“What is to give light must endure burning.”

— Viktor Frankl

I still hear the kids crying and I think of them often. They’re probably teenagers now, and I wonder how that day really impacted them. Because I know it changed me. Their tears. Their sadness.

I can’t even remember if it occurred over the lunch hour or I just happened to be the only doctor in the hospital that day, but I remember the stat call and all the blood. I remember the 4 month old pitbull puppy lying dead on my exam table while I’m trying to keep my composure and help the sobbing mother and her children.

Now as a doctor, I’m used to seeing blood. But this day with those kids, it was painful. As with any story there are multiple sides, but the story I learned was they had just gotten home from the grocery store and the kids let their 4 month old pitbull puppy outside into the front yard. They had been warned multiple times by the neighbor that they needed to have him on a leash. Whether they were actually working to keep him on a leash or the mother just had her hands full with multiple young kids and a young puppy, I’ll never know. And I tried not to judge. However this time their dog came too close to the neighbor’s kid and in front of all these children, their pitbull puppy was shot 8 times.

He was rushed to my hospital and I just happened to be the doctor on the case. But it was too late. The dog was dead on arrival.

The rest of the day was a blur as I helped clean him up and send the family with their deceased puppy to a nearby university for a formal necropsy.

What was left in my heart that day was a hole and deep sorrow for those children that that experience was now a part of their story. Over the next couple weeks and months I tried to make sense of the event. To better understand the world we live in. But instead I found myself spiraling through various amounts of anxiety, depression, and hatred. I thought to myself, “I could never be Mother Teresa. I cannot love all these terrible people in the world.”

That was just one example of the many difficult cases I’ve seen in my veterinary career. As a trained veterinarian, I knew that I would probably encounter animal abuse cases, neglect, and knew the grave numbers of millions of unwanted animals euthanized each year. But I didn’t know how much I would also witness the struggles and difficulties so many other humans faced.

Knowing about and living through these types of cases became two very different things for me. My heart felt for those little kids and I struggled to move past that this was now their story. I also didn’t realize that what I was also experiencing after the event were signs of secondary traumatic stress and that those intruding thoughts and fears of the next tragic case were part of a bigger issue.

Seven years ago as a profession, veterinarians we were just starting to talk about Compassion Fatigue. Since then it seems that there is a lot of hype and overuse of the phrase. Some even go so far as to discredit compassion fatigue as something that is not real and that they could never lose compassion. So, to help those wanting to gain a better understanding of what Compassion Fatigue is, here is the definition taught in the compassion fatigue professional certification course:

Compassion Fatigue is defined as:

Secondary Traumatic Stress + Burnout

Secondary Traumatic Stress (STS) is the emotional duress that results when a person hears about the first hand trauma experiences of another person or animal.

Burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. STS in a caregiver’s field can be a component of burnout but any toxic work environment can lead to burnout.

It’s understandable that there’s a misuse and hype around compassion fatigue because even now as I do my research for this blog post there is very little scientific studies written on secondary traumatic stress in veterinary medicine. In 2017 in the Traumatology journal published by the American Psychological Association, a discussion article was published to add clarity and call for additional research needed for veterinary professionals in order for better understanding of trauma in the workplace. “Within trauma research, no understanding exists within the extant literature about the relational significance of human-animals bonds in veterinary settings regarding the development of STS and how they may function as social determinants of health, impacting both professional and organizational well-being.” Even more interesting is the article proposed that because veterinary medicine is lower ranking in the overall medical hierarchy it has received lack of attention for the much needed research.

And as always the work issues helping professionals face are complex and multifactorial. What some may be calling compassion fatigue may very well be moral and ethical fatigue, just burnout, primary traumatic stress, or a mixture of all the things.

Nonetheless, compassion fatigue is something that is plaguing veterinary medicine and many other helping professions. So, for today’s blog we are doing a deeper look at the largely overlooked and still misunderstood part of compassion fatigue and that is secondary traumatic stress. The purpose of this blog is for you not to self-diagnosis or to try to diagnose others but to bring awareness to the subject and begin the discussion on preventative measures.

What is stress and trauma?

Stress is the experience of an immediate perceived threat, either physical, emotional, or psychological. There are many different types of stress and not all stress is unhealthy. The most common type is acute stress, and it is the least damaging. Examples of stress include your alarm clock going off, getting pulled over, having to have a difficult conversation with a coworker, taking a test, etc, etc.

