriate, individualized, and proportionate support, he/she can thrive in a way that no one would have imagined. I (CG), as a supervisor for residents working in our trauma recovery programs, have often found that trainees who “got in trouble” for speaking up or experienced professionalism lapses also had past wounds, and they turned out to be some of the most competent providers. Programs must be sensitive to an individual’s unique socio-cultural narrative, including the impact of gender identity and race, and curious about/attuned to the individual’s needs when offering support. . For instance, some female residents noted they are spending more time with patients or patients tend to have a more emotional display (like crying) in their presence as opposed to their male counterparts (probably because of trust or gender stereotypes, like the mother or nurturing figure they represent), so female residents end up being extra solicited and exhausted in these trying times. 

T Time Rounds 

Second, developing activities for residents and by residents is an essential component. The authors have collaborated in a mentor-mentee relationship for an online set of modules to prevent burnout and boost resilience. Later on, CG developed a discovery model for residents called “T” Time Rounds (T for drinking tea while discussing and writing about taboo subjects) based on Healer’s Art, and that is meant to cultivate a sense of awe in medicine using storytelling and meaning-making. Snacks were provided and reimbursed by the department at their institution when the activity occurred in person. CG gave some notebooks and provided pens. After a year of piloting this elective activity, her resident and collaborator (MA) who had first joined as a participant started to have a co-facilitator role for the group a year later. The structure involves a check-in with gratitude sharing, followed by mindfulness practice, a reiteration of group expectations (including reassurance about confidentiality), and the selection of a writing prompt (provided by CG). Each group, which participants can vary from time to time, naturally and consistently chose to pick a theme based on consensus. Even if it was not the goal initially (everyone having the option to pick a different prompt), it turned out to be a nice tradition.  

Since the beginning, these intimate encounters have created a powerful and memorable experience. The diversity of perspectives has made this exchange so rich and inspiring every time. Tales of heroic transcendence have been shared by souls of archetypal beauty, bringing tears to CG’s eyes, leading her to call the group “Pillars of Truth”  following the first session. This inclusive activity has been occurring every two months after clinic hours, for about 90 minutes, until we can convince the department to block some time during regular hours. Because of the pandemic, we have been able to offer this session virtually. We are seeking to improve this to match the dynamic aspects of the evolution of the group of trainees (for instance, we might consider sending a prompt ahead of time so the participants can come prepared and make the best out of the 20-min writing exercise). 

Preventing Burnout 

In conclusion, the phenomenon of burnout is still prevalent but preventable and treatable. Some modalities such as T Time have the potential to buffer the stress and cost-effectively promote healing and would warrant further research. It is our sincere hope that more such initiatives flourish in various venues. Providing a safe space for physicians to process, recharge, and continue to heal and grow is overdue. The victim-rescuer paradigm doesn’t have to be a life sentence. It should open the door to an increased awareness of the need for self-compassion, and then for sharing wisdom and hope with each other. 

References: 

1. Jung, Carl G. “Fundamental Questions of Psychotherapy.” The Collected Work of C.G. Jung, Vol. 16. Ed. Herbert Read, Michael Fordham, Gerhard Adler, and William McGuire. Trans. R.F.C. Hull. Princeton: Princeton UP, 1951. 116-25. 
2. Williams, Betsy White Ph.D., MPH;Welindt, Dillon; Hafferty, Frederic W. Ph.D.; Stumps, Anna; Flanders, Phillip Ph.D.; Williams, Michael V. Ph.D. Adverse Childhood Experiences in Trainees and Physicians With Professionalism Lapses, Academic Medicine: June 9, 2020 – Volume Publish Ahead of Print – Issue – DOI: 10.1097/ACM.0000000000003532  
3. Bynum IV, W. E., Artino Jr, A. R., Uijtdehaage, S., Webb, A. M., & Varpio, L. (2019). Sentinel emotional events: the nature, triggers, and effects of shame experiences in medical residents. Academic Medicine, 94(1), 85-93. 
4. Mata, D. A., Ramos, M. A., Bansal, N., Khan, R.,Guille, C., Angelantonio, E. D., & Sen, S. (2015). Prevalence of Depression and Depressive Symptoms among Resident Physicians. JAMA, 314(22), 2373. doi:10.1001/jama.2015.15845  
5. Singh, J.,Karanika-Murray, M., Baguley, T., & Hudson, J. (2020). A Systematic Review of Job Demand and Resources Associated with Compassion Fatigue in Mental Health Professionals. International Journal of Environmental Research and Public Health, 17(19), 6987.