Pediatric Behavioral Health in Disasters
5. Mitigation
5.2. Risks and Mitigation of Secondary Trauma
Patty A. Davis, LSCSW, LCSW, IMH-E® (III)
Objectives
- Describe the effects of working with populations affected by trauma.
- Recognize common warning signs of trauma-exposure responses.
- Describe at least two tools that promote workforce sustainability.
Introduction
Experiences that may seem rare to others can become routine for pediatric health care teams responding to children and families in crisis. These teams regularly care for children who are seriously ill, abused, or neglected. Some children have a poor prognosis, lack adequate support systems, or die.
Professionals working in these environments may begin to view such events as a normal part of their work. However, it is important to consider how team members process what they see and experience each day. Constant exposure to distress, combined with the need to manage one’s reactions and limited opportunities to process those experiences, can be emotionally and physically draining.
Secondary Traumatic Stress
Secondary traumatic stress is closely related to the terms vicarious trauma and compassion fatigue. It describes the emotional and behavioral effects that can arise from learning about another person’s trauma and from helping, or wanting to help, someone who has been traumatized.
Secondary traumatic stress can affect clinical staff as well as other employees who hear about events occurring in patient-care areas.
Symptoms may resemble posttraumatic stress reactions and include:
- Sudden recall of a patient’s situation
- Upsetting dreams and intrusive thoughts
- Difficulty “turning off” work-related thoughts at home
- Sleep disruption
- Hyperarousal or hypervigilance
- Avoidance or self-medication
- Numbness or detachment
- Physical or emotional exhaustion
If left unaddressed, secondary traumatic stress can negatively affect physical and emotional well-being, reduce empathy, and diminish the quality of patient care. Organizational consequences may include increased absenteeism, impaired judgment, reduced motivation and productivity, staff conflict, burnout, and turnover.
Secondary traumatic stress should be considered an occupational risk for employees working in and around health care.
People respond to traumatic stress in different ways. An experience that affects one person may not affect a colleague in the same setting in the same way. Organizations should normalize common reactions, provide sustainable support tools, and establish policies that support workforce well-being.
The first step in mitigating secondary traumatic stress is recognizing it and understanding how commonly it occurs.
Prevalence
Secondary traumatic stress is an occupational hazard for health care professionals who care for trauma survivors.
- The National Child Traumatic Stress Network reports that approximately 6%–26% of therapists working with traumatized populations and nearly 50% of child welfare workers are at elevated risk.
- A 2024 systematic review and meta-analysis by Xu and colleagues reported an average prevalence of approximately 65% among emergency nurses.
- O’Hara and colleagues found elevated secondary traumatic stress scores on the Professional Quality of Life Measure among pediatricians who care for children affected by abuse and neglect.
Common Warning Signs
- Anger or cynicism
- Hypervigilance
- A sense that one can never do enough
- Strong emotions that interfere with daily functioning
- Difficulty regulating emotions
- Problematic substance use or other addictive behaviors
- Dissociation
- Somatic symptoms such as headaches, muscle tension, or gastrointestinal problems
- Chronic exhaustion
- Difficulty empathizing with others’ circumstances
- Feelings of helplessness or hopelessness
Sustainability Tools
Recognizing that health care team members may experience understandable reactions to trauma exposure allows individuals to focus on personal care and advocate for organizational support.
Take Brief Breaks
Set aside short periods during the workday to disconnect from work-related tasks. Even a five-minute break can provide time to step outside, notice the weather, read a brief reflection, or focus on something other than work.
Care for the Body
Use practices such as meditation, deep breathing, and stretching. Eat regular, balanced meals; engage in physical activity; prioritize adequate sleep; and avoid or reduce alcohol and nonprescribed drug use.
Make Time to Unwind
Make time outside work for hobbies, enjoyable activities, and restorative experiences.
Connect with Others
Talk with trusted friends or coworkers about concerns and emotions. Social connection is an important protective factor.
Set Goals and Priorities
Determine what must be completed today and what can wait. Recognize that priorities and routines may change, and acknowledge accomplishments at the end of the day.
Keep a Journal
Recording goals and accomplishments can help direct attention toward progress and reduce feelings of overwhelm.
The Four Rs of Workforce Resilience
Leaders can support their teams through a resilience framework based on four actions: Recognize, Realize, Respond, and Resist Retraumatization.
1. Recognize the Effects of Work-Related Stress
Stress varies among individuals. Each team member has a unique background that affects how they respond.
- Stress may follow a single event or accumulate over time.
- It may arise from a personal experience or from learning about stressful events affecting others.
- Secondary traumatic stress should be treated as a potential risk for all health care team members.
- Warning signs may include nightmares, insomnia, persistent worry, nervousness, irritability, medically unexplained symptoms, or flashbacks.
2. Realize That Work-Related Stress Occurs
A team member’s response to stress is not evidence of managerial failure, individual weakness, blame, or wrongdoing. It may reflect an occupational hazard of the work.
