Secondary traumatisation: when the stories you listen to change you

“Since I started working at the social work centre, I won’t let my daughter sleep over at any friend’s house. I know I’m overdoing it. But every week I hear a story that started exactly like that.”

A social worker might say this after a few years of working with families in which there is violence. A paramedic might say something similar — someone who remembers the same road accident at every siren — or a police officer who can’t watch the news in the evening, or a teacher whose pupil told her something at break that she cannot forget. None of them experienced the violence or the accident themselves. Yet all of them carry its traces.

We call this secondary traumatisation: the changes that happen in a person who, professionally and often, listens to, watches or documents other people’s traumatic events. In this post I will explain what it is, how it differs from burnout, why it is not a sign of weakness, and what we know about it — about what protects the individual, and about what the team has to do.

When the story doesn’t stay at the office

In the mid-1990s the American psychologist Charles Figley brought together research on people who help the traumatised and described a phenomenon he called secondary traumatic stress — in everyday language, compassion fatigue. His finding was that a person who works professionally with other people’s trauma can develop signs very similar to post-traumatic stress disorder — intrusive images, avoidance, constant alertness — even though they did not experience the event themselves.

This is not just a theoretical possibility. Since 2013, the American diagnostic manual DSM-5 has explicitly listed, among the ways a person can be exposed to trauma, repeated or extreme exposure to aversive details of traumatic events in the course of work — giving as examples first responders collecting human remains and police officers repeatedly hearing details of child abuse.

How common is it? In an American study of social workers published by Brian Bride in 2007, roughly 15 per cent of respondents had enough signs of secondary traumatic stress to meet the core criteria for post-traumatic stress disorder. Considerably more had at least some signs. This doesn’t mean that everyone who works with trauma becomes unwell. But it does mean that those to whom it happens are not the exception.

Three names for similar, but not identical, things

Several words are used for this subject, and they easily get mixed up. The difference isn’t only academic, because each calls for something different.

Secondary traumatic stress (Figley) is closer to post-traumatic stress disorder: it can appear relatively quickly, even after a single particularly harrowing story, and it shows up in the body and in memory — images return, the body is on standby.

Vicarious traumatisation is a concept described in 1990 by the psychologists Lisa McCann and Laurie Anne Pearlman. It concerns slower changes in how you see the world: whether it is safe, whether you can trust people, whether you have control over anything, how much others and you yourself are worth. It doesn’t arise in a day; it builds up over years.

Burnout, on the other hand, is not connected with the content of the stories but with the balance between demands and resources: too much work, too little influence, too little recognition. You can burn out in a job where you never hear a single traumatic story. Where the individual ends and the system begins in burnout is the subject of System or individual: who is responsible for burnout.

Who is exposed

When we hear “secondary trauma”, we first think of therapists. But most of the people at risk work elsewhere:

• social workers dealing with domestic violence, neglect and child abuse;
• paramedics, firefighters and emergency healthcare staff, who see the aftermath of accidents up close;
• police officers and investigators, who interview victims and examine evidence;
• teachers and nursery staff, whom children sometimes tell first what is happening at home;
• lawyers, interpreters, journalists and everyone who has to write down or translate traumatic stories precisely.

What they have in common is that they are not allowed to look away. Their work requires them to come close to the story — to hear the details, write them down and make decisions about them. And it often requires them to do so without showing how much it has affected them. What this quiet part of the work costs I described in The professional mask: the cost of being someone else at work.

In healthcare, secondary trauma is often joined by moral distress in healthcare — the sense that you know what would be right but the system won’t let you do it. When the two meet, the burden is doubled.

How to recognise that the stories have touched you

Secondary traumatisation rarely shows itself as one dramatic event. More often it appears in small shifts that the people around you notice before you do:

• Images that aren’t yours. A scene from a report or an account comes back before sleep or in dreams.
• Constant readiness. You see danger everywhere, check where the children are, don’t trust new people. Your body operates in a state we call hypervigilance.
• Numbness. Stories that would once have shaken you no longer mean anything — and that worries you more than you admit.
• Avoidance. You stop watching films, stop reading the news, avoid certain places or subjects.
• A changed view of people. You see a threat in every man talking to a child; the world seems more dangerous than it used to.
• A body that won’t switch off. Poor sleep, tense muscles, headaches. How this gets written into the body is explained in How trauma stays written in the body — and how the body can let it go.

Dark humour often appears too. In itself it isn’t a bad sign — it is one of the ways teams get through hard days. It becomes a warning when it is the only way anything difficult can be spoken about at all.

Why empathy can hurt

It is often said that secondary trauma is “the price of empathy” — and that the solution is to feel less. That isn’t quite true.

The neuroscientists Tania Singer and Olga Klimecki showed that we need to separate two things we often call by the same word. Empathic distress means feeling another person’s pain as your own — areas of the brain respond much as they do to your own pain, and the person often wants to withdraw. Compassion means staying with the other person with warmth and a wish for them to be better, without merging with their pain. In their research, empathic distress was linked to negative emotions and exhaustion, while compassion was linked to positive emotions and a greater readiness to help.

So it is not that people who help should feel less. It is about how they feel. Empathy that takes a story inside and leaves it there slowly poisons a person. Empathy that receives the story but keeps the boundary between “this happened to you” and “this is happening to me” is more sustainable.

