Vicarious Traumatization in Psychiatrists

Last month I talked about PTSD in physicians. I want to turn now to a subject that is not talked about enough in psychiatry, that is, vicarious traumatization (VT). A recent study of medical students found that 26% of students reported symptoms of VT in their third year of medical school and of these, 50% identified their psychiatry clerkship as the source (1). 

Technically, VT differs from PTSD in that the therapist does not directly experience a traumatic incident. However, therapists can develop full blown PTSD by “bearing witness” to their patient’s trauma stories. Pearlman and colleagues defined VT as “the traumatization that occurs within the therapist as a result of empathic engagement with clients’ trauma experiences and their sequelae (2). 

Many of our patients have trauma histories. For some, this began in childhood when they experienced physical, sexual, verbal, and emotional abuse. Others are enmeshed in or trying to escape intimate partner violence. An unknown number of the chronically and persistently mentally ill, especially those who are homeless or incarcerated, are victims of physical assault. Some of our higher functioning female and male patients, especially those who are LGBTQ, are survivors of stranger or date rape. 

Psychiatrists who treat active service women and men, or veterans, see a full range of traumatic experiences in their patients. Psychiatrists who do disaster work treat victims of earthquakes, hurricanes, fires, floods, plane crashes and more. Not all of our traumatized patients will have classic symptoms of acute or posttraumatic stress disorder so it is wise to look for symptoms and behavioral changes lurking behind substance use disorders, mood disorders, eating disorders, somatic symptom disorders, sleep disorders and sexual dysfunctions. 

Some psychiatrists develop classic symptoms of PTSD that meet criteria as defined in DSM-5. This is what happened to noted forensic psychiatrist Dr John Bradford who candidly went public with his story in 2013 (3) He developed trauma symptoms after viewing videotapes of Canadian Air Force colonel Russell Williams brutally assaulting two young women whom he later killed. This sparked memories of other tapes he had viewed in the past as part of his testimony in high-profile serial killer forensic work. His journey of healing is a humbling account of how we must pay close attention to our mental health and the price that our day-to-day work may exact. 

Less dramatic but no less important are the cognitive and emotional changes that can occur in psychiatrists who treat traumatized patients, especially over time and with psychotherapy. These include a sense of vulnerability and frailness, mistrustfulness of others, guardedness, loss of idealism, despondency, and cynicism. Heightened anxiety and fearfulness about one’s personal safety can occur and these clinicians may adopt a defensive and cool demeanor for self-protection. Countertransference may swing from a frightening sense of engulfment or contagion to rage and blaming the patient. Psychiatrists who seem to be doing fine work professionally are not necessarily viewed that way by their loved ones and intimate others who find them exhausted, detached, irritable, or drinking too much. 

What can we do? Sansbury and colleagues have come up with practical guidelines for both individuals and organizations to protect themselves (4). Step 1 is “Know thyself”. Step 2 is “Commit to address the stress”. Step 3 is “Make a personal plan of action”. Step 4 is “Act on the plan”. Their organizational recommendations are grounded in basic principles of education and a perception of being supportive and caring. I highly recommend their paper. 

References

1. Al-Mateen CS, Linker JA, Damle N et al. Vicarious traumatization and coping in medical students: a pilot study. Acad Psychiatry. 2015;39:90-93.

2. Pearlman LA and Mac Ian PS. Vicarious traumatization: an empirical study of the effects of trauma work on trauma therapists. Prof Psychol Res Pract 1995;26:558-565.

3. Cobb C. “Tough forensic guy” John Bradford opens up about his PTSD. Ottawa Citizen. 11.10. 2013  https://www.ottawacitizen.com/health/Tough+forensic+John+Bradford+opens+about+PTSD/9152171/story.html

4. Sansbury BS, Graves K and Scott W. Managing traumatic stress responses among clinicians: individual and organizational tools for self-care. Trauma 2015;17(2):114-122.

Dr. Myers is Professor of Clinical Psychiatry and immediate past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, NY. He is the author of seven books the most recent of which are “Touched by Suicide: Hope and Healing After Loss” (with Carla Fine) and “The Physician as Patient: A Clinical Handbook for Mental Health Professionals” (with Glen Gabbard, MD). He is a specialist in physician health and has written extensively on that subject. Currently, Dr Myers serves on the Advisory Board to the Committee for Physician Health of the Medical Society of the State of New York. He is a recent past president (and emeritus board member) of the New York City Chapter of the American Foundation for Suicide Prevention.  

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.