January 25, 2017

Secondary Traumatic Stress, Moral Injury and Vicarious Trauma

Ann Loewen MD, CCFP, FCFP

The clinic is closed, the OR is done for the day, the emergency shift is over. It’s time to relax and not be burdened by responsibility and decision-making for a while. But there’s a case that won’t let you do that: the woman who finally got out of an abusive relationship, only to be diagnosed with cancer. The house fire that left surviving family members weeping and homeless. The man whose body is ravaged by diabetes, and who is only a year older than you. Scenarios that leave you feeling helpless, disillusioned, discouraged, and unable to transition to the world beyond the workplace, let alone enjoy being there. Physicians are highly-trained problem solvers, but there are problems that we cannot solve, inequalities that we cannot resolve, paradoxes and irreconcilable differences that can be painful for the healer. This article introduces the concept of vicarious trauma, secondary traumatic stress and moral injury as a way of understanding the effect our patients’ suffering has on us

Every so often one has the opportunity for a dark and difficult aspect of their life to be illuminated, sometimes in an unexpected way and at an unexpected time. I experienced such a revelation when I attended a pre-conference workshop called Resilience for Researchers at the National Family Violence Research Conference in Portsmouth, New Hampshire, last summer. The facilitator was Dr. Patricia Kerig, a clinical psychology professor at the University of Utah. Her area of research is resilience in adolescent survivors of family violence and victimization (the term ‘family violence’ encompassing neglect as well as all forms of physical, sexual and emotional abuse in this setting, and ‘victimizing’ including harm at the hands of peers or others in the child’s community). She observed that her graduate students also needed resilience in order to do their work, and that they could be negatively affected by their own research. I was attending the conference as a result of a graduate level course in Family Violence I had just taken; I was very satisfied with my final paper (which had been accepted for presentation at the same conference), but it was by no means easy to read some of the research in the field and synthesize them into a coherent whole. And some my own difficult past was unearthed in the process. I signed up for the workshop wanting to know how to buoy myself against those impacts so that I could continue to be productive in the area.  What I did not expect was how it also helped me understand the bystander effects of being a physician, the slings and arrows we endure by virtue of being exposed to other people’s harrowing experiences, and what to do about it.

The phenomenon of being trauma-affected is not one that most physicians will apply to themselves. I don’t particularly care to think of myself that way. Compared to the physical and psychological traumas we witness first-hand in the suffering and stories of our patients, our own may seem trivial. Besides, many of us can acknowledge that we come from a privileged background, or at least have had many advantages that got us to where we are. Likewise, that makes our difficulties pale in comparison to those of our patients.  But privilege, advantage, education and resources – both internal and external – while important to acknowledge, do not provide a bullet-proof defense against the suffering we experience in seeing distress at close range. They are merely a buffer. In the course of her workshop Dr. Kerig introduced the concepts of vicarious trauma, secondary traumatic stress and moral injury as distinct from the more familiar experiences of burnout and compassion fatigue (all of which can occur in both research and clinical settings). We are all human, and therefore not immune to any of these impacts.

First, some terminology. Vicarious trauma and secondary traumatic stress are distinct from the more commonly understood terms burnout and compassion fatigue. Burnout is the experience of physical and/or emotional exhaustion and ineffectiveness due to work-related stress, frustration and powerlessness. It is characterized by a loss of enthusiasm for what one had once felt passionate about. Compassion fatigue is a form of burnout that encompasses a loss of empathy and increase in cynicism; it is particular to the helping professions.

Vicarious trauma, on the other hand, is characterized by a change in one’s inner experience or world view due to empathic engagement with a traumatized person. A unique component of vicarious trauma is the phenomenon of moral injury, which is the sense that one one’s moral compass has been disrupted by knowing about the injury/harm that has been intentionally inflicted sustained by another. It is the sense that one is somehow complicit just knowing about the injury/harm sustained by another, especially when there is an element of injustice (whether real or perceived) involved. It is a resonating sense of “That’s not right!” without being empowered to make it right. Many Canadians are collectively experiencing both vicarious trauma and moral injury at the moment with the revelations about, and acknowledgement of, the terrible realities of residential schools and the suffering they inflicted on Indigenous people. Physicians in Canada have this experience twofold, in their sense of being complicit in a larger societal program that has had such devastating consequences. And at the same time we witness the outcome of those policies and practices in the frequency and severity of illnesses and injuries, the abject social circumstances, the generational child abuse and neglect in indigenous families who have been torn apart. These are not easy wrongs to right regardless of how well a physician may practice in their field of expertise.  The patient’s reality can continue to haunt a physician long after the actual encounter.

