Secondary Traumatic Stress
THE COST OF CARING
When Françoise Mathieu was a civilian therapist working with the military, one of her clients was a nurse case manager who had never seen combat but was experiencing symptoms identical to those of post-traumatic stress disorder.
“It wasn’t until the mid-1990s that we started studying secondary traumatic stress,” said Ms. Mathieu, who is a registered psychotherapist in Kingston, Ontario, and Executive Director of TEND. This organization offers training and education on secondary traumatic stress (STS) to help professionals, such as healthcare providers and first responders.
Since then, when research mostly focused on fields like pediatric oncology nursing, it has become apparent STS can affect people in a much broader range of occupations, as well as individuals in many other groups, from family members caring for loved ones with life-threatening illnesses, to foster parents, teachers, and even children.
That means understanding STS could be an important way to guard our own well-being and that of our communities. Read on to learn more about STS, including what it is, how it affects people, who’s impacted by it, and how to treat it.
WHAT IS STS?
STS (ALSO KNOWN AS INSIDIOUS TRAUMA) IS ONE OF SEVERAL RELATED TERMS THAT DESCRIBE THE PSYCHOLOGICAL TOLL THAT CAN BE WROUGHT BY INDIRECT OR SECOND-HAND EXPOSURE TO OTHERS’ TRAUMA.
Direct trauma, in contrast, refers to a traumatic event that occurs directly to us. Another similar term to STS is vicarious traumatization (VT), which describes what can happen when someone like a therapist is repeatedly exposed to detailed, traumatic stories. “These stories hitch a ride with you,” Ms. Mathieu explained.
VT tends to be cumulative, and its signature quality is a negative shift in worldview. It is sometimes referred to as compassion fatigue or empathy fatigue. While sharing similarities to indirect trauma, STS can occur suddenly after a single event. However, even in scientific literature, VT and STS are sometimes used interchangeably.
And indeed, some mental health professionals believe the distinction is not important. According to the TEND website, “whether you call it STS or VT, what we are referring to is the impact of indirect exposure to difficult, disturbing and/or traumatic images and stories of the suffering of others … and the way it might impact us as individuals and professionals. Over time, repeated exposure to difficult content can have a negative impact on our functioning and overall mental health.”
THE IMPACT OF SECONDARY TRAUMA
While neither VT nor STS are official diagnoses, the diagnostic criteria for post-traumatic stress syndrome (PTSD) have been expanded to include witnessing trauma to others and repeated or extreme exposure to details of a traumatic event as qualifying stressors.
“When we call something secondary, it’s almost diminutive, but the experience of secondary traumatic stress can be exactly as if you’d experienced it primarily,” said Dr. Nathalie Reid, Director of the Child Trauma Research Centre at the University of Regina.
It seems as if the brain doesn’t distinguish between the two – it shifts into survival mode in both situations.
“When we perceive a threat, we’re flooded with hormones that prepare us to fight, flee, or freeze,” explained Diana Tikasz, a registered social worker and trauma and organizational health specialist in private practice in Hamilton, who is affiliated with TEND. This response “is very normal, and can even be good for our growth, noted Dr. Lise Milne, an associate professor in the University of Regina’s Faculty of Social Work who is also affiliated with the Child Trauma Research Centre, “but when it happens in excess, we can start to experience troubling symptoms.”
PTSD and STS are thought to be due to prolonged “amygdala hijack,” meaning the fear centre of the brain does not shut off appropriately.
Consequently, you may constantly feel as if you’re in danger. As the word “hijack” implies, normal function can be inhibited in other brain areas responsible for memory (the hippocampus), decision-making, and emotional control (the pre-frontal cortex).
And indeed, the symptoms of PTSD and STS, “are the same,” Ms. Tikasz said. For example, symptoms characteristic of PTSD include “flashbacks, nightmares, and intrusive thoughts,” she noted. “These can happen in secondary trauma, but it’s not about your own material.”
STS can cause a range of other physical, cognitive, and behavioural symptoms. These include “memory problems, hopelessness, anger, cynicism, poor sleep, and minimizing of adversity around us,” Dr. Milne added. Also on the list of possible symptoms are hypervigilance (feeling jumpy or on edge), avoiding specific people or places, and difficulty concentrating or making decisions.
