PEDIATRICS Vol. 117 No. 5 May 2006, pp. S454-S457 (doi:10.1542/peds.2006-0099V)
SUPPLEMENT ARTICLE |
A Critical Concern: Pediatrician Self-care After Disasters
The Resiliency Program, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, New York, New York
Key Words: Hurricane Katrina • disaster response • mental health • pediatrician self-care • vicarious traumatization • compassion fatigue
As of this writing, health care in the areas impacted by Hurricane Katrina has shifted from emergency to primary care mode. Disasters take a heavy toll not only on victims but also on professionals and volunteers who experience the immediate, short-term, and long-term impact through their patients. The impact may occur because of the helping professional's effort to empathize with and be compassionate to patients. There is a rich literature that discusses the risks and impact of vicarious traumatization on psychotherapists, rescue workers, and health care providers who work with survivors, including those who have experienced community traumas such as natural disasters, state-sponsored terrorism, torture, mass murder, and acts of war.
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BURNOUT AND COMPASSION FATIGUE |
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The psychological impact of working with those who have suffered trauma has been variously referred to as "vicarious traumatization," "compassion fatigue," or, more simply, "burnout." Vicarious traumatization is described as the emotional and psychological reactions that are triggered by the experience of empathic engagement with patients who are survivors of trauma. This reaction is considered an inescapable aspect of trauma work. Working with a large population of individuals who have been traumatized by a shared catastrophic event raises many challenges to the individual health care provider.
Community traumas involve multiple threats to and actual losses of life but also can cause the breakdown of social structures such as family, communities, employment, and housing, thereby dealing a blow to the basic structure of social life by damaging connections between people and their sense of community. A large percentage of health care providers had to evacuate their homes and offices after Katrina and lost their livelihoods and sense of community. It is also likely that many experienced the loss of loved ones. As a result, the emotional toll on health care professionals continuing to treat a traumatized and dislocated population is likely to be significant. The psychological strains inherent in continuing to provide treatment under these circumstances may place pediatricians and other health care providers at risk for depression, anxiety, substance abuse, and maladaptive coping responses, exacerbated by the tendency to push one's limits and neglect self-care. In addition, the culture of medicine, which emphasizes emotional control and pushing aside feelings to grapple with the crisis at hand, combined with unrealistic expectations of personal invulnerability and the strong creed of taking care of others before taking care of oneself, may intensify these risks.
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SIGNS AND IMPACT OF VICARIOUS TRAUMATIZATION |
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Managing the stress of trauma work starts with the acknowledgment that this type of work can have a psychological impact on oneself. Working with traumatized populations makes one susceptible to a host of physical and psychological symptoms such as headaches, back pain, gastrointestinal discomfort, insomnia, emotional numbing or overreactivity, anxiety, depression, irritability, fatigue, anger, confusion, difficulty concentrating, and social withdrawal. Extreme feelings of hopelessness and despair may arise, and symptoms similar to posttraumatic stress disorder such as nightmares, intrusive images, hypervigilance, exaggerated startle responses, and other forms of autonomic hyperarousal, as well as transient dissociative experiences, may develop.
The effects may be felt in one's personal life, such as experiencing a sense of inadequacy and low self-esteem and a tendency toward self-blame. These feelings may leave one with little time or energy for individual and leisure pursuits and create a sense of irritability and impatience with, even disconnection from, loved ones. Over time, decreased intimacy in relationships may result, and use of alcohol or drugs to moderate stress is not uncommon. There is often a concurrent sense of loss of personal safety or invulnerability, and there may be a reawakening of feelings of grief and loss from one's own past life experiences.
The long-term effects of vicarious traumatization can impact a caretaker's professional behavior. Pediatricians may resort to excessive emotional distancing from their patients and unconsciously discourage their expression of intense emotion or personal disclosures as a way of coping with an increased sensitivity to themes of helplessness, violence, and pain. Often, feelings of guilt arise, coming from an impaired sense of competence and feeling that one could have done, or should be able to do, more for the victims. In the extreme, these feelings may lead to professional paralysis and a sense of being unable to perform the duties that one is trained to do and capable of doing. Also common are feelings of survivor guilt, physical and emotional exhaustion, and anger and scapegoating.
In contrast, sometimes vicarious trauma creates a sense of intense connection with victims and fellow crisis workers, creating overinvolvement with the bereaved and enmeshment with their grief. Inappropriate self-disclosures, unrealistic rescue fantasies or expectations, blurring of professional boundaries, and a sense of elation, "specialness," and grandiosity may develop, further impelling physicians to push themselves past their limits.
There are factors that place one at increased risk for vicarious traumatization, such as working in isolation without adequate supervision or peer support, working with a difficult, multiproblem client population, working long hours or with large caseloads, lacking control in the work environment, and being understaffed or otherwise lacking in sufficient resources. Current life stressors and available support systems, level of training and professional experience, and personal history of trauma or loss are also factors.
Vicarious traumatization can shake the clinician's sense of safety, trust, self-worth, capacity for intimacy, and sense of control and may manifest itself in strong reactions to particular clients. To remain clinically effective and connected with others, health care providers must address the impact of trauma work by countering its potential for negative effects with active efforts at self-care, such as participating in continuing education and supervision, balancing trauma work with other types of work, and attending to personal needs for rest and leisure.
