A patient I had been treating for trauma for about six months sat before me, his hands moving restlessly as he talked, his legs spasmodically bouncing up and down. It had been more than 15 years since J.J. had been a young firefighter, and he was recalling one of his first calls as if it happened yesterday. His anxiety and discomfort were palpable.
He had been barely 20, inexperienced, anxious to do everything right on one of his first major calls. It was a two-story clapboard house with old wiring and pre-code construction. The crew knew an older woman was inside but didn't know where. The neighbors had seen her before the engines pulled up: She was leaning out of her upstairs bedroom in a blue robe, waving her arms frantically, screaming, but then she disappeared suddenly.
J.J. was one of the first inside. Moving through the still-rising smoke with a limited range of vision through his mask, he walked through the hallway slowly, his eyes focused on the ceiling overhead, a part of which had already fallen. There were piles of smoldering beams, ash and the remains of a table. He stepped to his left around the banister and ... crunch.
He looked down and nearly vomited.
"Don't move!" his chief, who had been keeping an eye on the rookie, yelled from down the hall. J.J. froze until he got the sign that he should lift his foot back up -- slowly -- and then step to the right. The chief lifted a charred two-by-four to reveal a small piece of blue robe. It was the only color left in the room besides the yellow stripe along their coats. She had tried to get downstairs herself when the ceiling collapsed on top of her.
As J.J. spoke, I found my posture mirroring his own, my heart rate slightly elevated, and my hands and feet fidgeting more than usual. By the end of the story, I felt as if I had stepped on the woman myself.
I sat still, facing him, and took a deep breath. He had stopped fidgeting. Once again, I saw the pain in his eyes and considered the importance of what had happened. It was the same process that storytellers and listeners have experienced for centuries. The words we useƒeven in the most ordinary conversationsƒmove us. Not just metaphorically. Literally. The stories we hear don't just make us frown; they don't just elicit a good laugh from time to time. They impact us physically. They touch us where we feel it most deeply, sometimes without our permission. It washis trauma, but for a few moments I had all the symptoms of having undergone it myself.
In both clinical and first response settings, traumatic events can eventually intensify to the point where we feel too much distress. When we start taking it home with us, when our behavior begins to change, when we can't seem to get it out of our minds, we're said to be suffering from "secondary" or "vicarious" trauma. In hearing, watching, or in some way experiencing someone else's crisis, we, too, may assume some of the traumatic effect.
"Vicarious traumatization" refers specifically to "... the enduring psychological consequences for therapists of exposure to the traumatic experience of victim clients. Persons who work with victims may experience profound psychological effects, effects that can be disruptive and painful for the helper and persist for months or years after work with traumatized persons."
Although this definition was created with therapists in mind, it's highly applicable to EMS providers, who, by nature and training, make strong connections with their patients in crisis.
Psychologists call these connections "empathic connections," and they can manifest in many ways in and outside of health-care settings:
- Symptoms of traumatized children may appear in their non-traumatized playmates; Even if the actual trauma occurred years prior, family members may develop post-traumatic stress disorder (PTSD) symptoms. Children whose fathers are Vietnam veterans showed impaired self-esteem, poor reality testing, hyperactivity, aggressive behavior and difficulty managing their own feelings, especially fear, rage guilt and mistrust; The wives of Israeli veterans diagnosed with PTSD may demonstrate increased, observable psychiatric symptoms, suffered with more somatic disturbances, and complain more often of loneliness.
As providers who work with crisis every day, our susceptibility to vicarious trauma is high. In non-structured situations, such as the prehospital environment, the ripple effects of crisis can be even more unpredictable. People who interact with victims of secondary forms of trauma may suffer not only from hearing the story told repeatedly, but from changes in the individual's behavior that impact them personally. Friends and family members of the victims may have to endure mood swings, long bouts of silence, interminable crying jags, impossible loquacity, somatic disorders, hypochondrias and irritability with even the most trifling errors. Some examples of secondary trauma in professional settings are a loss of perspective, an over-identification with the victim, irritability or impatience, confusion, an impaired memory and an exaggerated sense of responsibility.
There seems to be consensus that PTSD may be "transferable," which isn't surprising when you consider that we are what we surround ourselves with. First responders, no matter how resilient, clinicians, no matter how well trained, and volunteers, no matter how scrupulously prepared, are no exception. When we face our patients, we ultimately have to face ourselves.
It's common for seasoned providers to experience a sudden feeling of incompetence and hopelessness when dealing with a traumatized patient. The experience of vicarious symptoms of PTSD may challenge the provider's basic faith and heighten a sense of personal vulnerability, distrust and cynicism about the human condition. The caregiver may experience profound grief and feel as though they were in crisis themselves. Additionally, the caregiver may feel caught between identifying with the perpetrator and the victim. There may be moments of hate and contempt, and a wish to be rid of the victim. These may be indicative of the caregiver's difficulty in coming to terms with the possibility of their own capacity for violent behavior or with prior trauma in their own life.
Gauging Your Susceptibility
Victimization impacts and disrupts the concept an individual holds about the self, as well as the way in which they perceive others. There are seven factors that can make individuals especially susceptible to trauma-induced alteration: the individual's personal frame of reference about self and others in the world, safety, dependency and trust, power, esteem, independence, and intimacy. First responders may have their self-concept altered, evidenced by such symptoms as nightmares, changes in sexual functioning and fear. Clinical observations from my own practice support findings about susceptibility to vicarious trauma.
Consider the following factors when determining your risk of experiencing stress as a result of traumatic incidents.
