Secondary Stress and the Professional Helper

Don R. Catherall

For more than a decade, the field of traumatology has recognized that those who interact with trauma survivors are themselves exposed to a form of traumatic stress. Whereas the trauma survivor is exposed to a primary trauma and the accompanying traumatic stress, the helper is exposed to the trauma survivor and an accompanying secondary traumatic stress. This distinction between primary and secondary exposure is blurred somewhat by the evolution of the Diagnostic and Statistical Manual’s definition of PTSD. DSM-IV now defines the stressor event to include learning of a trauma occurring to a loved one. Parents who are traumatized when they learn of their child’s trauma are classified as having PTSD. In the past, many theorists might have classified the parents as having secondary exposure because they were not directly exposed to the traumatic event. However, in the language of DSM-IV, the traumatic event is the discovery that a loved one has been in a trauma. This still differs from the experience of interacting with that trauma survivor. It is within the domain of interacting with someone affected by trauma that the concept of secondary stress remains applicable.

Since parents may both learn of a trauma to a loved one and subsequently interact with the survivor, they are subject to both direct and secondary exposure. The professional helper, on the other hand, is usually not involved with the survivor until after the trauma has occurred. Thus, the professional helper’s experience is generally confined to secondary exposure. The exception is in the case of disasters, where helpers may be on the scene either while the disaster is still in progress or while victims are still being rescued.

Secondary Exposure

The literature on secondary exposure has largely focused on the development of trauma symptoms. Several terms have been advanced to describe apparent cases of PTSD that do not qualify for the official PTSD diagnosis because the exposure was secondary rather than direct. Instead, the individual has been said to have a different disorder, usually called Secondary Traumatic Stress Disorder (STSD), vicarious traumatization, compassion fatigue or empathic strain. Regardless of which term is used, there is evidence indicating that these cases do exist and have occurred among professional helpers. Although it is not yet clear how often secondary exposure leads to the development of trauma symptoms, it is probably safe to say that it is fairly infrequent that secondary exposure produces the complete PTSD syndrome. But does this mean that it is safe to say that professional helpers are only infrequently affected by their secondary exposure to trauma survivors? I believe the answer is no. The development of dramatic PTSD symptoms is only one of the ways in which professional helpers are affected by their exposure to secondary traumatic stress

The ways in which professional helpers are affected may not be as obvious only because we don't think of them as symptoms. For example, can you imagine a professional helper coming home from performing a critical incident debriefing and going right to bed? It's highly unlikely. Why? Because we typically need to "unwind" after such experiences. We each tend to develop our own means of settling down when we get home--whether it be by reading a book, watching TV or cleaning the kitchen--because we are all dealing with the same issue; i.e., our arousal level is heightened. It is obviously so when we have been on the scene of a disaster. It may be less obvious when we have "only" been counseling the victims of the disaster, particularly when the disaster is long past. But if we have been maintaining a good connection with people who themselves are aroused (because they're still dealing with primary traumatic stress), then it's likely that we too have entered a state of heightened arousal. Sometimes the only difference is that we are able to unwind and go to sleep, while the trauma victim can often only do so by exhausting himself or resorting to chemical aids.

The Knowledge of What Can Happen

Another way in which we can recognize the impact of secondary exposure is in our world view. Just as the trauma survivor becomes aware of dangers that he previously ignored or denied, those who listen to his story come to see the world differently as well. This usually leads to changes in the way we approach our lives. Workers who deal with plane crash survivors may learn to pay more attention to the location of the emergency exits when they themselves fly—just as firemen are more attuned to escape routes in their own homes. Indeed, this kind of awareness tends to continue to expand to include those who are close to us—the fireman’s child also grows up more aware of escape routes. After working with a group of children who had been molested by an employee at a day care center, I placed my own child in such a center. The staff there may have thought I was a bit perverse when I wanted to see the bathrooms and know the details of their routine for taking children to the bathroom. But it is simply that I possessed the knowledge that comes from listening to trauma survivors, I knew what can happen.

