Episode 8: Understanding Vicarious Trauma
Within this episode, Henry Tobey shares his wealth of experience regarding secondary trauma. He shares what he has found to be helpful, along with what he doesn’t find to be helpful when it comes to supporting health-care providers in dealing with the stress and trauma of their work. He shares his vicarious trauma dialogue, which he and his colleagues developed. Be sure to listen, as you may even hear some of the thoughts you’ve had.
Henry Tobey, Ph.D.
Key terms: secondary trauma, vicarious trauma, resilience, healthcare providers
CASAT Podcast Network
Welcome to season two of CASAT Conversations.
I am your host Heather Haslem.
This season we will explore the timely and complex topic of resilience for healthcare providers within each conversation, you will hear from experts, clinicians and providers Who will explore and share the latest research, best practices and applications for how to be resilient.
Please enjoy today’s conversation.
Today we welcome Henry Tobey.
Henry has worked as a trauma psychologist for over 35 years.
He has led clinical debriefings in New York City after 9-11 and after the Columbine High School shootings
Earlier in his career, Henry was a police psychologist, forensic psychologist and hospital administrator.
He currently has a psychotherapy practice called Colorado Psychological Resources and he is the founder and executive director of Vital hearts, A resilience training initiative.
He has led their secondary trauma resiliency training 141 times for over 3000 professional care providers.
And on a fun note he taught his dog to play tic-tac-toe and he swears his dog has never lost.
Welcome Henry, We’re so happy to have you here today on CASAT Conversations.
Thank you Heather.
So please tell us, how did you get into this work?
Well, as you just shared, I was the police psychologist for the Washington D.C.
Metropolitan Police Department and when I moved to Colorado, my therapy practice was then focused on working with victims of crime and as a trauma psychologist, I saw that the other providers of care to traumatize people didn’t need more skill specific training, they needed to learn to better take care of themselves.
If care providers work in a supportive environment, they’ll regularly hear the admonition, be sure you’re taking care of yourself.
But what does that actually mean?
And so the organization I helped direct vital hearts developed our program, the secondary trauma resiliency training to provide answers to that question.
So with all the work that you’ve done, what do you see as the impact of exposure on trauma on care providers, care providers experience of trauma is not direct, they are not bloodied or violated or lose loved ones.
Instead they suffer an accretion of exposure to the trauma suffered by their patients or clients.
And this second hand exposure multiplied case after case has the likely effect of traumatizing care providers in ways that can be palpably obvious or exquisitely subtle and care providers suffer consequences on a range of physical, psychological, cognitive and spiritual levels and obvious or subtle.
This reduces care providers effectiveness, shortens their tenure.
How long can they do their work?
And unfortunately when people leave, they often leave with the sense of shame that they weren’t tougher or stronger or more dedicated rather than leaving when they do leave with the sense of pride in the amazing work that they did.
So as you’ve been providing resilience training to care providers For the past 22 years.
Uh please tell us what you see in resilience training that really doesn’t work.
In response to care provider burnout and other stressors, there have been many resiliency trainings developed and sadly in my opinion, most of these have been of minimal value.
The typical training includes such elements as providing participants a list of stress symptoms and reactions.
And the problem with providing training participants such a list is that it’s essentially fatuous uh to tell participants what they already are experiencing.
I mean, healthcare uh providers would not be attending a resiliency training, were they not aware of their stress reactions?
I mean, sharing such lists is a waste of professionals time.
Uh and even greater waste uh is something that I’ve seen in some resiliency trainings which show functional MRI’s of a traumatized brain.
And then contrast that with a calm brain.
And these pictures have no application for how care providers might do, uh better to take care of themselves.
They merely give the presenters the patina of scientific rigor.
Uh and if I don’t sound like too much of a curmudgeon, I I also want to say that many resiliency trainers uh provide participants a list of stress management techniques.
Items on these lists commonly include get plenty of exercise yoga, perhaps pursue hobbies removed from work, journaling, eat sensibly, lots of fruit and vegetables do not increase your caffeine or alcohol at times of heightened stress.