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SELF-CARE |
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To help ensure that patients receive the best care possible during a crisis, and to prevent burnout and foster job satisfaction, physicians have a responsibility to take care of themselves, and their colleagues, physically and psychologically. Because disasters are extreme situations in which professionals are required to work long hours in inadequate facilities and under stressful and sometimes dangerous situations, personal needs for rest and recuperation are difficult to provide for. Although long work hours and stressful work conditions are an expected part of trauma work, and many disciplines are used to working in extreme conditions, the disaster left behind by Hurricane Katrina ushered in unprecedented circumstances for health care workers. Many helpers have continued to work despite the lack of stable practices, homes, or salaries and continue to endure ongoing extreme circumstances.
It is important that pediatricians and other health care providers attend to personal needs for rest and leisure. Although it is largely accepted that this is an important part of maintaining a balanced work and personal life, it is especially easy to neglect or dismiss these straightforward practices in the face of the overwhelming needs of a traumatized population. Instead of using self-care techniques prophylactically, it is often neglected until serious signs of stress develop. Helpers ignore signs of distress, feel they have more important concerns to deal with, or wait for a calm and less busy period to ensue before focusing on their needs. Commonly, physicians and other helpers may experience guilt in taking care of basic needs for sleep, good nutrition, and relaxation when their patient population may be lacking homes, their family, a clean bed in which to sleep, or food and water. It often is easier to sacrifice rather than to take care of oneself as the question of "how can I think about my own needs when others are suffering so much more than I am" arises. For these reasons, and others, it can be very helpful to participate in an informal professional support group to help manage the anxiety that comes from balancing the needs of self with caretaking for others and to increase positive coping. The following are red flags to be attentive to and tips for self-care.
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RED FLAGS |
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It is important to be alert to signs of maladaptive coping patterns such as the following and to seek appropriate help when they are noticed:
- withdrawal from family and friends;
- emotional numbing or hyperalertness and emotional overreactivity;
- anxiety attacks;
- depersonalization;
- loss of interest in everyday pleasures, including loss of appetite;
- preoccupation with clients' problems;
- chronic physical symptoms such as headaches, muscle tension, and back pain;
- insomnia or weight loss;
- sexual dysfunction;
- increased consumption of alcohol, overuse of over-the-counter sleep aids, or recreational drug use;
- a sense of hopelessness or helplessness; and/or
- suicidal or violent thoughts or urges.
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TIPS FOR SELF-CARE |
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- Eat well, and engage in pleasurable activities and rest.
- Get regular exercise such as walking, jogging, yoga, going to the gym, or even walking the dog.
- Help yourself and your children by helping establish and implement a daily routine that provides comfort and predictability. This is especially important in the first months postdisaster.
- Assess yourself subjectively and objectively. Keep in mind the importance of keeping a balance between personal and professional demands. Separate yourself from your work. When at home, it means leaving your work at work.
- Learn to notice what you do when you get stressed out, understand your own somatic signs of distress, and identify your own personal comfort level, and then take steps to rebalance your life.
- Seek or establish a professional support group as a way to discuss experiences and obtain support from others. Take advantage of continuing education and training opportunities.
- Get psychotherapy if you need or want it.
- Regularly use stress-management exercises such as deep breathing, positive visual imagery, meditation, and muscle relaxation.
- Engage in activities that help distract and soothe, such as pleasure-reading, writing, watching movies, doing crafts, listening to music, or engaging in other forms of creative expression.
- Use positive self-talk to help counteract feelings of guilt or personal inadequacy; catch yourself in negative, unproductive thoughts, challenge unrealistic expectations, and replace these thoughts with a positive message and realistic expectations.
- Balance trauma work with other types of work.
- Do things that feel personally meaningful and rejuvenating (eg, spend more time with the grandkids).
- Engage in activities that encourage personal growth or acquire new skills.
- Combat pessimism and cynicism with activities that help reaffirm your faith in the world and in others.
- Remain connected with others and build community; find social outlets and spend time with family, friends, and neighbors.
- Pace your work, take small breaks, try not to schedule difficult cases back to back, and limit shifts or tours of duty.
- Provide opportunities for case review, regular debriefings, and peer support.
- Set personal limits to help maintain personal and professional boundaries.
- Be attentive to time-management needs.
- Have your own personal and family disaster-preparedness plan.
We are entering a phase of long-term care for children with more complex needs than they had before Katrina, and with limited resources. Stress will escalate. We are not trained well to recognize our limitations or when we are becoming ineffective or placing our patients at risk. More so, we are not well trained to recognize when we are putting ourselves at risk. To prevent burnout and provide optimal care for children, we must take care of ourselves. Take time for yourself, and don't feel guilty about it. Enjoy it. Your patients, and your family, will be glad that you did.
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FOOTNOTES |
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Accepted Jan 25, 2006.
Address correspondence to Paula A. Madrid, PsyD, The Resiliency Program, National Center for Disaster Preparedness, Mailman School of Public Health, 722 W 168th St, 10th Floor, New York, NY 10032. E-mail: pam2109{at}columbia.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Editor's note: It is painful to report that one of our colleagues, James Kent Treadway Jr, MD, FAAP, found the stress of the disaster more than he could emotionally endure and took his own life. Unfortunately, we are not immune to the stresses that our patients have when they come to us for treatment and solace. His unfortunate demise emphasizes the importance of taking care of ourselves so that we can better take care of others. This terrible tragedy cannot be denied and emphasizes the importance of the following article. We all wish we could have prevented this tragedy, and we certainly hope we can effectively support and comfort those who are physically and emotionally overwhelmed with future disasters.
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REFERENCES |
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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