Signs and Symptoms of Vicarious/Secondary Trauma

Adapted from “The Compassion Fatigue Workbook”

Learning to recognise one’s own symptoms of compassion fatigue (CF) and vicarious/secondary trauma (VT/STS) has a two-fold purpose:

First, it can serve as an important check-in process for someone who has been feeling unhappy and dissatisfied, but did not have the words to explain what was happening to them, and secondly, it can allow us to develop a warning system for ourselves.

Developing a warning system allows you to track your levels of emotional and physical depletion. It also offers you tools and strategies that you can implement right away.

If you would like more resources after reading this article, please have a look at our online training resources and books.

Let me give you an example of what a warning system may look like:

Say, for example, that you were to learn to identify your CF/STS symptoms on a scale of 1 to 10 (10 being the worst you have ever felt about your work/compassion/energy, and 1 being the best that you have ever felt).

Then, you learn to identify what an 8 or a 9 looks like for you i.e. “when I’m getting up to an 8, I notice it because I don’t return phone calls, think about calling in sick a lot and can’t watch any violence on TV” or “I know that I’m moving towards a 7 when I turn down my best friend’s invitation to go out for dinner because I’m too drained to talk to someone else, and when I stop exercising.”

Being able to recognize that your level of CF/STS is creeping up to the red zone is the most effective way to implement strategies immediately before things get worse.

But look back to what also emerges in this process: you are starting to identify the solutions to your depletion.

If I know that I am getting close to an 8, I may not take on new clients with a trauma history, I may take a day off a week, or I may return to see my own therapist.

In order for you to develop your warning scale, you need to develop an understanding and an increased awareness of your own symptoms of compassion fatigue and vicarious trauma/STS.

I suggest that you begin by reading through the signs and symptoms below, and circle those that feel true to you. If you want to explore this in more depth, have a look at the Compassion Fatigue Workbook.

CF and VT/STS will manifest themselves differently in each of us. This is not a diagnostic test but rather a process whereby we begin to understand our own physical and psychological reactions to the work that we do.

Saakvitne and Pearlman (1995) have suggested that we look at symptoms on three levels: physical, behavioural and psychological.

Physical Signs of Compassion Fatigue

Exhaustion

– feeling exhausted when you start your day, dragging your feet, coming back to work after a weekend off and still feeling physically drained.

Insomnia

Headaches

Increased susceptibility to illness

– getting sick more often.

Somatization and hypochondria

Somatization refers to the process whereby we translate emotional stress into physical symptoms. Examples are tension headaches, frequent stress-induced migraines, gastro-intestinal symptoms, stress-induced nausea, unexplained fainting spells, etc. The ailments are very real, but the root cause is largely emotional and stress related. You may be able to identify which organ/body part is your vulnerable area: many people say it’s their gut, stomach, or head. Someone I know has an upset stomach every time she is anxious or stressed. She used to think it was food poisoning, but finally had to come to the conclusion that not all restaurants in our fine city could possibly have tainted food!

Hypochondriasis refers to a form of anxiety and hypervigilance about potential physical ailments that we may have (or about the health of our loved ones). When it is severe, hypochondria can become a debilitating anxiety disorder. Mild versions of hypochondria can happen to many of us who work in the health care field. A good example of this is a colleague of mine who worked as a physician in a dermatology office and who became convinced that every mole on her body was likely cancer. If you work in cancer care, particularly at the diagnostic end, you may find yourself overworried about every bump and bruise on your child or yourself. The media and the internet can fuel the flames of hypochondriasis. Many people who live in Ontario say that they had some mild phantom symptoms of listeria during the summer of 2008 following a large scale tainted meat recall.

Again, any of these symptoms do not, on their own, constitute a serious problem.

Behavioural Signs and Symptoms

Increased use of alcohol and drugs

There is evidence that many of us are relying on alcohol, marijuana or over the counter sedatives to unwind after a hard day. And as I say in my workshops: Have you seen the size of wine glasses these days? Some of them are bigger than my fishbowl. So the “one glass after work” you are having is possibly 1/2 of a bottle of wine.

