Defining Terms
A key component of preventing secondary trauma & other stresses from progressing is a thorough understanding of the causes, symptoms, & neurobiology of these conditions. Here are some quick definitions for reference-- for a more detailed look with neurobiological explanations and examples in the immigration law context see the guidebook I created here.
Primary Stress & Trauma
Stress: According to Nagoski & Nagoski (2019) “Stress is the neurological and physiological shift that happens in your body when you encounter [a stressor]” (p. 5). Stressors are internal (thoughts) and external stimuli (a tiger chasing you, everyday work and family obligations) that activate the stress response of the sympathetic nervous system known as the fight, flight, freeze response because they are perceived as threats. The stress response will be explored further in the following section. Stress is not always negative—it can be productive when it is used effectively and discharged from the body. However, chronic stress can produce long-term serious health problems and is related to early death.
Trauma: The most concise definition of trauma is offered by Peter Levine in his book Healing Trauma (2005): “we become traumatized when our ability to respond to a perceived threat is in some way overwhelmed” (p. 9). The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed “the 3 E’s of trauma” which are 3 factors that constitute the process of traumatization: event(s), experience of event(s), and effect. First, a potentially traumatic event occurs; second, an individual may experience that event as life-threatening, fail to process and respond effectively, and develop initial traumatic symptoms; third, if the effect of this experience is long-lasting and hinders normal functioning and wellbeing, then that person has experienced trauma (SAMHSA, 2014). You can think about the causes of traumatic events in terms of “Big T” and “little t” traumatic events, or what Levine calls the “obvious” and “less obvious” causes of trauma. Big T Traumas are the obvious causes of trauma that you hear about the most: war, major car crashes/other accidents, sexual assaults. Little t traumas are the less obvious incidents such as childhood bullying, minor accidents/injuries, even difficult births. Little t traumas are often overlooked and particularly harmful when multiple occur over time (Levine, 2005, pp. 12-3).
Acute Stress Disorder (ASD): This is the initial traumatic response that may or may not develop into PTSD. A person is diagnosed with ASD if a range of diagnostic traumatic symptoms last 3 days to 1 month after a traumatic event occurs (American Psychiatric Association, 2013).
Post-Traumatic Stress Disorder (PTSD): A person is diagnosed with PTSD when they meet the range of diagnostic criteria and exhibit diagnostic symptoms for PTSD for more than 1 month. Common symptoms of PTSD include re-experiencing (flashbacks, nightmares), avoidance (avoiding certain places, thoughts), hyperarousal (hypervigilance, exaggerated startle, concentration and sleep problems), dissociation (American Psychiatric Association, 2013).
Complex Post-Traumatic Stress Disorder (CPTSD): A diagnosis not yet included in the DSM, CPTSD develops due to ongoing or repeated traumas over months or years. Causes of CPTSD include childhood trauma, domestic violence, and other situations that someone often cannot escape so they are exposed to trauma continuously over time. CPTSD may share symptoms with PTSD but is associated with other comorbidities and unique behavioral/emotional/ psychological/cognitive symptoms like problems with emotional regulation, issues with self-perception and perception of the abuser, and cognitive shifts to despair and hopelessness (National Center for PTSD, 2020).
Racial Trauma: A term not included in the DSM, racial trauma refers to the traumatic effect of real or perceived racial discrimination. According to Comas-Díaz et al. (2019), “these include threats of harm and injury, humiliating and shaming events, and witnessing harm to other [People of Color] due to real or perceived racism (Carter, 2007).” Events of racial trauma are chronic and cumulative. They are also exacerbated by intersectional experiences of oppression by class, gender, sexuality, etc. Racial trauma shares symptoms with PTSD but also manifests in unique symptoms like intergenerational effects (epigenetic alterations in babies of traumatized parents) and injury to sense of self. It is vicarious to other BIPOC (Comas-Díaz et al., 2019).
Traumatic triggers: an internal stimulus (thoughts) or external stimulus (sounds, places, smells) that reminds someone of a traumatic event they experienced prompting a traumatic response.
Trauma-Informed Approach/Practice: In essence, a trauma-informed approach understands the pervasiveness and impact of trauma on client experiences and responds by incorporating this knowledge into their procedures. SAMHSA conceptualizes “the 4 R’s” of a trauma-informed approach: “A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and seeks to actively resist retraumatization” (SAMHSA, 2014).
Secondary Trauma
Secondary Trauma/Trauma Exposure Response: “Secondary trauma” and “trauma exposure response” are umbrella terms for the range of stress, trauma, and empathy-related issues common in “helping professions” where professionals are exposed to clients’ traumatic experiences and other kinds of suffering, coupled with organizational and systemic barriers to helping.
