When Stories Hurt

Clinicians who help victims of trauma increasingly realize that they also need help in coping with the impacts that their clients' stories inflict.

During her early years as a therapist, Demitra McDonald worked at a counseling center in Sacramento, helping survivors of domestic violence and their families cope with the trauma they had endured. A few years ago, during one particularly difficult week, she was flooded with new domestic abuse clients. “It was just day after day, story after story of young … women who were practically beaten to death by those [who] they loved the most,” she said. McDonald had become accustomed to hearing similar stories from clients, but the relentlessness of that week pushed her farther than she was used to.

McDonald made it through the week. But after work one day, while walking to her car, she realized how loud it had been inside the busy center. And now, all of a sudden, it was quiet. “Something just cracked me open, and I just started to sob,” she recalled.

It wasn’t just one story that had affected her deeply. It was cumulative — all the stories had piled up inside her until she couldn’t hold them anymore. She said it hit her “that we’re all human; we’re all connected; we’re all sisters and brothers.” She identified so much with her clients that, even though she knew their abusers weren’t harming her directly, she felt the emotional and psychological pain nonetheless. “[The feeling] overwhelmed me, and once I realized that, I gave into it for a few minutes. And I said, you know, ‘Just sob for it. Sob for all of it, all of them, and all of those [who] are going to come next week. Just sob for all of them right now and let it go.'”

McDonald’s deep empathy for her clients changed her, so that after hearing their stories each day, their trauma had become her trauma. ‘”That can’t keep happening,'” she recalled saying to herself. “What happens to a puzzle when you take it out every day, and then it goes all to pieces? Eventually you pull it out, and you’ve got a piece missing, and then the next time it’s two or three pieces.”

That day, McDonald experienced a culmination of her “vicarious traumatization,” she said. She decided she had to make a choice about what kind of therapist she wanted to be. Did she want to be the kind that could only hold herself together long enough to get to the parking lot?

No. For her, it was vital that her clients knew “that if they are reaching out to me, they [are] going to have something to hold on to,” she said.

McDonald, who now works at the La Cheim Behavioral Health Services in Oakland, is not alone in her realization of the impacts that vicarious trauma — which is often the result of repeatedly hearing trauma victims’ stories — can inflict on social workers, psychologists, and other behavior health professionals. During the past decade, shelters, behavioral health clinics, and agencies around the country have attempted to begin coping with vicarious trauma by adopting a “trauma-informed care” approach, which not only acknowledges the role that past trauma plays in patients’ lives, but also emphasizes the gravity of recognizing and addressing the vicarious trauma that affects clinicians.

When social workers and mental health care providers are suffering, they can’t gauge whether they are “being present” with their clients, or if they’re inadvertently causing them harm, according to Laura van Dernoot Lipsky, who is the author of the widely read and well regarded book, Trauma Stewardship: An Everyday Guide to Caring for Self while Caring for Others, which describes “being present” as a “radical act.” It states: “[I]t’s not about what we do, what we say, or how we touch — it’s about being present in a way that tells those who are suffering that they are not and never will be alone.”

The concept of “being present” came up repeatedly in interviews that I conducted in recent weeks with behavioral health workers, psychologists, and other experts. They said it’s a vital part of providing quality care to traumatized people. If a caregiver’s own mental health is compromised, he or she cannot be fully present with clients, and thus has trouble empathizing and helping clients cope with the violence they’ve suffered. “I haven’t met a therapy bot yet,” said McDonald, stressing that an unfeeling therapist, lacking the ability to make a human connection, will always fail. “Humans survive in relation to each other. So this is also how we heal.”

But while the move toward trauma-informed care represents progress in acknowledging the existence and importance of vicarious trauma, experts say that many organizations still do not take the necessary steps to support their staffers and prevent trauma overload. Van Dernoot Lipsky, a veteran social worker and founder of the Seattle-based Trauma Stewardship Institute, said in an interview that there are still many barriers to creating environments that nurture healthy caregivers. Organizations are often under-funded and very sensitive to perceived financial challenges, she said. She asserted that there are plenty of creative, cost-free steps that can be taken, but “when you are exhausted, it’s not people’s most creative time. It can feel like a task, like one more thing to do.” Steps that require more resources, like reducing caseloads and prioritizing supportive supervisory meetings, are sometimes dismissed as unsustainable.

Stigma, too, is a barrier. According to van Dernoot Lipsky, there is “a belief that if you are good enough and tough enough and committed, you’re going to suck it up.” She doesn’t consider the grin-and-bear-it approach to be a viable option. She said that an individual or organization’s ability to process the trauma to which they’re exposed can be compared to a metabolic process. “If you are not readily metabolizing it or intentionally metabolizing [trauma], we see an individual can get saturated, and we see that a whole collective body can become saturated,” she said. “You can only stay saturated for so long before hemorrhaging may start happening.”

