I used to work closely with veterans and retired soldiers at the VA Hospital. I did bedside psychological evaluations following their surgeries, amputations, and traumatic brain injuries. I treated them for post-traumatic stress disorder, addictions, depression and suicidality. Throughout this work, I was listening to decades’ worth of stories. While most of my hospital patients were recovering from both physical and psychological injuries from their service in Iraq and Afghanistan, a considerable number were still dealing with the long-lasting stressors from the Vietnam War and even the Korean War. After a while, day in and day out of evaluations and assessments, it started to feel “routine” to be exposed to stories of injury, medical trauma, loss of life, and great pain. What do I remember about this time? Only that I was exhausted. Some days were just a fog. I would arrive at my house at the end of my workshift and not even remember how I got there. In the morning, I’d review charts and try to delay dealing with the “worst” ones. When I visited the inpatient unit, I’d knock on doors and pray that the rehab specialist or post-op nurse would send me away. “We can’t do a psych assessment right now, we’re getting Mr. Smith’s vitals.” Fine.
Once in a while someone in my life would ask me how I was “holding up” and whether I was “OK.” I never quite understood these questions. I always thought, “It’s my job, of course I’m OK.” In fact, if I felt anything less than “OK,” I’d be a horrible person for minimizing what has happened to my patients. I didn’t understand what other experienced practitioners already knew: Exposure to other people’s trauma will transform me on a fundamental level. It will become a part of me. My views about the world will change.
Years later, as an educator and administrator at a children’s mental health agency, I realize just how much influence traumatic stories have on us. Though different in some ways than war-related trauma, childhood trauma can have a similar impact on people in the helping profession. The constant exposure to distressing and tragic stories can take an emotional toll and actually compromises our professional functioning. Put simply: We lose our ability to nurture. We can’t do our jobs effectively anymore. And despite being the “holders” of trauma, we’re expected to be “immune” or untouched as if we share a superpower that no one talks about.
“The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet.”
– Rachel Remen, Kitchen Table Wisdom: Stories that Heal
Burnout, Vicarious trauma, and Compassion Fatigue
What is Burnout? The word says it all: Burnout. Burned out. FRIED. Burnout is the experience of feeling emotionally exhausted due to work. Burnout is characterized by fatigue, weariness, depersonalization (feeling disengaged from your surroundings or your body), and a reduced sense of accomplishment. It’s far worse than feeling “meh.” A lot of times, burnout results from long work hours, frequent shift changes, poor working conditions, feeling undercompensated, or receiving little support from colleagues. Burnout results from workplace stress no matter your occupation.
What is Vicarious Trauma? More common among professionals in the “helping fields,” vicarious trauma occurs due to indirect exposure to traumatic events. Although some helping fields involve “primary” exposure to traumatic events (e.g., when working as paramedics, firefighters, police officers, emergency hospital workers, etc.), there are some fields that include “secondary” exposure (hearing clients talk about past trauma, helping people who have been victimized, treating children who show signs of emotional and/or physical abuse, etc.). Indirect trauma exposure means that you are hearing/experiencing a trauma through another person who is sharing their story. Even though we did not experience the trauma ourselves, we find it difficult to rid ourselves of the images and details they have shared with us. Over the course of our career, we’re absorbing and accumulating hundreds if not thousands of traumatic stories. This can actually cause a shift in our fundamental beliefs about the world.
Is Vicarious Trauma like “Secondary Traumatic Stress”? In some ways, yes. In fact, therapists, psychologists, child welfare workers, case managers and other “helping professionals” are at risk for developing PTSD symptoms because they work closely with traumatized individuals. Secondary traumatic stress essentially mimics PTSD symptoms and is characterized by re-experiencing your own personal trauma, increased feelings of being “on edge,” avoidance reactions, alterations in your self-efficacy, or disruptions in your perception of safety, trust, and independence.
What is Compassion Fatigue? This refers to the profound emotional and physical exhaustion that helping professionals develop over the course of their careers. It’s the gradual erosion of what makes us healers: our hope, our empathy, and of course our compassion. When we suffer from compassion fatigue, we become dispirited, embittered, and resentful. We start to feel helpless within our profession. Some of us may not admit this, but when we’ve hit this point we also dread working with certain clients and even avoid them because it is difficult to tolerate strong feelings when we’re in the same room with them. Additionally, we might avoid or distance ourselves from colleagues, friends, and loved ones. We have thoughts like “what’s the point?” “Am I even making a difference anymore?” Compassion fatigue is the insidious occupational hazard that often goes ignored.
How do you know you’re struggling with Compassion Fatigue? Researchers and experts have noted a number of signs ranging from numbness to destructiveness. They explain that we often turn to “destructive” self-comfort to cope with what’s going on. In other words, we resort to extreme ways to alter our mood, jump-start emotions or push away feelings–for example, spending the whole day marathoning movies at the theater instead of seeing clients, hooking up with strangers, using alcohol in large amounts, drug use/abuse, etc. I’m not saying these are bad choices. They are ways in which we try to feel better or cope, but might be maladaptive and/or distracting if we’re trying to push away certain thoughts and emotions.