Secondary Traumatic Stress Disorder: Initially used interchangeably with compassion fatigue by the creator of the term (Figley, 1995), STSD refers to the development of some PTSD symptoms due to secondhand exposure to traumatic material of people who work in “helping professions” (therapists, healthcare professionals, first responders, social workers, attorneys, teachers, etc.). If symptoms progress, it can lead to a PTSD diagnosis (Figley, 1995).
Compassion Fatigue: There is a great deal of theoretical ambiguity with the correct use of this term due to different definitions and models developed over time, but according to Newell & MacNeill (2010) and Figley (2002), compassion fatigue is a disorder characterized by empathic strain and depletion (thus, the name “compassion fatigue”) caused by chronic use of empathy by practitioners in helping professions who are exposed to both secondhand traumatic material and other forms of human suffering in combination with organizational and systemic barriers to helping. Compassion fatigue manifests as a combination of the symptoms of burnout and STSD.
Vicarious Trauma: Caused by secondhand trauma exposure, vicarious trauma is characterized by symptoms of cognitive changes or changes to the “inner experience” of a practitioner around topics of identity, worldview, spirituality, affect tolerance, efficacy/agency, safety, trust, control, intimacy, and more (Saakvitne et al., 1996).
Burnout: Burnout is not strictly related to traumatic exposure but rather workplace conditions. First coined by Freudenberger (1975) and elaborated by Maslach (1982), burnout has 3 dimensions of symptoms: emotional exhaustion (fatigue caused by empathic overuse), depersonalization (decreased ability to express empathy), and a decreased sense of accomplishment (Maslach & Leiter, 2016).
Moral distress: First theorized among healthcare professionals, moral distress is caused by a practitioner knowing the ethically correct course of action but being unable to act on it due to some barrier: “Thus, moral distress occurs when the internal environment of [practitioners] -- their values and perceived obligations -- are incompatible with the needs and prevailing views of the external work environment” (Epstein & Delgado, 2010). It also “involves a threat to one’s moral integrity. Moral integrity is the sense of wholeness and self-worth that comes from having clearly defined values that are congruent with one’s actions and perceptions (Hardingham, 2004).” The key symptoms are a sense of powerlessness, changed thoughts about the self, and it may lead to practitioners leaving the profession (Epstein & Delgado, 2010).
Loss & Grief
Loss: Loss is losing someone or something; there are death and non-death related losses. Different kinds of loss include primary, secondary, symbolic, ambiguous loss (Sparks, 2020a).
Grief: Grief is the natural emotional response to any change or loss. There are many different types of grief including anticipatory, complicated, and disenfranchised. Disenfranchised grief occurs when the type of loss or relationship with the object of loss is not socially recognized; in short, when particular individuals are not socially viewed as entitled to grieve. Because it is disenfranchised, there may be social stigma and a lack of societal mourning rituals that grieving people can rely on to access social support. Each of these types of grief have their own physical, mental, and emotional symptoms including feeling sad, lonely, angry, guilty, frustrated, depressed, anxious, numb, agitation, sleep and eating changes, fatigue, body aches (Sparks, 2020b; Doka, 1989).
Distinguishing between secondary trauma conditions
While secondary traumatic stress disorder (STSD) and vicarious trauma (VT) are both caused by secondhand trauma exposure, STSD manifests as PTSD symptoms where VT manifests as cognitive shifts. Compassion fatigue (CF) is a broader term that is caused by a combination of trauma exposure and organizational and systemic factors, and encompasses some of the symptoms of STSD, VT, and burnout. CF, VT, and burnout develop gradually; STSD may develop immediately or gradually and may have a compounded effect.
Stress: According to Nagoski & Nagoski (2019) “Stress is the neurological and physiological shift that happens in your body when you encounter [a stressor]” (p. 5). Stressors are internal (thoughts) and external stimuli (a tiger chasing you, everyday work and family obligations) that activate the stress response of the sympathetic nervous system known as the fight, flight, freeze response because they are perceived as threats. The stress response will be explored further in the following section. Stress is not always negative—it can be productive when it is used effectively and discharged from the body. However, chronic stress can produce long-term serious health problems and is related to early death.
Trauma: The most concise definition of trauma is offered by Peter Levine in his book Healing Trauma (2005): “we become traumatized when our ability to respond to a perceived threat is in some way overwhelmed” (p. 9). The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed “the 3 E’s of trauma” which are 3 factors that constitute the process of traumatization: event(s), experience of event(s), and effect. First, a potentially traumatic event occurs; second, an individual may experience that event as life-threatening, fail to process and respond effectively, and develop initial traumatic symptoms; third, if the effect of this experience is long-lasting and hinders normal functioning and wellbeing, then that person has experienced trauma (SAMHSA, 2014). You can think about the causes of traumatic events in terms of “Big T” and “little t” traumatic events, or what Levine calls the “obvious” and “less obvious” causes of trauma. Big T Traumas are the obvious causes of trauma that you hear about the most: war, major car crashes/other accidents, sexual assaults. Little t traumas are the less obvious incidents such as childhood bullying, minor accidents/injuries, even difficult births. Little t traumas are often overlooked and particularly harmful when multiple occur over time (Levine, 2005, pp. 12-3).