Don’t medicate self medicate.
Uh Well, any item on any trainers version of this list by itself might be a good piece of caretaking advice, but every uh professional care provider knows all of this anyway.
Nobody’s secondary traumatic stress comes about because they didn’t know the kinds of things that are included on these lists.
Uh, and ultimately, I think uh these lists of stress management behaviors are demeaning to tell care providers who include who experience such suffering that say getting eight hours of sleep a night would protect them from the secondary trauma inherent in their work.
What vital hearts does in our training is different.
We read what we call the vicarious trauma dialogue, which is made up of statements care providers have shared about the cost they pay in doing their important work.
And so all the lines in the dialogue were said by care providers, some of whom work in the high morbidity.
Medical services like cancer treatment or hospice.
Uh some work in the emotionally challenging human services like treating domestic violence or sexual assault or child protection are working with the homeless and the comments uh that we’ve heard have been rearranged to flow as a dialogue.
And we read the vicarious trauma dialogue because when people hear lines that resonate with them, it helps normalize and honor their own experience Heather, will you help me read the vicarious trauma dialogue?
Sure Henry, I’d be happy to Okay, are you ready?
I am reasons I do this work to change the world, fix it, Making a difference.
You reach out and it comes back 10fold.
It feeds my soul being able to bring peace and resolution to a troubled person, helping them believe in the system and then say thank you.
It feels good to act as a guiding light to people.
During a time of trauma.
It’s a calling, not a profession.
We are pioneers, we are activists, helping people find hope, helping Children and family to change.
And he’ll I think I help.
Here’s my worst secret.
This woman, my most difficult patient was ragging me again and I thought to myself, why don’t you just hurry up and die bringing hope for change and a calming perspective to a stressful situation perspective.
Anyone this woman has just lost her husband and you’re worried about your fucking car radio being stolen, coping mechanisms that don’t work too much professional distance.
I get an adrenaline rush, the power of handling it.
I can help all of you.
But I don’t know if I can fix myself.
Vicarious trauma is almost like being in a domestic violence house.
It’s very subtle and you don’t even realize it’s happening to you.
Feeling the work isn’t valued.
I feel like the force that tears through cultural denial, my distortion of power, Who am I, that I think I can heal this person who’s so screwed up.
I’m frustrated with people expecting me to tell them what to do.
I’m frustrated when I can’t tell people what to do.
Sometimes I want to tell patients don’t keep calling.
If you’re not going to listen to what I have to say.
This work is life transforming.
It will change your life.
You’ll see the best of people and the worst.
Sometimes I want to say to clients, are you out of your fucking mind?
I’m always angry angry at domestic violence victims who then hurt their own Children.
I feel used.
I’m angry all the time.
I come home and yell at my kids, angry at the male population as a result of listening to these stories day after day, I’m angry with no regard for anyone.
This affected the way I saw my own sons.
I picked them apart.
How sad that I projected that anger on them.
My anger gauges how much I swear at people in traffic.
My anger is so heightened toward my agency.
I’m always angry or I’m exhausted.
One of the two, I was angry at everything in the beginning, but then I found the gift of seeing anger as passion.
I could use that passion in a constructive way.
I have such sadness now, but I miss my anger.
The anger was so motivating.
You need to understand the reality of working in this field and have realistic expectations.
So you’re not hurt.
Stay in the moment.
Don’t label people or situations.
If I was a dog, I’d put myself to sleep, I cry in my car a lot must keep hearts and souls together while we do this work me.
I need medication in order to go to my office.
My boss is not understanding my boss is Attila.
The hun management is so shut down, so shut off!
When I’m crying in my office, my boss says I am not being productive.
Management is not in tune, which drives me crazy.
Considering the field we’re in, it should be seen as normal to be a wreck.
We represent those who have stayed many good people have left.
Can I continue to do this?
My work is about providing dignity, but Medicare doesn’t audit for that.
The system sucks you dry and then they blame you for it.