The difficulty with increased reliance on drugs and alcohol is also that there may be a lot of shame associated with it, and it is not something that we necessarily feel we can disclose to anyone. Is the child protection worker going to tell his supervisor that he smokes a big fat joint every night when he gets home to unwind? Is the nurse going to tell her colleagues that she takes a few oxycontins here and there from her mother’s medicine cabinet?

Absenteeism (missing work)

Anger and Irritability

I could write an entire book chapter on this topic alone. Along with cynicism, anger and irritability are considered two of the key symptoms of compassion fatigue. This can come out as expressed or felt anger towards colleagues, family members, clients, chronic crisis clients. You may find yourself irritated with minor events at work: hearing laughter in the lunch room, announcements at staff meetings, the phone ringing. You may feel annoyed and even angry when hearing a client talk about how they did not complete the homework you had assigned to them. You may yell at your own children for not taking out the garbage. The list goes on and on and it does not add up to a series of behaviours that make you feel good about yourself as a helper, as a parent or as a spouse.

Try this: spend a full day tracking your anger and irritability. What do you observe? Any themes, recurrences? Any situations you regret in hindsight or where your irritability was perhaps out of proportion?

Avoidance of clients/patients

Examples of this can be: not returning a person’s phone call in a timely fashion, hiding in a broom closet when you see a challenging family walking down the hall, delaying booking a client or patient who is in crisis even though you should see them right away. Again, these are not behaviours that most of us feel proud of, or that we are comfortable sharing with our colleagues and supervisors, but they do sometimes occur and then we feel guilty or ashamed which feeds into the cycle of compassion fatigue.

Many of us work with some very challenging individuals. If you do front-line work, I am sure that you can easily conjure up, right now, the portrait of an individual or a family that has severely taxed your patience and your compassion. One telephone crisis worker put it perfectly: “Why on earth is it a thousand times easier for me to talk to 25 different crisis callers in a day than if the same caller calls me 25 times in a row? I am, after all, paid to answer the phone and talk to individuals in crisis for 7 hours a day. That’s my job. What is so depleting about the chronic caller?” And, I would add, why do we start feeling particularly irritated, avoidant and unempathetic towards the chronic caller? More on this below.

Impaired ability to make decisions

This is another symptom that can make a helper go underground. Helpers can start feeling professionally incompetent and start doubting their clinical skills and ability to help others. A more severe form of this can be finding yourself in the middle of an intervention of some kind, and feeling totally lost, unable to decide what should happen next. I once had a mild version of this in the middle of a grocery store after a grueling clinical day (I was working as a crisis counsellor at the time and was dealing with very extreme situations and a very large volume of demand). I remember standing in the middle of the grocery store thinking “should I buy the chocolate chip cookies or the oreos?” And being unable to decide between the two for what felt like hours. Difficulty making simple decisions can also be a symptom of depression.

Problems in personal relationships

I worked for many years as a couple’s therapist and worked with hundreds of couples seeking help with communication, parenting, finance, sex and intimacy and other relationship challenges. Many of my clients confessed that they often felt spent, “done” by the end of their day, with nothing left to give. Others say they found themselves being impatient with spouse and children, thinking internally: “How dare you complain about that, do you have any idea what I saw today?”

Attrition

This refers to leaving the field, either by quitting or by going on extended sick leave.

Compromised care for clients/patients

This can take many forms: using dismissive labels such as “borderline” or “frequent flyer” for some clients or patients as a code word for “manipulative” is one common example. Whenever a diagnosis is being used in a way that pigeonholes a person that we serve, we are showing our inability to offer them the same level of care as to others. There is evidence that individuals with a BPD (borderline personality disorder) label often do not receive adequate care in hospitals, are not assessed for suicidal ideation properly and are often ignored and patronised. Granted, individuals with personality disorders can be extremely difficult to work with, but when we lose compassion for them, and start eye rolling when we see their name on our roster, something has gone awry. In addition, many trauma experts now believe that a very large proportion of individuals diagnosed with BPD have in fact complex childhood trauma, and are very damaged because of these experiences. They end up being revictimized by a system that cannot cope with their complex and frequent needs.

There are many other examples of compromised care for people that we serve, but I think this is a particularly illustrative one.