Secondary traumatic stress includes the presence of PTSD symptoms following exposure to others’ trauma. An emergency room physician who has had a patient die in a deeply affecting way may go on to have difficulty in subsequent shifts because of workplace triggers that bring on flashbacks and avoidance; when they are not at work they may experience nightmares and intrusive thoughts. Any death of a child, and many forms of death by trauma, can stay with a physician in these ways. A colleague may appear to be functioning quite normally to all who observe them because of their high-level cognition, focus, objectivity and emotional regulation, all of which are associated with success.  Those qualities that got them into – and through – medical school, and make them an excellent front-line practitioner. However, those traits also limit the ways in which a physician can fully express the impact of their day-to-day clinical experiences.

With twenty-five years of family and emergency room practice behind me, all in underserviced, high-need populations, I can recognize a number of encounters that tucked away among my own gyri and sulci that would qualify as secondary traumatic stressors and vicarious trauma, with a fair smattering of moral injury thrown in for good measure.  House fires, ATV accidents, incidents of child neglect and abuse all come to mind. I have come to understand, and appreciate, that traumatic experiences both form, and are formed by, the very structure of our brains. I accept that we may never understand all those structures and their connections but that is the beauty and mystery of our unique role as healers.

You may find yourself within the list of risk factors for vicarious trauma and secondary traumatic stress that Dr. Kerig outlined in her workshop: those who work in isolation, who have a personal experience of adverse childhood events, who are female, who have an empathetic nature. It is a paradox that the more empathetic a caregiver, the more they are capable of feeling what their patient feels, the more active and visual their imagination in picturing their patient’s circumstances and the harrowing scene that their patient endured, the more likely they are to share a portion of that experience and its aftermath and thereby experience vicarious trauma and secondary traumatic stress. What makes us the best we can possibly be as healers, also make us vulnerable.

Of the qualities Dr. Kerig listed in the risk factors above, I question the assumption that women experience secondary traumatic stress and vicarious trauma more than men. I believe that men who have the capacity and opportunity to fully express their compassion will, for better or for worse, be just as likely to have these forms of operational stress injury, as the military calls them. After all, Romeo Dallaire is our nation’s most prominent example of trauma exposure and its consequences.

Combined with a well-entrenched culture of bravado, in which physicians are reluctant or resistant to endorse the pain they may experience in proximity to another’s suffering, and the training that emphasizes objectivity and emotional regulation (for all kinds of good reasons), physicians may experience a variety of emotions after entering the sphere of their patient’s suffering but lack an outlet to express them. There is little opportunity for physicians to simply be ordinary human beings in this regard, to express the sadness, anger, outrage, dismay or other strong emotions provoked by the encounter. A practitioner may carry these feelings with them for years, and because of the nature of trauma and its aftermath, the intensity of the emotion does not necessarily diminish with time. Additionally, traumatic experiences are cumulative: you don’t get to replace one difficult experience with another, time does not necessarily heal all wounds, and somehow our psyche is capable of packing more of them in as long as we keep getting exposed.

What’s a sensitive, caring physician to do? There are a variety of strategies and resources available, though they may take more searching out than usual self-care (which is, of course, always important). Klinic on Broadway does a variety of workshops on trauma for frontline workers. They include techniques for being able to work with trauma-affected clients to taking care of oneself specifically in the face of traumatic events and encounters. They are very inexpensive and are offered at regular intervals (http://klinic.mb.ca/education-training/training-opportunities/trauma-informed/).

Mindfulness based stress reduction and cognitive therapy are well documented to improve the symptoms of PTSD and anxiety. Mindfulness is particularly effective with improving trauma outcomes, because those reactions do not always come from the higher cognitive centers. Many CMEs and other programs teach these techniques. Physicians should have no hesitation in considering their own well-being a priority for learning them.

I will conclude by going out on a not-so-evidenced-based limb, and say that I believe it is through artistic and spiritual expression that we arrive at a better place subsequent to trauma. Art employs the difficult and destructive forces around us and seeks to give them meaning, to release us from the clamor of our uneasy moments and to provide us with at least a measure of peace. It both takes us away from our immediate circumstances, and puts us in a place we might not have gone otherwise, emotionally and psychologically. Art asks only that put our dominant brain on mute for a while and be emotive and intuitive, non-verbal and open to the possibility of transformative change. In the realm of the spiritual, anything from attending a patient’s funeral, going on a pilgrimage walk, to making time for formal religious participation can help nurture the bruised soul back to its usual functional status. In this regard it is more important to pay attention to doing what works for you, than to the odds ratio for the outcome of a particular technique or intervention.

Ultimately, I believe that taking the time, and making the effort, to be fully human – outside of measurable and material achievements – allows physicians to be part of the whole of humanity. In that way, we find a way to accommodate our unique experiences as physicians that would otherwise separate and isolate us from our fellow travelers.