On my first day as a psych liaison nurse on the surgical trauma unit at San Francisco General Hospital, I observed as my colleague, Janice, interviewed Shalimar, a 26-year-old woman with paraplegia. Her nurse had contacted our psychiatric consultation service because Shalimar had been crying and looked depressed. When Janice asked Shalimar about the circumstances of her spinal cord injury, she told us that at age 11, she had run away from home with a friend who was 13. Her friend said she knew someone who would take care of them. The pimp, Prince, shot them up with heroin which she described as “the best hug you could have.” Five years later, when Shalimar told Prince she was leaving him to get married, he stabbed her in the back.
Even though I had worked as a psych nurse for the previous 16 years, Shalimar’s story shocked me through and through. Listening to her, I felt changes in my body: my heart beat faster, my stomach knotted up, my breathing was rapid and shallow. Inside I was thinking, “How could someone do this to a child? Where were her parents? Where is justice? Where is God?” But as a caregiver, I had to still my emotions, tame my outrage, and force myself to listen.
People who study psychological trauma would say that I had become dysregulated, meaning that my amygdala, the alarm center of the brain, had hijacked my neocortex resulting in arousal of the autonomic nervous system.
"As an experienced nurse, I knew that I would soon regain my emotional foothold. And for a long while, I did."
For the next five years I worked on the trauma unit evaluating and treating many people who had survived motor vehicle accidents, falls, and unfortunate encounters with guns, knives, fires, and fists. I also worked with people who were depressed, tearful, anxious, moody, acting out, or those billed as “a bit off, see what you think.” I heard hundreds trauma stories, past and present. A pattern emerged: many of my patients—and virtually all of my heroin-addicted patients—had experienced serious abuse and neglect during childhood.
A few years into my job, I started to wake up each morning feeling as though an elephant was standing on my chest. This was unusual for me. Although my parents had had an unhappy marriage and divorced when I was 21—I’d been spared serious trauma, depression, or anxiety. Pressure on my chest was soon followed by nightmares, palpitations, shortness of breath, fear for my children’s safety, intrusive images based on my patients’ stories, anxiety, and an inability to “lighten up.”
"At a psychological trauma conference I attended four years into my job, I learned that my symptoms had a name—-vicarious trauma—and that VT was not an uncommon occurrence among empathic caregivers."
I also learned that caregivers who received a strong “dose” of trauma in their daily work with troubled people, were more likely to have VT.
The fact is that all of us in our Department of Psychiatric Consultation —psych nurses, neuropsychologists, and psychiatrists—were assessing and treating the same population: patients who were mostly poor, mostly African-American or Latino, with multiple chronic diseases, alcohol and drug abuse, and histories of multiple traumas. Yet, none of us spoke openly about the impact that daily exposure to others’ hardship and tragedy had on our lives.
In talking with other attendees at the trauma conference, I learned that many trauma program directors considered weekly “process” meetings a necessity for maintaining the well-being of their staff. This is the way it should be. Over the years, several of us in the department had asked for regular support groups but our requests were always denied.
Upon my return to work, I mentioned what I had learned at the conference and pressed our director—a neuropsychologist—once again. Once again she dismissed the request with a flip response: “Do it on your own time.”
What time? With small children, no family in the area, and a husband who worked 60-hour weeks, I had little time for myself. Within a year, in the interest of preserving my mental and physical health, I left my position.
At home, my patients’ stories continued to invade my dreams and intrude into my waking life. Simply leaving work was not enough. Although I had scribbled my feelings at night when a patient’s story kept me up, now I began writing in earnest. Volunteering at the kids’ schools and walking with a friend a few times a week also made me feel better. Later, I began to practice mindfulness meditation and completed a round of neurofeedback—biofeedback for the brain. Still, it took the better part of a year before I noticed that my body had started to calm down.
"In the ensuing years, I have learned a lot about self-care."
A psychologist I know says that the best preventative for VT is “any exercise that makes you sweat.” I’ve also gathered ideas from people in workshops I’ve led about VT: weekly facials or massages, yoga, attending church, singing in a chorus, aromatherapy, weight-lifting, African dancing, spa days, Zumba classes, planning fabulous vacations, monthly girls’ nights out, walking in the park, making pottery, and playing team sports. The important thing is this: When your body and brain flash the “Maintenance Required” sign, listen and take action.
In addition to monitoring one’s caseload to maintain a manageable “dose” of trauma and sticking with an effective self-care regimen, private practitioners can partner with another therapist for “peer supervision” or join a “study group” composed of other psychotherapists to prevent professional isolation.
Clinic or hospital-based practitioners need support from administrators to create safe clinical environments, to provide supervision as needed, to limit or vary caseloads, and to reimburse educational expenses.
Bearing witness to our clients’ pain and suffering affects our psyches, our brains, and our bodies. In order to continue taking good care of others, we must take good care of ourselves. As poet Audra Lorde wrote in her 1988 book, “A Burst of Light,” “…caring for myself is not self indulgence, it is self-preservation and that is an act of political warfare.”