When learning to understand how stress impacts a person, what’s most important to realize is that it is the person’s perception of a stressful event that is the most critical. The threat can be real or imagined.

When a stressful event happens, the autonomic nervous system is activated and the body releases cortisol, the stress hormone, in addition to adrenaline, and other hormones. What happens in the body is an increased heart rate, increased breathing rate, and higher blood pressure.

Your body is preparing for the fight-or-flight response.

And in most daily situations that cause stress, the response in the body is short lived. It occurs and then we are able to deal with the situation and then it is over.

However in today’s modern life, prolonged and repeated arousal of the stress response can have mental and physical consequences such as heart disease, GI diseases, diabetes, anxiety, and depression just to name a few.

Trauma has different definitions depending on if you are looking at it from a medical component or from a psychological component. In psychiatry, trauma results from an event, series of events, or set of circumstances that is emotionally painful, shocking and often results in lasting adverse effects on a person’s mental, physical, social, or spiritual well-being.

What is the difference between post-traumatic stress Disorder (PTSD) vs. secondary traumatic stress?

When a traumatic event occurs the stress response may be prolonged and depending on the situation lead to post-traumatic stress or secondary traumatic stress.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines PTSD as exposure to an actual or threatened death, serious injury, traumatic accident, war, sexual violence, or neglect in one or more of the following ways: direct experience, witnessing the events as it occur to others, or experiencing repeated or extreme exposure to details of the traumatic events (first responders).

In the veterinary hospital that may include being threatened by clients, bitten by animals, and anesthetic deaths or other professional errors.

Secondary Traumatic Stress on the other hand can occur when you hear about an event that happens to another but then begin to feel the effects in your own brain and body. In this situation, even though the exact event didn’t happen to you, your body still keeps the score. All similar symptoms that can occur with PSTD can develop.

In the veterinary hospital setting STS can be hearing about a traumatic death of a patient or client, knowing that a patient suffered before it was able to come to the hospital, or hearing about a upset client interaction at the hospital.

Who is affected by Secondary traumatic stress?

Care workers in any number of helping fields and professionals are at risk for developing STS.

These include nurses, physicians, veterinarians, veterinary nurses, teachers, social workers, those that work with child protective services, therapists, and military health providers.

And as mentioned earlier much more research is needed to better understand STS and its effects as occupational stressors within the veterinary field in hopes of identifying preferred coping styles, stress management, and care work.

Interesting enough in today’s society just watching the news can lead to secondary traumatic stress and the increase activation of our sympathetic nervous system. A topic for another post could be just on our fear culture and how that may be leading to an enhanced arousal of sympathetic nervous system dominance.

However, even though we live in a culture where we are exposed to events that may trigger secondary traumatic stress, the DSM-V clearly excludes exposure via electronic or printed media. It is worth noting that maybe the stress in your own life is being contributed to what you are watching and consuming.

What are the symptoms of secondary traumatic stress and how can we recognize this in our own body?

For the purposes of this article we are focusing on bringing awareness and not going to go into how these actual disorders are diagnosed. If after reading this blog you are concerned you may be suffering from PTSD or STS please contact your health professional. There is also a great free assessment to take that will help measure your secondary traumatic stress and burnout called the Professional Quality of Life Measure (ProQOL) formal assessment.

Some of the previous difficulties in understanding trauma includes the fact that what is traumatic to one person, may not be to another, and just because a person experiences or hears about trauma does not mean they will go on to develop PTSD or STS.

Trauma also affects a person’s neurobiology in ways that are long lasting or permanent. In the book The Body Keeps the Score: Brain, Mind, and Body in the Treatment of Trauma by Dr. Bessel van der Kolk, we learn that trauma is not just something that happens in very extreme circumstances but is a universal part of the human experience. And even if we try to discredit our trauma as not being that bad, it doesn’t matter, because the body keeps the score.

Here are some of the symptoms of secondary traumatic stress:

Arousal -- which is the increase in perceived threats: fear/anxiety, obsessive thoughts, poor concentration, sleep problems, weight +/-, GI issues, immune problems.
Avoidance -- which is chronic fatigue: procrastination, dread, depression, hopelessness, constriction, isolation, rumination, blame.

