Working with Trauma Survivors: What Workers Need to Know

After a traumatic event, many individuals working as rescue workers, health care workers, journalists, and volunteers may come into contact with trauma survivors. Some of these people interact with survivors as the traumatic incident is unfolding, and other situations may require contacting and working with survivors of trauma weeks, months, or even years after a traumatic event has occurred. These contacts may be precipitated by a memorial service, developments in a criminal or disaster case (e.g., a trial ten months after the event), an anniversary (e.g., commemorating a disaster), or other events.

Why is it important for those who work with trauma survivors to know about traumatic stress?

Increases ability to help

It is important for those who work with trauma survivors to know about traumatic stress because trauma survivors are in an ongoing process of healing and recovery. For instance, a journalist knowledgeable about traumatic stress will be more sensitive to a violent crime victim's need to feel humanized and respected, especially after an intentionally cruel experience.

Approaching survivors with genuine respect, concern, and knowledge about their process increases the likelihood that you can:

• Answer some of their questions about what they may be experiencing.
• Normalize their distress by letting them know that what they are experiencing is normal.
• Help them to learn effective coping strategies.
• Help them to be aware of possible symptoms that may require additional assistance.
• Reduce their perception of helpers' potential insensitivity.
• Give them a positive experience that will increase their chances of seeking help in the future.

Decreases chance of doing harm

It is important to keep in mind that pressing someone into discussion of a traumatic event soon after exposure may have a detrimental effect on some traumatized individuals. While some trauma survivors prefer to discuss the traumatic experience, overriding a reluctant individual's need (1) for distance, (2) to avoid reminders of the trauma, and (3) to dissociate in the immediate phase of a trauma, particularly in situations where bereavement is involved, may be associated with increased risk for developing PTSD in some individuals. This is particularly true for those with heightened distress. Experts on traumatic stress emphasize that people have their own pace for processing trauma, and it is important for helpers to let survivors know that they should listen to and honor their own inner pace.

Increases self-care

Another reason why it is important to know about traumatic stress is so you can apply this knowledge to yourself. While many individuals who work with trauma survivors experience an enhanced sense of meaning, self-esteem, respect for the strength of others, and connection with humanity, research is beginning to show that, for some individuals, working with trauma survivors, under certain conditions, may have negative effects. Those who work with survivors may begin to show signs of stress disorders ranging from difficulty sleeping to PTSD symptoms such as intrusive thoughts, avoidance, and heightened reactivity. While this area of research is relatively new, researchers have coined a number of terms to describe the effects of working with trauma. These terms are described below to explain the changes workers may observe in themselves as a result of experiencing traumatic events or witnessing the effects of those events on others.

Burnout

The term "burnout" has been applied across helping professions and refers to the cumulative psychological strain of working with many different stressors. It often manifests as a gradual wearing down over time.

The factors contributing to burnout include:

• Professional isolation
• Emotional drain from empathizing
• Difficult client population
• Long hours with few resources
• Ambiguous success
• Unreciprocated giving and attentiveness
• Failure to live up to one's own expectations for effecting positive change

The symptoms of burnout include:

• Depression
• Cynicism
• Boredom
• Loss of compassion
• Discouragement

Secondary traumatic stress

The term "Secondary Traumatic Stress" has been coined by various authors (1) to describe professional workers' subclinical or clinical signs and symptoms of PTSD that mirror those experienced by trauma clients, friends, or family members. While it is not recognized by current psychiatric standards as a clinical disorder, many clinicians note that those who witness traumatic stress in others may develop symptoms similar to or associated with PTSD. These symptoms include:

• Hyper-arousal (heightened reactivity -- startle, heart rate, pulse)
• Intrusive symptoms
• Avoidance or emotional "numbing"
• Anxiety
• Depression

Compassion stress

Charles Figley (2) coined this term as a "non-clinical, non-pathological" way to characterize the stress of helping or wanting to help a trauma survivor. Compassion stress is seen as a natural outcome of knowing about trauma experienced by a client, friend, or family member, rather than a pathological process. It can be of sudden onset, and the symptoms include:

• Helplessness
• Confusion
• Isolation
• Secondary traumatic stress symptoms

Compassion fatigue

Compassion fatigue, also coined by Figley, is considered a more severe example of cumulative compassion stress. It is a defined as "a state of exhaustion and dysfunction, biologically, physiologically, and emotionally, as a result of prolonged exposure to compassion stress" (2).

Vicarious traumatization

Vicarious traumatization was coined by Pearlman and Saakvitne (3) to describe those permanently transformative, inevitable changes that result from doing therapeutic work with trauma survivors. In their research, they noted that a number of changes were common among those mental-health workers who had clients who were trauma survivors. The changes were considered not pathological, as described for secondary traumatic stress, and were seen instead as normal cognitive or emotional changes relating to how the mental-health worker felt and thought about him- or herself. The changes were cumulative as, over time, the mental-health workers worked with several trauma survivors. The changes were also pervasive in their effects on an individual's life. These changes tended to occur more often in highly empathic, sensitive individuals, those with a previous history of trauma, and newer therapists.
Vicarious traumatization can detrimentally affect one's:

• Relationship with meaning and hope
• Ability to get one's psychological needs met
• Intelligence
• Willpower
• Sense of humor
• Ability to protect oneself
• Memory/Imagery
• Existential sense of connection to others
• Self-capacities, including:
  • The enduring ability to maintain a steady sense of self
  • Tolerance for a range of emotional reactions in one's self and others
  • A sense of inner connection to others
  • A sense of self as viable, worth loving, deserving
  • A sense of self that is grounded

There are a number of possible behavioral changes that might result from vicarious traumatization, including:

• 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 overinvolved, 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

If you recognize these changes in yourself

It is recommended that an individual take steps toward self-care and lifestyle balance if he or she is experiencing symptoms of burnout, secondary stress, or vicarious traumatization. These steps are defined in self care following disasters.

Compassion satisfaction

It is important to note that while the information above focuses on the possible negative effects one might experience when working with trauma survivors, there is also the possibility of a powerful sense of satisfaction with this work. Figley has coined the term "Compassion Satisfaction" to describe this process, which involves the development over time of a much stronger:

• Sense of strength
• Self-knowledge
• Confidence
• Sense of meaning
• Spiritual connection
• Respect for human resiliency

Individuals who have worked with trauma survivors over time may experience negative effects during times of heavier workloads, heightened personal stress, and overwhelming exposure to terroristic events and their aftereffects. However, a large majority of individuals who work with trauma survivors indicate that it has brought great meaning into their lives, increased their sense of purpose and strength, and heightened their sense of connection with others. Often these individuals took breaks, sought assistance or mentoring, or increased self-care when they began to see signs of negative effects. These professionals were able to resume their work and/or feel decreased stress and an overall gratitude for this work with time.

References

1. Stamm, B. H. (Ed.). (1995). Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators. Lutherville, Maryland: Sidran Press.
2. Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.
3. Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: Norton.