When the hemorrhaging starts happening, that’s when the quality of care becomes compromised on an individual, organizational, or systemic level. According to the California Health Care Foundation’s 2013 report, “Mental Health Care in California: Painting a Picture,” only half of adults and less than half of children who were prescribed medications for their mental health conditions received care that met quality standards.

California’s mental health care system is, of course, a behemoth plagued by many challenges, and vicarious trauma might seem like a small problem, but experts say that for frontline workers, dealing effectively with vicarious trauma is key to improving the quality of care for victims of crime — the source of so much trauma.

That’s especially important in cities with high violent-crime rates like Oakland. Last year, there were more than 6,000 reported violent crimes in Oakland, plus nearly 3,000 additional cases of domestic, child, and elder abuse. And while not all of those victims will seek professional help, many experts say it’s essential that those who do receive care are treated by clinicians who have the support and tools they need to avoid becoming victims themselves in order to help their clients deal with trauma.

In the early Nineties, psychologist Laurie Pearlman coined the term “vicarious trauma” to describe the transformative personal repercussions a caregiver can experience when engaging empathetically with trauma survivors. There are many types of caregivers: social workers, psychologists, shelter workers, humanitarian assistance workers, medical professionals, and first responders — anyone who works with survivors of severe violence, abuse, and neglect.

These professionals are also at risk of primary trauma, which is distinct from vicarious or secondary trauma. “A mental health worker, like myself, experiencing someone screaming at them in a fit of psychosis — that’s primary trauma,” explained Jim Caringi, a professor of social work at the University of Montana who has co-authored a paper with Pearlman.

Vicarious trauma is different because it’s a secondary experience. Caregivers experience trauma when they hear their clients’ stories.

Quantitative data on the prevalence of vicarious traumatization are scarce. According to Northeastern University’s Institute on Urban Health Research and Practice, the handful of studies that exist focus on individual sectors and have inconsistent definitions of vicarious trauma. However, several findings have reported that between 40 percent and 80 percent of helping professionals have experienced vicarious trauma, secondary trauma, or compassion fatigue.

“It’s an occupational hazard,” said Greg Merrill, director of Field Education at UC Berkeley’s School of Social Welfare. “If you work with a highly traumatized population, it actually will happen to you. It’s not whether it will or not, it’s my belief that it actually will.”

Merrill’s interest in vicarious trauma originated when he was a social worker at San Francisco General Hospital and Trauma Center from 2001 to 2005. He worked daily with victims of severe trauma: gunshots, stabs, gang rapes. He recalled one day in particular, when he walked into a client’s room as her bandages were being changed. She had been shot, and the wound from her emergency surgery stretched across her chest.

“I spoke with her at length, and she had a child. She had a lot of terror around what had happened, and because I was empathic with her, I felt very in the moment with her. And so I kind of experienced an empathic kind of terror. Just from connecting with her. And then I noted I just couldn’t stop thinking about her for days,” he said. “I had images of her wound pop up in my head.”

Merrill said that afterward, he was afraid to talk about what he was feeling with his supervisor and other social workers. “I thought it was highly unusual and probably not professional,” he said.

Merrill said that as a student and young professional, he learned to fear burnout — the emotional exhaustion that often comes with a strained workload. “What wasn’t talked about was [when] dealing with a high volume and intensity of highly traumatized individuals, there are specific and unique ways that weigh on you,” he said. “I do just think there are honestly some unique psychological things going on for people who work in high trauma settings that are just not always recognized.”

Eventually, he did talk to his supervisor, and when he spoke to other social workers, he found that they were all experiencing similar effects in response to working with severely traumatized people. He decided to become a resource to other social workers who were struggling with their trauma exposure and later developed a vicarious trauma training curriculum.

The terms “vicarious trauma,” “secondary traumatic stress,” and “compassion fatigue” are sometimes used interchangeably to signify the effects that giving care has on caregivers, but for many researchers, they are distinct concepts. The literature describes secondary traumatic stress as having symptoms that mirror post-traumatic stress disorder — like insomnia, appetite changes, and exhaustion. Compassion fatigue is often defined as the broad, predictable effects of working with suffering people.

“It can get messy,” said Caringi, when asked to separate the terms. “All of the experts in this field, including myself, are having conversations about how we deal with this nebulous, unclear set of phenomena.”

The hallmark symptom of vicarious traumatization is what the literature calls a “change in worldview” around safety, trust, and control. That can mean that the sufferer sees hazards everywhere, in places they wouldn’t otherwise occur. And they might find that they start to view other people as malevolent or untrustworthy.

Merrill recalled working with abduction survivors, and they would describe the vehicle their abductors drove. He said that later, when walking around in his neighborhood, he would see a car that resembled his client’s description. “It really freaked me out. I mean, it was just a car, but that’s the kind of thing that starts to happen to people,” he said. “You can start to feel that the world is all trauma all the time, everybody’s dangerous, everyone is out to get you.”