As these symptoms start to manifest many of the diagnostic criteria for PTSD can actually occur in those suffering from STS. Those include:

Intrusion symptoms such as unwanted upsetting memories, nightmares, flashbacks, emotional distress or physical reactivity after exposure to traumatic reminders.
Persistent avoidance of stimuli associated with the secondary or primary traumatic event.
Negative alterations in moods associated with the traumatic event such as inability to recall important aspects of the trauma, feeling of detachment from others, markedly diminished interest or participation in significant activities.
Anger towards perpetrators or events causing trauma and suffering.

All these signs can lead to isolation, depression, loss of morale, loss of self-worth and emotional well-being, loss of hope and meaning, and existential despair.

Suicidal or hopeless thoughts? Get help: Remember that no matter how stressful or traumatic our work situation is, it is not a normal consequence of STS to experience suicidal thoughts or prolonged bouts of depression or hopelessness. Again reach out to a mental health professional or consult online sources of support. There are urgent suicide support hotlines available 24/7. Do not suffer alone.

How can we become more aware and prevent secondary traumatic stress?

Awareness is the first step towards understanding the feelings that your body has been telling you. For me it took leaving clinical practice, meeting hundreds of other doctors sharing similar stories as mine, as well going on a personal development journey to finally develop the peace and awe of what veterinary professionals really provide: the celebration, stewardship, and support of the human animal bond.

Once we can become aware that on any given day, many of us may experience and learn about a traumatic event of our patients or their owners, it is then needed to understand what learning about that event can do to our bodies. And to give ourselves grace to feel those feelings and not discredit what our bodies are telling us.

And remember like anything, prevention is key.

So how do we prevent the symptoms from secondary traumatic stress from worsening over time?

Prevention through RESILIENCY.

Adopt the new paradigms:

Being stoic doesn’t work. It creates shame, isolation, and repression. And remember, our body is keeping score. You cannot out rationalize traumatic experiences.

Understand pain is inevitable, but suffering is optional. Pain is just the neural signals to our brain about an event. Suffering is the meaning we make about that energy.

Practice EXTREME SELF CARE!

“Your capacity to love others is limited only by your capacity to love yourself. ”

— Adam Roa

It starts with ourselves! Self care will either be your greatest asset or your great liability.

What does extreme self care look like:

Live with intentionality: Go on a personal development journey to understand your true conscious based values. Discover your purpose for this current time period in your life. Learn your mission.

Practice relaxation and mindfulness techniques: Learn to decrease your sympathetic dominance and self-regulate your parasympathetic nervous system so you fatigue less during stressful situations. Practices include learning to relax your muscles during stressful events, practicing meditation, learning deep abdominal breathing techniques, practicing yoga, spending time during your workday to play with your patients, spend time outside, and many more.

Outline a community for support: Community is very much needed to continue to do the hard work you are doing. Sharing your personal narrative has healing powers. The reality is most of us have learned to deny our symptoms. Having a support network will allow you to tell on yourselves as well as empower others in your network to confront you if they are recognizing signs before you recognize them in yourself.

Develop a self-care and revitalization plan that works for you: Aspire to find a physical exercise routine that you can commit to at least 3x/week. Practice mental self-care methods such as writing in a journal, reading books that are unrelated to your work, learn to set boundaries, and get better at saying no. Develop emotional self-care habits such as allowing yourself to cry without judgement, apologizing to yourself after saying inner critical statements, laughing, and looking at yourself in the mirror and telling yourself you love you.

Know that it is okay to take a break: Just as my blog post here talks about making a career move after burnout, know that if the effects of secondary traumatic stress are more than you can handle, know it is okay to take a break.

And finally to all leaders, business owners, and influencers in the veterinary space. We must work to improve our toxic work environments. The results of two longitudinal studies of behavioral and mental healthcare providers working with U.S. military personnel suffering from trauma found that job burnout may increase the risk of developing STS. It’s time to stop saying, “That’s how we have always done it.” and develop a more psychologically safe environment for our associates and paraprofessional staff to learn and grow in.

Remember, secondary traumatic stress is just one piece of the pie that is contributing to a diminished well-being within veterinary medicine. In just my own first two and a half years of practice I experienced signs of secondary traumatic stress, primary traumatic stress from losing an anesthetic patient, moral/ethical fatigue while practicing the “art” of veterinary medicine, toxic work environments, and long work hours.

And for me, what I was missing most, that literally took 5 years to develop, was a toolbox of resources to handle those difficult cases and finally aspire to be like Mother Teresa.

Let’s continue the discussion to create awareness around secondary traumatic stress, its effects on ourselves, and how we can develop our own resiliency plan. Let’s dare to dream bigger.