Some days I feel if I have to talk to one more person, telling me I’m an angel, I’m gonna puke.
If I die tomorrow, my supervisor will complain.
I didn’t finish my charting.
Ah It’s both positive and negative that my sensitivity to the world has sharpened as a result of my job.
I pay attention and actually hear better issues relating to trauma and crisis.
My mind is always on trauma and crisis.
I feel guilty about not sharing with my family.
I feel so guilty about sharing with my family.
My senses are attuned to traumatic material.
Normal things just don’t grab me anymore.
The thrill is gone.
I don’t get excited anymore by anything.
I can’t deal with my friends whose lives seem so placid.
I see things all the time.
I hope no one in my family ever sees.
I’m always editing out my thoughts in social situations.
I feel like the most boring person at a party.
I’m no fun anymore.
I’m sorry three deaths this week.
Then I have to go home and deal with my mother’s cancer.
I’ve stopped feeling anything.
I’m learning to nome.
If I don’t feel I’m not effective, I want to feel strong boundaries.
Don’t really help if they’re so rigid, you leave it all at work, but then never process it.
I’m not feeling my feelings.
I don’t expect anyone to understand what I am feeling.
I just keep doing the work fantasies about incestuous liaisons.
Too much stimulation and arousal.
You know, I just keep doing the work sex.
My body feels to beat up my whole life is consumed by this stuff.
I just keep doing the work.
Sexual fantasies aren’t safe.
It’s difficult letting go.
It’s so much easier when you hear the judge say guilty, it doesn’t feel safe to play emotionally or sexually with my husband.
I think everyone is a perpetrator.
Sometimes I walked into a home recently and it was so filthy, so foul smelling.
I found myself getting mad rather than feeling sorry for the client.
Is everybody a purpose.
Perpetrator is the world safe.
After a horrible case.
I go home and hug my five year old, I fear being the victim myself.
The world is unsafe and everyone is a perpetrator.
I can’t stop the violence lower your expectations.
Stay in the moment.
Don’t project long term, open your mind.
Debrief one more poor job choice needs more debriefing more case supervision.
More determination to make a difference.
I think working in computers might be better.
I was on a call and got a flat tire, missed a huge bloody homicide.
I liked the drama.
A piece of me wanted the case.
Another piece of me said good career move.
I can’t tell you how many times I’ve heard co workers say, oh, he had a good death.
What are we doing?
Judging this work brings me back to what is really important in life.
My confusion is over whether I’m cut out for this work.
So much stress up and down.
I like it.
Then I feel overwhelmed.
I feel like I’m holding back the ocean with a rake.
Things hit you at different times and it’s out of your control.
I was just sitting with the grieving family and I started crying.
It’s comforting to hear that other people are going through the same thing.
You know this is the most spiritual work I can imagine doing, but I can’t imagine doing it any longer.
I am so tired living in a straight white middle class male privileged society.
I used to believe we’re winning slowly.
My work, how my life is different Now this feels wonderful.
We could never talk like this in my office.
You are such brave people.
My success comes when I don’t perpetrate violence against myself by initializing the cycle.
Being hopeless, helpless, angry, trying to get power and control instead of feelings.
If I can just feel my own feelings, I can stop the cycle Heather.
That’s our vicarious trauma dialogue.
Thanks for joining me in that.
Thank you Henry.
And can you share with us really kind of how this vicarious trauma dialogue was developed and um how that you found sharing this in your training’s has been supportive.
Well, at the beginning of developing the secondary trauma resiliency training, we ran a series of focus groups where people just came and told us what their work has come to feel like.
And so we captured about I think 700 statements through those focus groups and then uh what we read is about 100 of those lines and as I said, the lines have been rearranged to flow as a dialogue.
What great thank you.
So please tell us you told us really what doesn’t work.
But if you’ll tell us now what you’ve seen that does work in supporting providers deal with vicarious trauma.
I think resiliency trainings need to go deeper into such issues as the difference between empathy and compassion.