Psychological signs and symptoms

Emotional exhaustion

Distancing

You find yourself avoiding friends and family, not spending time with colleagues at lunch or during breaks, becoming increasingly isolated. You find that you don’t have the patience or the energy/interest to spend time with others.

Negative self image

Feeling unskilled as a helper. Wondering whether you are any good at this job.

Depression

Difficulty sleeping, impaired appetite, feelings of hopelessness and guilt, suicidal thoughts, difficulty imagining that there is a future, etc.

Reduced ability to feel sympathy and empathy

This is a very common symptom among experienced helpers. Some describe feeling numb or highly desensitised to what they perceive to be minor issues in their clients or patients or their loved ones’ lives. The old stereotype is the doctor who lets his child walk around with a broken arm for three days before taking him to hospital as he has missed the symptoms and minimised them as a slight sprain, or oncology nurses who deal with patients in severe pain who feel angry or irritated when a family member complains of a non life-threatening injury.

Reduced ability to feel empathy can also occur when you are working with a very homogeneous client population. After seeing hundreds of 20 year old university students come through my crisis counselling office, I noticed two things happening: One, I would silently jump ahead of their story and fill in the blanks (“I know where this story is going”). Two, if I had just seen someone whose entire family had died in an automobile accident, I found it very difficult to summon up strong empathy for a student whose boyfriend had just broken up with her after two weeks of dating.

There are of course inherent risks associated with this reduced empathy and “jumping ahead/filling in the blank”. Clients and patients are not all the same, and we risk missing a crucial issue when we are three steps ahead of them.

We always need to navigate the fine line between not being ambulance chasers who think every single person is a suicide risk, and being numb to the point that we fail to ask basic risk assessment questions to everyone, including the person who looks just fine. The good news is that the solution to this is very simple: vary your caseload to stay fresh.

Cynicism

Cynicism has been called the “hallmark” of compassion fatigue and vicarious traumatization. You may express cynicism towards your colleagues, towards your clients/patients and towards your family and friends. Eye rolling at the brand new nurse who is enthusiastically talking about an upcoming change or idea she has to improve staff morale, groaning when seeing a certain client’s name on your roster and cynicism towards your children’s ideas or enthusiasm.

You can probably conjure up an image of the crustiest, most negative and cynical helper that you know. Now think of that person as suffering from advanced CF and VT/STS instead. Does that change the picture somewhat?

Resentment

Resenting demands that are being put on you by everyone. Resenting fun events that are being organised in your personal life. Resenting your best friend calling you on your birthday. Resenting taking an extra shift because your colleague is away on stress leave.

Dread of working with certain clients/patients

Do you ever look at your roster for the day and see a name that
makes your stomach lurch, where you feel total anticipatory dread? What if that starts happening with greater frequency?

Feeling professional helplessness

Feeling increasingly that you are unable to make a difference in your clients’ lives. Being unable to help because of situational barriers, lack of resources in the community or your own limitations.

Diminished sense of enjoyment/career (i.e., low compassion satisfaction)

Depersonalization

Dissociating frequently during sessions or interviews with patients/clients. Again, this is a matter of frequency – many of us space out once in a while, and this is normal, but if you find that you are dissociating on a more frequent basis, it could be a symptom of VT/STS.

Disruption of world view/heightened anxiety or irrational fears

This is one of the key symptoms caused by vicarious traumatization. When you hear a traumatic story, or five hundred traumatic stories, each one of these stories has an impact on you and your view of the world. Over time, your ability to see the world as a safe place is severely impacted. You may begin seeing the world as an unsafe place. Examples of this are: A counsellor who works with children who have been sexually abused becomes unable to hire a male babysitter for fear that he will abuse her children. A physician forbids his children to ever chew gum after seeing a tragic event happen with a child and gum at his work. A prison psychologist develops a fear of home invasion after working with a serial rapist. An acquired brain injury therapist develops a phobia of driving on the highway after doing too many motor vehicle accident rehabs. A recent workshop participant told me that after working at a youth homeless shelter she became obsessed with monitoring her teenage children’s every move, convinced that they were using drugs and having unprotected sex. She finally realised she had gone too far when she started lecturing her 12 year old son’s friends about methamphetamines and condoms, only to see their horrified faces at the breakfast table. The list can go on and on.