The higher the degree of visualization, the more intensely we're moved physiologically, both positively and negatively. This is why we pay upward of $10 to watch a movieƒbecause what we see on a flat, unmoving screen can in fact generate terror, tension, loss, hope, longing and escape.
The greater your capacity for empathy, the higher the chance of developing secondary trauma. Teaching people to erect boundaries, both psychological and spiritual, has been one of the core aspects of my work.
The more trauma in our past, the more likely we are to be affected once again. Whether the present trauma is retained or not depends on the intensity of past trauma, the propensity to dissociate, the degree of repression innate to an individual, and the amount of support the professional can call onƒand if, of course, they utilize it when they need to. The old expression, "we are as sick as our secrets" holds true.
There are distinctive thought patterns that tend to facilitate secondary trauma: "It could have been me;" "It could be me;" "It is me;" "I can feel it;" "We're all doomed;" and "Go away."
There are also distinctive cognitions that tend to facilitate well-being: "I can help them through this;" "Keep it simple;" "I do what I can and let the rest go;" "I'm doing my best. You (the higher power) get the rest."
What we say in the spaces of our own mindsƒthat internal running dialogue with ourselvesƒis the rudder that steers us in one direction or another, toward health or toward destructive psychological behavior.
A Survival Guide
What are our cognitive options as professionals in the face of pain and suffering? How can we help the patient, yet protect ourselves from psychological harm?
- We need to see our patients with a wider-angle lens, as more than just people experiencing the worst moments of their lives. We all suffer stress and can (and do) find ways to grow. There's meaning to all things, even suffering.
- Pain is temporary. Even chronic pain typically appears in waves.
- I am not my patient. I am here, and I am OK.
- There are some additional simple points to remember, whether you're caring for a chronically ill loved one or tending to a patient. The pitfalls are the same regardless of the situation, because they're less contingent on the circumstances surrounding us than on what we bring to them.
You didn't cause it. You can't cure it:Know the trauma isn't your fault, and the behavior associated with secondary trauma isn_t your fault. Learn the distinction between what you can do and what you can_t. Sometimes this is especially difficult when there's a sense of guilt or unresolved grief.
Some people rely on the Serenity Prayer or a modified version of it to remind them where their power begins and ends. This is a critical issue for many of us. We can't help everyone, no matter how much we want to. Sometimes the most important thing we can do is be present in a person's last moments or help their loved ones through it.
Don't become a martyr: Be careful how far you go in an effort to help. When we give too much, to the exclusion of our own needs, we're leading ourselves down the path of bitterness, resentment, reclusiveness, ill health, loss of work and self-negation. Becoming a martyr is not a selfless act. It's self-destructive. Patients need you to be well and strong.
We need rest to do this work: If your sleep cycle is being interrupted, get help. The lack of sleep can be particularly damaging to our bodies and minds. We become irritable, more likely to become physically ill, less clear-minded and far less effective. Make sure you rest.
You really are what you eat: Healthy eating is the first thing to go when we're under stress and the simplest thing to correct. Bad nutrition depletes the entire systemƒquickly. If you_re not sure of what you need or what you_re missing, see a nutritionist.
Exercise: Maintain your posture. Take a long walk or take up running. Learn yoga. The point is, regular exercise is critical. Without it, we're prone to depression and lethargy and are particularly susceptible to secondary trauma.
Be social: One retired detective put it best; he said, "The people I know who survived the job best are the ones who had lives outside the job." Keep your friendships alive. Go out. Stay involved in the community. Keep your hobbies active. Stay interested and invested in your own life. It may seem selfish at first, but it's a critical component of kindness.
Stay aware of your spirituality: Traditionally, stress management is outwardly directed: change your job, slow down, alter your diet, etc. These things are important, but there's an inner process, a cognitive and emotional process that initiates the cascade of chemicals in the body associated with stress. The best way to manage yourself during and after a traumatic event is to have a spiritual context for your life. See the bigger picture. Be able to remind yourself that you're not your job, you're not your circumstances. Trauma, by its dissociative nature, tends to narrow our lens. Having a broader existential context redefines us more accurately.
Cultivate inner stillness: Breath work and meditation are incredibly valuable and change the way we think and process sensory input. University of California, San Francisco, Professor of Medicine Dean Ornish's study on heart disease showed that meditation may actually reverse arteriosclerosis when done twice daily for 20 minutes.
Keeping this advice in mind and practicing these techniques every day will go a long way toward preventing vicarious trauma, but at some point in your career, you may still find yourself in the grip of intense stress resulting from somebody else's traumatic event. When this happens, reach out to your support network and get counseling. Just as no victim can recover alone, no emergency responder can deal with crisis alone.JEMS
1. McCann L, Pearlman LA: "Vicarious traumatization: A framework for understanding the psychological effects of working with victims." Journal of Traumatic Stress. 3(1):131Ï149, 1990.
2. Figley CR, Harkness LL: "Transgenerational Transmission of War-related Trauma." International Handbook of Traumatic Stress Syndrome. Plenum Press: New York, N.Y., 1993.
3. Herman J: Trauma and Recovery: The Aftermath of Violence from Domestic Abuse to Political Terror. Basic Books: New York, N.Y., 1992.
4. Ornish D: Stress, Diet, and Your Heart: Dr. Ornish_s Program for Reversing Heart Disease: The Only System Scientifically Proven to Reverse Heart Disease Without Drugs or Surgery. Ivy Books: New York, N.Y., 1982.
This article originally appeared in May 2009 JEMS as "Borrowed Trauma: Why we relive our patient's pain & how to avoid it."