OVER TIME, STS CAN LEAD TO STRAINED RELATIONSHIPS, PROFESSIONAL BURNOUT, AND SUICIDAL THOUGHTS.
In the longer term, like other forms of toxic stress, it can cause a type of “wear and tear on the body and the brain,” known as allostatic overload, Dr. Milne said. “With prolonged exposure, that’s where we can see physical and physiological outcomes that can last across a lifespan if it isn’t addressed as early as possible.”
While there is scant research specifically in STS, according to Epigenetics of Stress and Stress Disorders, published in 2022, “a large body of research has linked PTSD to a variety of physical health outcomes, including the leading causes of death and disability: heart disease, stroke, diabetes and dementia.”
“Both mental and physical health are very much affected by trauma,” said Dr. Ruth Lanius, a professor of psychiatry and Director of the Post-Traumatic Stress research unit at Western University’s Schulich School of Medicine and Dentistry in London, Ontario.
IS STS WIDESPREAD?
It’s hard to pinpoint how common STS might be overall. “We don’t have incidence rates outside of certain specialized populations,” Ms. Mathieu explained. Those “that were first studied were folks who work in child protection, people who work with survivors of sexual violence, veterinarians, and animal care technicians.”
RESEARCH SUGGESTS THAT THE RATE AMONG THERAPISTS AND COUNSELLORS WHO CARE FOR THOSE IN HIGH-TRAUMA OCCUPATIONS IS RELATIVELY HIGH.
For instance, in a study of 224 mental health professionals working with U.S. military patients, published in The Journal of Nervous and Mental Diseasein 2013, STS prevalence was nearly one in five — 19.2%.
However, based on other research, STS may be at least as widespread in therapists and counsellors with a broader client base. One study of 256 social workers in Montana, for example, found that nearly 41% met the criteria for PTSD. This research was published in Traumatology in 2017.
Recently, STS has been recognized as affecting teachers and other school personnel. “Educational assistants, school support specialists, and counsellors in schools experience secondary traumatic stress,” said Dr. Reid, who was just four days into her teaching career when the 9/11 terrorist attacks took place.
Shortly after the Child Trauma Research Centre opened four years ago, she said, “we quickly realized we couldn’t even think about engaging with child trauma if we weren’t engaging with the experiences of the practitioners entrusted with their care.”
STS is not always vocation-related, however. Studies have found it affects groups such as family care partners of cancer patients and partners of people with PTSD, suggesting trauma can ripple outwards within families.
Children can also be susceptible to STS.
For instance, according to research conducted among junior and senior high school students 18 months after the massive wildfire in Fort McMurray, Alberta, not only did 37% meet conditions for a probable diagnosis of PTSD, but kids who had moved to the community after the cataclysmic event also showed higher rates of PTSD symptoms. The study appeared in the journals BMC Psychiatry and Frontiers in Psychiatry in 2019.
Research suggests that certain life circumstances increase the likelihood of developing STS. Growing up with a parent living with mental illness is one example of a list of predisposing factors for STS.
PEOPLE WITH A HISTORY OF ADVERSE CHILDHOOD EXPERIENCES HAVE A HIGHER RISK OF DEVELOPING PTSD IF THEY’RE EXPOSED TO SUBSEQUENT TRAUMA.
Adverse Childhood Experiences (ACEs) is a broad category that goes beyond physical and emotional abuse and neglect. For example, “You may have been loved and felt safe, but did your parents go through a divorce, or was one of them abusing substances?” Ms. Mathieu noted.
She explained that a free online questionnaire called the Adverse Childhood Experiences self-test asks you if before age 18 you have had any of these difficult things happen. “If you score higher on ACEs, you are more vulnerable to secondary traumatic stress.”
Women may be disproportionately affected by STS, as well.
Female-identifying individuals are far more likely to be family caregivers. They also outnumber men in many helping professions, such as nursing and social work. Whatever the reasons, women may be more prone to STS than their male peers.
According to a systematic review of gender findings in research looking at secondary traumatic stress in health professionals, published in Trauma, Violence & Abuse in May 2015, “almost all the studies based on PTSD symptomatology show greater female susceptibility.”