Some of this is completely inevitable. We call VT and CF occupational hazards for this very reason: It is not possible to open our hearts and minds to our clients without being deeply affected by the stories they tell us. But what is important to notice is how severe these disruptions have become. We can also sometimes mitigate the impact by doing restorative activities (working with healthy children for example, working on a quilt for AIDS sufferers, etc.)

Problems with intimacy

As a couples therapist, I heard many stories about relationship challenges including differences of opinion about money management, parenting, household chores and sex and intimacy. Many helpers confess that they come home completely uninterested in the idea of having sex with their spouses. As one client said to me “I come home, after giving and giving to all of my patients all day. Then I give to the kids, then I clean up and get ready for the next day. Finally, it’s 9:30 pm and all I want to do is collapse in bed with a trashy novel. Then my partner comes upstairs and wants some nookie and I feel like saying “are you kidding me? I’m all done. Please leave me alone” And these are not necessarily couples with significant marital problems or certainly no preexisting marital problems. The depletion caused by the job is the problem. Of course, communication and educating spouses about the realities of CF can help greatly here. If you work with sexual abuse survivors you may also have to deal with the added challenge of intrusive imagery from their stories.

Intrusive imagery

This is another symptom of vicarious trauma: Finding that the stories you hear at work are intruding on your own thoughts and daily activities. Examples are: having a dream that does not belong to you; having difficulty getting rid of a disturbing image an individual shared with you; being unable to see a rope as a benign rope, after someone has disclosed a graphic suicide story with you; or having certain foods be unappealing to you after hearing about certain smells or sounds from a war veteran. It is not unusual for those intrusive images to last a few days after hearing a particularly graphic story, but when they stay with you beyond this, you are having a secondary traumatic stress experience. (You can read an excellent description of this in Eric Gentry’s Crucible of Transformation article).

Hypersensitivity to emotionally charged stimuli

Crying when you see the fluffy kittens from the toilet paper commercial; crying beyond measure in a session that is emotionally distressing (welling up is normal, sobbing is not).

Insensitivity to emotional material

I used to know someone who was a family doctor who eventually realised that she was struggling with VT. She used to share, at our dinner table, extremely graphic stories of medical procedures of horrible growths or cancerous tumours (usually in the nether regions) with our 3 and 5 year old children sitting with us. She seemed completely unaware of the children’s horrified looks on their faces, never mind the adults.

Other examples are finding that you are watching graphically violent television and it does not bother you in the slightest while people next to you are cringing. Sitting in a session with a client who is telling you a very disturbing or distressing story of abuse, and you find yourself faking empathy, while inside you are either thinking either “I’ve heard much worse” or “Yup, I know where she is going with this story, I wonder what’s for lunch at the canteen.”

Loss of hope

Over time, there is a real risk of losing hope. Losing hope for our clients (that they will ever get better) and maybe even hope for humanity as a whole.

Difficulty separating personal and professional lives

I have met many helping professionals who, quite frankly, have no life outside of work. They work through lunch, rarely take their vacations, carry a phone (or even two) at all times and are on several committees and boards related to their work. They also help their families and are the “caregiver extraordinaire” for everyone around them. I once knew a helping professional who carried her work cell phone at all times. I used to see her at daycare, frequently answering client calls at 7:30 am while dropping her children off. I was very curious about this and asked her later what her working hours were and she said “Oh, I start at 9am but clients can reach me any time of day or night.” Now this person worked at the local hospital, and belonged to a large roster of social workers there, with their on-call beepers on a rotating basis. None of the other social workers at the hospital took client calls at 7:30 am unless they were at work or on call.

Failure to nurture and develop non-work related aspects of life

Many of the helpers that I meet confess that they have lost track of the hobbies, sports and activities that they used to enjoy. Some tell me that they collapse in bed at the end of their work day, too tired to consider joining an amateur theatre group, go curling or join a book club. Yet, “having a life” has been identified as one of the key protective elements to remaining healthy in this field.