Caringi, a longtime clinician, echoed Merrill’s experience. Early in his career, he was working in Alaska, flying from village to village, dealing almost exclusively with tough trauma cases. At the time, his wife had just had their first child and was preparing to go back to work. “How do you think it went for me, a guy who was seeing trauma perpetrators and trauma survivors all day long, to find someone who was safe enough to watch my baby?” he asked. “It didn’t go well.”

La Cheim Behavioral Health Services, where Demitra McDonald now works, is a community mental health center in Oakland specializing in treating clients with acute psychological distress from severe depression and psychosis due to chemical dependency. According to the Center for Disease Control’s Adverse Childhood Experiences Study, which includes about 17,000 Kaiser patients, there is a strong correlation between an individual’s history of childhood abuse and problems with drug and alcohol abuse.

La Cheim sees about three hundred clients a year in its program of structured day services. “People are coming off of catastrophic crises, so there’s a lot of trauma, a lot of anxiety, a lot of fear,” said Brad Falconer, a psychologist at the center. “It can be a very over-stimulating, overwhelming environment.”

The program’s director, Frances Raeside, is committed to creating a supportive environment for the staff. She describes La Cheim’s orientation as “strength-based,” meaning that clients and staff members alike are regarded as resilient and resourceful in the face of adversity. “It’s not just helping [our clients] to hold their trauma, it’s helping us hold their trauma,” she explained.

“This room is constantly alive,” said Mical Falk, clinical director, referring to the room in the center that staff members use to seek help from each other after difficult, potentially traumatizing client sessions. “If people are experiencing it together, they are much less likely to be traumatized than if they were experiencing it alone.”

Every day, staffers take time to check in as a group and provide mutual support. The center initiated daily meetings of clinical staff members two years ago, and the organization instituted a weekly small group meeting to ensure staff members are coping well.

“The organizational support is everything to this work,” said McDonald, who has worked in the field since 2009 and joined La Cheim last fall. “Not a week has gone by since I started when I haven’t been asked, how are you doing? Is the workload going all right?” McDonald said that the affirmations and acknowledgment she receives at work empower her and help her provide better care to her clients.

Merrill sees this kind of organizational support as key to a caregiver’s longevity. “I believe people can do really hard work long-term if they are supported well,” he said.

“If you know there is an occupational hazard, and there are wraparound supports that are reasonable that could be provided by the supervisor or the organization, it’s just not responsible not to provide that,” he added.

Unfortunately, Merrill said, organizations commonly lack the resources to properly support their employees. “If we’re not helping our workers long-term, they’re toast,” he warned.

After her breakdown in the parking lot, Demitra McDonald knew she wasn’t willing to risk losing pieces of herself. She said she turned to practices that were restorative — pursuing yoga and deepening her spiritual life. She consulted with other therapists. “It helped me get my head together,” she said.

She learned that she had to foster a strong and clear identity supported by a healthy set of boundaries. “I have to be able to understand where I start and end, and where the client starts and ends,” she said.

“It takes a lot of self-reflection, a lot of observation,” said McDonald, when asked how she knows where her limits lie. “Ideally, you wouldn’t hit the limit. It’s like gas in the car. You wouldn’t wait until it ran out to gas it. You’d be checking that beforehand. … As you’re noticing that your stores are depleting, you build yourself up.”

Jewel Love, a marriage and family therapy intern at La Cheim, said he builds himself up by focusing on the basics — his relationships, eating habits, sleep patterns, extracurricular activities. “I’m just making sure that I’m balancing those areas of my life, making sure that I’m ready and up to par to come here and handle what’s thrown my way.”

“Practice wisdom” is how Merrill describes the personalized tricks and rituals he has heard in his years as a trainer. He told the story of a social worker at an Oakland hospital who, at the end of each day, would unlock her glove compartment, turn off her pager, hold it for a minute while closing her eyes, and wish her clients inside the hospital well. Then she’d lock the pager in the glove compartment. The next morning, she’d repeat the ritual in reverse. “She felt like she was able to psychologically wall it off better,” explained Merrill.

“[Pacing] the energy you give out over a thirty-year career is really hard to do,” he added. Ultimately, it comes down to choosing to take care of yourself while caring for others, and finding light in the darkness, he said.

“I feel very grateful for my life because I saw peoples’ lives taken away from them, like that,” he said, snapping his fingers. “It’s kind of incredible what people can survive, and that they can find meaning in it. Not [just] devastation, but some kind of positive meaning. If you’re aware of the impact it has on you, then you can shape how your beliefs change or what you need to do, and I believe it can actually make you greater.”

After work each day, McDonald picks up her young son from school. She said that as she drives, she focuses on what residual stress is left over from the day. “And every tick on the speedometer, every mile, I let it go,” she said. “And I tell myself, if there’s anything residual, when I see his smile, it will melt.”

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