Secondary Stress and the Health Care Provider
The following perspective, offered by an ER physician, does not necessarily reflect the views of the Division of Mental Health, Developmental Disabilities and Addictive Disease. It is offered as a point of view about the personal and professional costs of working with suffering.
I think, perhaps, I have seen enough pain for one life. I know, I know, I'm only 40 years old. I'm soft now. I used to love intubations and resuscitations; I used to love the thump of the defibrillator, the thrill of blood from deep wounds, the surprise of something horrible on a CT scan. I was once thrilled by helicopter blades whirring and ambulance light bars flashing, by anxious voices over radios. I wanted to see bullet holes and bullet fragments. I was irresistibly drawn to the chaos of disaster. But then, I used to be separate from it all, outside it, a young, powerful man with a kind of immortality and immunity to the suffering of this world. But that is fading with the years, and fading fast.
I wonder how much pain we have to witness, or be part of, to make an adequate career. I have been informed that expertise in emergency medicine requires something like seven years, or 40,000 patient encounters. But how much suffering is sufficient to say, "Thanks, that's plenty. I quit"? I don't know the number. I'm sure that it differs for every woman and man who practices medicine. But we seldom admit it, because we equate that feeling with weakness.
We walk through it as if it is nothing. We put our clumsy hands into the bodies of the wounded, we take away their breath to give them synthetic airways. We listen as they open a dark door into their dark worlds, where daughters are raped by fathers, where children are left with strangers while mothers get high, and the strangers beat them mercilessly. We sit by strangers and say things like, "I'm sorry, but your child's injuries were too severe, and despite everything we did, she died."
She died. We say that over and over. He died, she died, they died. He has a hemorrhage in his brain, she has a heart attack, they are in surgery, he will never walk again. This is who we are. We are the messengers of chaos, the wardens of entropy, where the dissolution of the universe takes the very personal appearance of death and wounds and terrible illnesses. And where the technicalities of medicine's inadequacy simply mean loss, and loss becomes screams and sobbing before it becomes a sterile news clipping or obituary.
At the sharp point of medicine, the very tip where all bad things go first, we balance our lives, and cover up our hard secret with science and research, with our desire 'to help the suffering, to save lives', and with the necessarily callous humor that no one else grasps.
Our secret, brothers and sisters, is that for every bit of pain we see, a little bit stays inside. In some secret place in our hearts and minds, we accumulate it. Sometimes, a professional will be knocked down and out by a single dose of it. Like a nuclear weapon, it melts their circuits. But most of us get accumulated small doses, and the effects are stochastic, unpredictable.
But, I predict, the effects are greater than we know. Thanks to the politics and rules of modern medicine, we see more pain, more rapidly, with less chance to process it than ever before. It comes in great waves in some centers, day after day of violence and tragedy, death, pain and misery. And all those who face it are like Caligula's guards, ordered to drive back the sea with swords and shields.
In some places, like mine, it comes in smaller waves, but no less devastating. Worse, perhaps, since the longer I live here in one small place, the more likely I will see friends and family and co-workers and others I know, lying supine on the gurney before me, with cancers, accidents, assaults and death.
That's the thing. Love makes it all harder. When we are younger, we love intensely, passionately, but not with the depth, or desperation, of our years. Now, husband of my lovely wife, father of my perfect children, I fear for them. Or maybe, I fear for me, for the possibility that I might lose them, or that I might have to face their suffering.
And this love makes me feel the loss of other spouses and parents more acutely. I imagine myself in their situations. I hurt for them. Maybe I'm doing the right thing, 'mourning with those who mourn', but it takes so much out of me, out of all of us, when we do it over and over and over again, and when we put a little more inside us each time, one more artifact of someone else's agony, one more memory of a scream, of a look, of a sob.
As I grow older, I realize that some wounds will always be with us. I can call up images that I will never be rid of, at least not in this life. All I can hope is that in heaven, where suffering is not even a memory, I will see my patients, and they will see me, and the best we will be able to do is, "don't I know you?" I won't remember their troubles, they won't associate my face with their former pain, as people in this life certainly must.