Losing Our Sense of Perspective


Knowing what can happen is both a blessing and a curse. It is a greater awareness of the potential dangers in the world, and it requires us to give up denial, to accept certain ugly realities. On the positive side, it allows us to anticipate danger and hence be better prepared. Personally, I would have it no other way. But sometimes this knowledge can itself become a distortion. If we lose our sense of perspective, then our awareness that planes actually do crash and innocent appearing adults actually do molest children can transform into an expectation that every plane is likely to crash and every adult is likely to hurt our child. When we lose our sense of perspective in this way, we enter the world of the traumatized. This outlook is accompanied by a state of heightened arousal; we stay constantly on our guard because we anticipate danger at every turn. If we’re unable to regain our sense of perspective, then the next step is avoidance and our life becomes organized around what might happen, rather than what is happening. This is the point where secondary exposure produces secondary traumatization.


It is not so easy to maintain our sense of perspective when our interactions with others are skewed by exposure to the traumatized among us. Only a tiny percentage of citizens are completely untrustworthy; most people deserve the benefit of the doubt. But in large urban areas, some police officers and constables are exposed to that tiny percentage on a daily basis. These men and women are at increased risk of losing their sense of perspective and becoming more suspicious of all citizens. We know that the same process can occur in working with trauma survivors. Just as with primary traumatic stress, the risk of losing our sense of perspective increases with greater exposure to secondary stressors. But, just as with survivors of primary trauma, the effects of secondary exposure are moderated by an environment populated by supportive listeners. We may not be able to prevent the changes in our world view, but we can help each other keep it in perspective.

The Emotional Impact of Trauma Work

A third way in which professional helpers can be affected is emotionally. This is the dimension most people think of when they hear terms like "compassion fatigue". But being affected emotionally is not restricted to extremes like depression. Working with traumatized people can be emotionally draining, especially if the client's trauma reverberates with our own experience. Most professional helpers recognize a need to limit the numbers of traumatized clients they see because they can become emotionally exhausted by the work. Ironically, working with trauma clients can cause us to feel emotionally drained even as we experience a heightened level of physiological arousal. Then, just as with trauma survivors themselves, we helpers can reach a state in which we're exhausted yet can't slow down our physiology. At such times, we're more vulnerable to the distressing thoughts and perceptions that can come from working with people whose sense of living in a safe and predictable world has been shattered.

Thus, secondary exposure can lead to an extreme reaction, such as the development of the full PTSD syndrome, or it can lead to a less clearly symptomatic--yet perhaps chronic--condition in which our work seems to take over our life. In many respects, this is similar to the old concept of burnout (which some people consider to be an element of compassion fatigue). Burnout is not confined to professional helpers but it takes on a special quality when it is combined with exposure to secondary traumatic stress. Many jobs involve stress. Many jobs cause workers to maintain a high level of physiological arousal, with an accompanying need to unwind afterwards. Many jobs are emotionally draining, although the most emotionally draining tend to be those jobs that require us to deal with others' emotions. And there are other jobs that challenge our world view and our fundamental assumptions about our personal safety. But there are few jobs that combine all of these. All professional helpers bear a vulnerability to living out the traumatic experience of those they help, whether in limited doses or as the full PTSD syndrome. This is true for helpers whether they (a) deal with the immediate traumatic situation as policemen, firemen, EMS personnel, etc, (b) work right behind the "front lines" as crisis interventionists, or (c) are removed from the primary traumatic situation and only hearing of it as therapists.

Fortunately, we professional helpers have more tools than the average person. We have our knowledge of the ways in which trauma affects people. We have our skills for soothing arousal and processing states of distress. And most importantly, we have each other, a support system with the potential to help each of us maintain perspective and find understanding during those times when we get caught in the web of secondary traumatic stress. We are not invulnerable, but if we maintain a strong sense of community among ourselves, we can be resilient.

Don R. Catherall, Ph.D.
Executive Director,
The Phoenix Institute