That boundary is not a matter of willpower. It depends on whether your nervous system is settled enough to hold it. When you have been outside your window of tolerance for a long time, nobody can hold it.

The workplace as a system that learns trauma

As a family therapist in training, I look at people in systems, not only as individuals. And teams that work with trauma all the time often begin to behave like the people they work with.

If a team works with families ruled by secrets, silence can set in within the team too. If it deals with violence, harshness, blame-seeking and a split into “us” and “them” can appear in the workplace. If it works with crises, everything can become a crisis — including who will be on call next week. In therapy we call this a parallel process: a pattern from one relationship repeats itself in another without anyone planning it.

In this way a burden that the team should carry moves onto the individual. The most sensitive person shows it first — and is often labelled the “weak link”. In reality they are often just the first to show what everyone is carrying. How such a team works is described in A team where nobody speaks: silence as a rule and what it hides.

The system at home changes too. Some people tell their partners everything and unintentionally burden them. Others say nothing, to protect the people at home — and feel at home as though they are living two lives. Both are understandable. Neither is good in the long run.

How it sounds in conversation

This is how part of a session with a paramedic after several years in the job might sound (composite, not a real person):

“My partner says I’ve changed. That nothing moves me any more.”
“What do you think?”
“That it moves me too much. I just don’t show it. If I started, I don’t know where I’d stop.”
“Who knows what you see at work?”
“My colleagues. But we just joke around with each other.”
“And her?”
“She knows I was on a call-out. She doesn’t know what I saw there. And I don’t want her to.”

In a conversation like this I am not looking for the details of what he saw. I am looking for a place where he won’t have to carry it alone — and for a way he could tell his partner how he is without passing the images on to her.

What protects the individual and what protects the team

Research on what increases and reduces the risk is not as clear-cut as we would like. A review published in 2015 by Jennifer Hensel and colleagues found more signs in those who encounter traumatic material more often and fewer in those with good social support — but the associations were mostly small. There is no single factor that decides everything.

Still, research and practice point to several things that help:

• Dosing exposure. Not all the hardest cases with the same person. This is the manager’s task, not the individual’s.
• Regular supervision — not as oversight, but as a place where what you have heard can be talked about. As a therapist in training I work under supervision myself, and I know it is not a luxury but part of the work.
• A team in which difficult things may be spoken about — not only in jokes.
• A life outside work that has nothing to do with work: the body, nature, people who don’t know what you do.
• Personal therapy, when other people’s stories wake something of your own.

Exercise: closing the day after a hard story

This exercise doesn’t replace supervision or therapy. But it is something you can do today — at the end of a shift or on the way home — so that the story doesn’t come to bed with you.

1. Choose a threshold. The door of your workplace, the car park, a bus stop. Agree with yourself that this is the place where the day closes.
2. Briefly write down what you are carrying. Not the story, just one line: “Today I heard something that shook me.” No details — the aim is to acknowledge, not to relive.
3. Come back into your body. Stand with both feet on the ground, name five things you can see around you, and breathe out a few times more slowly than you breathe in.
4. Separate what is yours from what is someone else’s. Tell yourself: “This happened to her. I was there to help. Now I am here.”
5. Take one small step towards your own life. Call someone you love, walk part of the way, listen to music you don’t associate with work.

If the same story keeps returning for weeks, whatever you do, that is a sign you need to tell someone — a supervisor, a therapist or a doctor.

Where this explanation falls short

I want to be careful, because “secondary trauma” is a concept that can be applied too quickly.

Not all distress in trauma work is secondary trauma. Sometimes it is burnout from overload, sometimes moral distress, sometimes both. The difference matters, because with burnout less work helps, while with secondary trauma what helps is not necessarily less work but different exposure and room to process it.

Sometimes another person’s story opens your own. If a particular kind of story affects you far more than others, it may be touching something you have experienced yourself. Then it is no longer only a consequence of the work, but an old trauma that needs its own space in personal therapy.

Immediate “offloading” is not a cure for everything. For a long time it was believed that after a serious incident you should tell everything in detail as soon as possible. A Cochrane review found that single-session psychological debriefing straight after a traumatic event does not prevent post-traumatic stress disorder. What helps is support, not pressure to talk.

Trauma work doesn’t only bring harm. Many people who help others for a long time also describe a deeper sense of meaning, greater gratitude and admiration for human strength. This is called vicarious post-traumatic growth — and it doesn’t contradict secondary trauma; the two often exist side by side.

When to seek help straight away. If images return every day, you can’t sleep, you drink more than before, or thoughts of not wanting to live appear, don’t rely on exercises alone. Turn to your GP or a psychiatrist. In a crisis in Slovenia you can call the mental distress helpline Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritan helpline on 116 123 (24 hours), and in an emergency 112. Doctors and other helpers often hesitate the longest — more on this in Helping everyone but yourself: doctors as patients.

What to remember

• Secondary traumatisation is a response to professional exposure to other people’s trauma — not a sign of weakness, but a consequence of the work.
• Distinguish secondary traumatic stress (quicker, similar to PTSD), vicarious traumatisation (a slow change in how you see the world) and burnout (overload).
• It doesn’t help to feel less, but to feel differently: compassion is more sustainable than empathic distress.
• Teams that work with trauma can start repeating their clients’ patterns — so protection is the task of the system, not only the individual.
• If images keep returning for weeks, seek out a supervisor, a therapist or a doctor.