Uh the letting go of attachment to the outcome of their work as a means to tell providers who they are.
Uh I think uh people have to craft their own self care plan rather than being given some trainers version of the plan.
Uh I think it’s important to understand the idea of letting go of over identification with the professional role, meaning we want people to continue to do their work through the role but not be identified as the role.
And I think trainings uh I need to not just focus on what’s going wrong uh in their work, but how to get the maximum self esteem self esteem out of the work.
And I think training need to help people become personally resilient regardless of the character of their workplace.
And I think a training needs to normalize and de shame, secondary traumatic stress reactions.
I like it that often the shame people feel that they’re even suffering any of these secondary traumatic stress is the shame is worse than the stress reaction itself because the shame so isolates people.
And finally, I think a resume she training uh, needs to help people get the idea that their work is really a vehicle to work on themselves.
And what I’ve just shared, uh maybe a committee compendium of what we think training need to be to be less superficial.
And and it’s also many of the ideas that vital hearts offers in our secondary trauma resiliency training.
And I think it’s what makes our training effective at a level that 95% of participants report a reduction in their secondary traumatic stress, Henry.
What do you see as the biggest need for supporting providers.
Well, there are there are two things I’d want to share.
Uh one of them relates to motivations people have for doing their care providing.
Of course providers have deep altruistic motivations, but in addition to these there are personal growth benefits people receive or hope to receive from doing their work.
And it’s important that providers get very honest with themselves about what they hope the work will provide them uh because no one has such a perfect job that it enables them to feel every day the way they want to feel.
Uh and I’m talking about the idea of awareness here, the more you know what you hope the work will provide you, the more you can process it on the days the work fails to provide you your desired uh payoff rather than just go home disgruntled and irritate your partner or mindlessly drink a glass of wine.
The other thing I would talk about is the stances from which a care provider can do the work.
And the first stance I would mention is what I call the hyper personalized stance.
In the hyper personalized stance.
It feels like the work is all happening to you or because of you or through you.
And there is a richness when our relationship to the work is so hyper personal, but it’s a trap which leads uh to too many aspects of vicarious trauma and the next stance I would mention is the deep personal where the work doesn’t feel like it has any relationship to who you are.
And so this is certainly the stance of of burnout.
And fortunately there’s a third stance and this third stance is the non personal and I actually think about it as the slightly non personal away to do the work without the subjective feeling that it’s all a function of us meaning that things good things or bad things can just happen without it all feeling like it’s happening because of us or through us.
Ah and in this slightly non personal stance, we can find a distance from which to witness the work being done even as we’re in it.
And in this non personal stance, there’s just enough separation that you can witness your patients or clients as they experience what they have to experience.
Ah without, I might say the heroic sense of the righteousness of your work.
And this is a difficult topic to talk about because the work that they’re doing is righteous but caring that personal sense of the heroic righteousness of the work can lead to dangerous places.
And I know that the way I’m language, ng uh this the wording between the deep personal and the non personal can obscure how these stances actually function.
That gives us a lot to digest and think about um really appreciate your perspective and sharing all of your wealth of wisdom with us.
How can people learn more about your work.
Certainly people can go to our website www.vitalhearts.org.
And of course people are invited to reach out to me directly at email@example.com.
Wonderful, thank you.
We’ll make sure that those get posted in the show notes.
And as we wrap up here, uh would love to hear really how you taught your dog to play tic-tac-toe.
What’s amazing in people playing my dog uh is how many people try to beat the dog.
I mean if you or I uh played tic tac toe uh as two adults, every game would end in a tie.
And so when people try to beat the dog, the game’s just ended in a tie, but I always thought it would be a better story for people to be able to tell their friends.
I lost to a dog at tic-tac-toe.
Ah that’s great.
Well, thank you Henry.
We really appreciate your time and um just really good luck with all of the training that you’ve done and it’s such important work.
So thanks for all that you do.
You’re very welcome Heather.
Thank you for inviting me to be with you.
Absolutely have a great day.
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