Beliefs about Professionals in the Mental Health Field
When I appeared in the DC comic book Batgirl as Barbara Gordon’s clinical psychologist, many people asked me, “So when does your character go crazy and turn into a villain?” It seems like a natural response since we see so many scientists and doctors transform into villains or show signs of deviance in comic book stories. I think that this response also comes from the widely held belief that psychologists and psychiatrists are “quacks” themselves. Given the amount of suffering, pain, and crises that we deal with, it is in fact more realistic to expect that mental health clinicians are equipped with emotional resiliency in order to effectively do their jobs.
Mental health service professionals like clinicians, psychologists and social workers certainly are impacted by their patients,but we all receive specialized training to ensure our own wellness during the process of intervening; while the media might show therapists “contracting” their patients’ illnesses, that rarely happens in real life. We’re neither immune nor plagued. In fact, we’re just as likely to suffer from some of the same conditions our patients deal with. Harley Quinn, a DC Comics character whose story was created by Paul Dini in Batman: The Animated Series, is a psychiatry intern who essentially falls in love with the Joker while treating him at the mental health facility, Arkham Asylum. While her story is fictional (Dini once told me that a relative of his is a mental health professional and helped him develop her background), the vulnerability of her character is actually quite realistic. Let’s be clear here: Being charmed by the Joker is not itself a sign of mental illness, nor is wanting to work with him. Harley did not “contract” the Joker’s mental illness, nor did he “give” it to her. She is an intelligent, capable professional who wanted to work with one of the most notoriously pathological patients (wouldn’t we all be intrigued?), and she approached him with well-intentioned curiosity and determination to understand. Ultimately, as the story goes, she finds herself infatuated with him and assists in his escape from Arkham. I firmly believe Harley aligned with the Joker’s cynicism and callousness in order to reconcile both of their traumatic pasts.
Some of the most compelling stories in comics deal with heroes questioning their missions and losing faith in humanity. Like the helpers on our planet who become increasingly numb to the pain and suffering of our clients, it’s not unrealistic to expect that the superheroes experience similar disillusionment.
What can we do?
A “healer” is anyone who interacts with a survivor of trauma or tragedy and has the opportunity to help. If you are not a healer yourself, you probably know, work with, or love someone who is. In addition to mental health professionals, think of: teachers, educators, medical personnel, police officers, military service members, staff at animal shelters, immigration judges, domestic violence lawyers, activists, environmentalists… the list seems endless.
Know your warning signs. What does compassion fatigue look like for you? What symptoms stand out to you? What do you tend to “bring home” with you at the end of the day? Who else is in your life that notices these signs? Do you feel a sense of hopelessness, a diminished creativity, a personal sense of a loneliness? Do you have an avoidant response—one that keeps you from being able to help others? Some people react with feelings of anger, cynicism, and even persecution. I know, for instance, that working with patients who are victims of hate crimes and recurrent prejudice would impact me deeply. Their stories trigger unresolved feelings I have about unfairness, marginalization, and privilege. You know how certain stories just make your claws come out? Be familiar with which ones those are. I find it all too easy to access my bitter attitudes about society when my role should be about helping people find meaning, self-value, and resiliency when coming out of tragic experiences.
Build Compassion Satisfaction. Compassion Satisfaction is characterized by positive relationships with colleagues and the conviction that one’s work makes a meaningful contribution to clients and society. Practicing self-compassion means taking time for yourself and valuing yourself. This means having a “life” outside of work! Participation in hobbies, physical activities, and socializing are actually key protective elements to remaining healthy in the field. Taking vacations are actually recommended–in fact, studies show that people who rarely take vacation days have an increased risk of illnesses such as heart disease. Those moments away from work allow you to refuel, reflect, and regain the positive feelings derived from your competent performance as a trauma professional.
Have a plan B. Some experts who study compassion fatigue suggest that changing your career course altogether is sometimes the best option. Sometimes we are ready to put our masks and capes away. If you have lost the fundamental belief in your mission, maybe it is time for another mission. For most, though, the struggle is finding the right balance between self-care and giving. It is reaching out your hand to others and decidedly letting go when you need to.
“The rule of no realm is mine, neither Gondor nor any other, great or small. But all worthy things that are in peril as the world now stands, those are my care. And for my part, I shall not wholly fail in my task, though Gondor should perish, if anything that passes through this night can still grow fairer or bear fruit and flower again in days to come. For I too am a steward. Did you not know?”
–Gandalf, in J. R. R. Tolkien’s Lord of the Rings: Return of the King
For more information on trauma-informed mental health care and compassion fatigue, visit the National Child Traumatic Stress Network. The primary reference for this article is the book Trauma Stewardship: An Everday Guide to Caring for Self While Caring for Others. Also, pick up The Compassion Fatigue Workbook for creative tools for dealing with vicarious trauma. Finally, send me a message and let’s talk about it.