That's my hope, for me and for all who labor in a job that casts us daily into all the troubles of humanity. And if you don't want to wait around for heaven to ease your pain, it's OK to say, 'enough'.
Those who interact with trauma survivors are themselves exposed to a form of traumatic stress. More recent diagnostic formulations of Post-traumatic Stress Disorder such as those in DSM-IV have broadened the definition of trauma to include participation in others’ traumatic response. As you see and treat patients who have experienced disaster, whether in the emergency period immediately following it or thereafter, you will be exposed to secondary stress and traumatization, the focus of this fact sheet.
- Secondary stress has also been termed Secondary Traumatic Stress Disorder (STSD), vicarious traumatization, compassion fatigue, or empathic strain.
- Some helpers exposed to stress develop PTSD, but the experience of the full syndrome is only one of the ways in which professional helpers are affected by their exposure to secondary traumatic stress.
- Your vulnerability to secondary stress is influenced by:
- personal history, current life circumstances, as well as proximity and personal connection to the events and people involved in the disaster
- your level of empathic engagement with your patients’ experience of the disaster
- your perceived similarity to the victims of the disaster
- Secondary stress involves the following features:
- A broadened sense of “what can happen,” sometimes experienced as a “loss of innocence” or as cynical detachment influencing your frame of reference and identity, worldview, and spirituality.
- Cognitive distortion around normalcy and baseline rates. Our awareness that planes actually do crash and innocent appearing adults actually do molest children can transform into an expectation that every plane is likely to crash and every adult is likely to hurt our child. When we lose our sense of perspective in this way, we enter the world of the traumatized.
- Heightened arousal and vigilance, a way of being human in which we are characteristically aroused and remain constantly on our guard because we anticipate danger at every turn.
- Avoidance, as we find ourselves organizing our lives around what might happen, rather than what is happening.
- Emotional consequences of involvement, experienced as:
- Threats to self-capacities of emotional management, self-worth
- Changes in basic beliefs about psychological needs (i.e. safety, trust, esteem, intimacy, and control)
- Loss of hope and meaning; increased cynicism and pessimism; nihilism, existential despair
- Anger at the disaster or the perceived causes
- Symptoms similar to those of the patients being treated; a blurring of what experiences are “ours” and what belongs to the victims (a process involving dissociation)
- A sense of unworthiness and survival guilt
- A persistent and extreme sadness, or dysphoria
- A sense of mourning and grief
- Behavioral changes such as:
- Becoming judgmental of others
- Tuning out
- Having a reduced sense of connection with loved ones and colleagues
- Becoming cynical or angry and losing hope or a sense of meaning
- Developing rescue fantasies, becoming over-involved, taking on others' problems
- Developing overly rigid, strict boundaries
- Feeling heightened protectiveness as a result of a decreased sense of the safety of loved ones
- Avoiding social contact
- Avoiding work contact
- Secondary stress can affect your:
- Relationship with meaning and hope
- Ability to get your psychological needs met
- Sense of humor
- Ability to protect oneself
- Existential sense of connection to others
- Dangers of secondary stress lie in both direct negative effects (intrusive imagery, disrupted beliefs) and in our way of responding to it (numbing, over-generalized negative expectations, cynicism).
Coping with secondary stress:
- Self-assessment: Ask yourself, "How am I doing? What do I need? How have I changed?” Discuss the questions and answers with a colleague, friend, or therapist.
- Protect yourself through awareness of your vulnerability and recognition of the negative consequences of your work as echoed in the voices of others.
- Work to cultivate a:
- Sense of strength
- Sense of meaning
- Spiritual connection
- Respect for human resiliency
- Address the stress of your work through practicing self-care. Nurture yourself by focusing on sources of pleasure and joy, and allow yourself to escape when necessary.
Fortunately, health care professionals have tools to manage secondary stress: we have knowledge of the ways in which trauma affects people, we have skills for soothing arousal and processing states of distress, and most importantly, we have each other, a support system with the potential to help each of us maintain perspective and find understanding during those times when we get caught in the web of secondary traumatic stress. We are not invulnerable, but if we maintain a strong sense of community among ourselves, we can be resilient.