- Repeated stressful workplace events without adequate buffers may contribute to burnout.
- Burnout may involve exhaustion, feelings of ineffectiveness, detachment, and increased cynicism or bitterness about work.
- Normalize stress reactions. It is acceptable not to feel okay.
- Following a crisis, prioritize team recovery and stress management before conducting a critical evaluation of the event.
- For many people, stress reactions diminish within several weeks. Those with persistent or worsening symptoms may benefit from professional support.
3. Respond with Support
When concerned about a team member’s safety, communicate the concern directly and follow organizational safety protocols. Ask clearly whether the person is having thoughts of harming themselves or someone else, and connect them with immediate support when indicated.
- Maintain a calm, predictable environment.
- Communicate expectations clearly.
- Address mistakes and difficulties collaboratively and supportively.
- Offer an opportunity to talk and be available to listen.
- Share relevant support resources.
- Be kind, consistent, and reassuring.
- Explore the source of distress and help address or appropriately escalate the concern.
4. Resist Retraumatization
Retraumatization occurs when a person reexperiences aspects of a previous stressor in a setting expected to be safe. It may be unintentionally triggered by an environment, attitude, expression, or interaction that recreates a loss of power, control, or safety.
Indifference to another person’s experience can contribute to retraumatization, even when harm is not intended. Acknowledge the person’s reactions and needs.
Use Supportive Language
- Instead of saying, “It could be much worse” or “You will get over it,” say, “It makes sense that this is upsetting.”
- Instead of saying, “You need to pull yourself together” or “You need to be strong for the team,” say, “You are an important part of our team.”
- Instead of dismissing the need for additional help, say, “It is normal to need time to recover and renew a sense of safety.”
Recognize Contributions and Successes
- Invite team members to reflect on rewarding moments at work.
- Discuss what they value or enjoy about their work.
- Acknowledge each team member’s contributions and accomplishments.
- Share positive feedback received from colleagues and families.
Takeaway Points
- Secondary traumatic stress is an occupational risk in health care, particularly for professionals working with children and families affected by trauma.
- Stress may follow a single event or accumulate over time.
- Secondary traumatic stress may affect a person’s sense of safety and overwhelm their ability to cope at work.
- Recognizing and destigmatizing secondary traumatic stress is an important first step toward recovery.
- Online education, books, self-assessment measures, and organizational guidelines can help individuals and organizations mitigate its effects.
Action Items
- At the beginning and end of each workday, identify one thing for which you are grateful.
- Identify one change that could improve your workday. Consider partnering with a colleague to support one another in making the change.
- Share secondary traumatic stress resources with your organization, clinic, or colleagues.
Additional Information
Books
- Bloom, S. L. (2013). “The Sanctuary Model: Changing Habits and Transforming the Organizational Operating System.” In J. D. Ford and C. A. Courtois, eds., Treating Complex Traumatic Stress Disorders in Childhood and Adolescence. Guilford Press.
- van Dernoot Lipsky, L. (2009). Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others.
- Mathieu, F. (2007). Running on Empty: Compassion Fatigue in Health Professionals. Rehab & Community Care Medicine.
Resources and Tools
- Trauma Stewardship Institute —education and practical tools for sustaining professionals who serve others.
- Tiny Survival Guide —a brief guide to strengthening personal protective and restorative practices.
- Professional Quality of Life Measure (ProQOL) —a self-scored measure that explores compassion satisfaction, perceived support, burnout, secondary traumatic stress, and moral distress. It is not a diagnostic tool.
- Secondary Traumatic Stress: A Fact Sheet for Child-Serving Professionals
- Guided Self-Compassion Practices and Exercises , Dr. Kristin Neff.
Additional Sources
- Bride, B. E. (2007). “Prevalence of Secondary Traumatic Stress Among Social Workers.” Social Work, 52(1), 63–70. doi:10.1093/sw/52.1.63.
- Supporting Mental Health During the COVID-19 Pandemic , National Institute of Mental Health.
- O’Hara, M. A., McCann, T. A., Fan, W., Lane, M. M., Kernie, S. G., and Rosenthal, S. L. (2020). “Child Abuse Taking Its Toll on the Emotional Well-Being of Pediatricians.” Clinical Pediatrics, 59(4–5), 450–457. doi:10.1177/0009922820905865.
- Walton, M., Murray, E., and Christian, M. (2020). “Mental Health Care for Medical Staff and Affiliated Health Care Workers During the COVID-19 Pandemic.” European Heart Journal: Acute Cardiovascular Care, 9(3), 241–247.
- Xu, Z., Zhao, B., Zhang, Z., Wang, X., Jiang, Y., Zhang, M., and Li, P. (2024). “Prevalence and Associated Factors of Secondary Traumatic Stress in Emergency Nurses: A Systematic Review and Meta-Analysis.” European Journal of Psychotraumatology, 15(1), 2321761. doi:10.1080/20008066.2024.2321761.