THE SIGNS OF STS
Ms. Mathieu encourages people to be alert for clues that they might be on the path toward developing STS. “It’s a continuum from healthy functioning at one end to being really functionally impaired at the other end,” she said, with many people occupying a yellow zone just bordering full-blown STS.
EACH OF US HAS AN INDIVIDUAL SET OF EARLY WARNING SIGNS THAT SIGNAL ESCALATING STRESS LEVELS.
These can range from physical symptoms (like headaches or lack of appetite) to emotional (irritability, for example) and behavioural hints (such as doom-scrolling or compulsive shopping).
For those working in helping professions, “there are some informal checklists you can use to pick up on STS symptoms,” Dr. Milne said. “Are they exhausted all the time? Are they feeling dissociated from work? Are they afraid to come to work? Those types of things are quite common” in STS.
HOW TO MITIGATE STS
IF SOMEONE NOTICES SUCH CHANGES OR BEGINS EXPERIENCING A SURVIVAL RESPONSE FOLLOWING AN INTENSELY DISTRESSING EVENT, SEVERAL STRATEGIES MAY HELP AVERT A DOWNWARD SLIDE.
In the case of an immediate stress spike, “we know that nervous systems resonate with other nervous systems, so if the person is with someone they feel safe and secure with, their nervous system can start to regulate a bit more,” Ms. Tikasz said.
However, for those with a history of childhood trauma, a human presence may have the opposite effect. “Individuals who have been hurt by their caregivers often tend to feel more safe with animals,” Dr. Lanius explained.
Certain techniques that take only seconds can act as a reset button for the parasympathetic nervous system, which governs the fight-or-flight response. “That can be use of breath, such as longer inhales than exhales, or soothing touch, like cold water splashed on our hands or faces,” Ms. Tikasz said.
These measures can help pave the way to using talk to diffuse stress further. “When a stress response is extreme, we don’t have access to language very easily,” Ms. Tikasz said. “Once our language centres come onboard a little bit, then it’s important we do some talking to build a narrative around what we’re experiencing that isn’t going to keep us stuck.”
Daily habits can also affect our susceptibility to toxic stress.
“I invite people to think about what you are putting into your sweet, beautiful nervous system,” said Ms.Mathieu. Caffeine, task-switching, social media use, and media consumption can all have a negative impact, while adequate sleep, time spent with loved ones (including pets), and exercise have the opposite effect. “For me, it’s really about how we address our nervous system dysregulation on a day-to-day basis,” she said.
However, this type of self-care is only a fraction of the equation. “This notion of ‘just do yoga, and you’ll be fine’ puts the responsibility on individual people who already feel like they don’t have time to do anything more than they’re doing,” said Dr. Reid.
“With some secondary trauma responses, self-care isn’t going to touch it – it needs different strategies,” stressed Ms. Tikasz. “If we don’t understand that, there can be lots of shaming and blaming.”
Workplace leadership, support, and culture play a critical role in helping workers reduce potential exposure to traumatic events, said Dr. Milne.
I CAN SAY FROM MY RESEARCH THAT LEADERSHIP NEEDS TO PAY ATTENTION TO WORK HOURS, WORKLOAD, SICK TIME, PERSONAL DAYS, AND ACCESS TO COUNSELLING SUPPORTS.
“They also need to provide opportunities for their employees to connect with peers and colleagues so people don’t feel alone in their experiences,” she added.
As well, more work needs to be done to squash the stigma that is associated with admitting one is experiencing secondary trauma, both within helping professions and society as a whole.
For example, Dr. Milne recalled earlier in her career, “I refused to go on sick leave because I thought it would make me look weak,” she said. “Looking back, I suffered as a result of not having a workplace that meaningfully supported prevention or response to secondary traumatic stress, but also because I had guilt about ‘who am I to be feeling like this?’ – I’m not the person that experienced the trauma.”
Dr. Reid added that professionals need to challenge the dominant narratives in caring professions “that a good teacher or a good caseworker can hear traumatic stories all day and go back the next day with a smile on their face. Preventatively, the most important thing we can do is to spread knowledge (about STS) so people can have the tools to check in with themselves and say: ‘wait a minute, I’m not sleeping well, I don’t want to hang out with my friends like I used to – there’s something going on.’”