Acute Stress Disorder (ASD): This is the initial traumatic response that may or may not develop into PTSD. A person is diagnosed with ASD if a range of diagnostic traumatic symptoms last 3 days to 1 month after a traumatic event occurs (American Psychiatric Association, 2013).
Post-Traumatic Stress Disorder (PTSD): A person is diagnosed with PTSD when they meet the range of diagnostic criteria and exhibit diagnostic symptoms for PTSD for more than 1 month. Common symptoms of PTSD include re-experiencing (flashbacks, nightmares), avoidance (avoiding certain places, thoughts), hyperarousal (hypervigilance, exaggerated startle, concentration and sleep problems), dissociation (American Psychiatric Association, 2013).
Complex Post-Traumatic Stress Disorder (CPTSD): A diagnosis not yet included in the DSM, CPTSD develops due to ongoing or repeated traumas over months or years. Causes of CPTSD include childhood trauma, domestic violence, and other situations that someone often cannot escape so they are exposed to trauma continuously over time. CPTSD may share symptoms with PTSD but is associated with other comorbidities and unique behavioral/emotional/ psychological/cognitive symptoms like problems with emotional regulation, issues with self-perception and perception of the abuser, and cognitive shifts to despair and hopelessness (National Center for PTSD, 2020).
Racial Trauma: A term not included in the DSM, racial trauma refers to the traumatic effect of real or perceived racial discrimination. According to Comas-Díaz et al. (2019), “these include threats of harm and injury, humiliating and shaming events, and witnessing harm to other [People of Color] due to real or perceived racism (Carter, 2007).” Events of racial trauma are chronic and cumulative. They are also exacerbated by intersectional experiences of oppression by class, gender, sexuality, etc. Racial trauma shares symptoms with PTSD but also manifests in unique symptoms like intergenerational effects (epigenetic alterations in babies of traumatized parents) and injury to sense of self. It is vicarious to other BIPOC (Comas-Díaz et al., 2019).
Traumatic triggers: an internal stimulus (thoughts) or external stimulus (sounds, places, smells) that reminds someone of a traumatic event they experienced prompting a traumatic response.
Trauma-Informed Approach/Practice: In essence, a trauma-informed approach understands the pervasiveness and impact of trauma on client experiences and responds by incorporating this knowledge into their procedures. SAMHSA conceptualizes “the 4 R’s” of a trauma-informed approach: “A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and seeks to actively resist retraumatization” (SAMHSA, 2014).
Secondary Trauma
Secondary Trauma/Trauma Exposure Response: “Secondary trauma” and “trauma exposure response” are umbrella terms for the range of stress, trauma, and empathy-related issues common in “helping professions” where professionals are exposed to clients’ traumatic experiences and other kinds of suffering, coupled with organizational and systemic barriers to helping.
Secondary Traumatic Stress Disorder: Initially used interchangeably with compassion fatigue by the creator of the term (Figley, 1995), STSD refers to the development of some PTSD symptoms due to secondhand exposure to traumatic material of people who work in “helping professions” (therapists, healthcare professionals, first responders, social workers, attorneys, teachers, etc.). If symptoms progress, it can lead to a PTSD diagnosis (Figley, 1995).
Compassion Fatigue: There is a great deal of theoretical ambiguity with the correct use of this term due to different definitions and models developed over time, but according to Newell & MacNeill (2010) and Figley (2002), compassion fatigue is a disorder characterized by empathic strain and depletion (thus, the name “compassion fatigue”) caused by chronic use of empathy by practitioners in helping professions who are exposed to both secondhand traumatic material and other forms of human suffering in combination with organizational and systemic barriers to helping. Compassion fatigue manifests as a combination of the symptoms of burnout and STSD.
Vicarious Trauma: Caused by secondhand trauma exposure, vicarious trauma is characterized by symptoms of cognitive changes or changes to the “inner experience” of a practitioner around topics of identity, worldview, spirituality, affect tolerance, efficacy/agency, safety, trust, control, intimacy, and more (Saakvitne et al., 1996).
Burnout: Burnout is not strictly related to traumatic exposure but rather workplace conditions. First coined by Freudenberger (1975) and elaborated by Maslach (1982), burnout has 3 dimensions of symptoms: emotional exhaustion (fatigue caused by empathic overuse), depersonalization (decreased ability to express empathy), and a decreased sense of accomplishment (Maslach & Leiter, 2016).
Moral distress: First theorized among healthcare professionals, moral distress is caused by a practitioner knowing the ethically correct course of action but being unable to act on it due to some barrier: “Thus, moral distress occurs when the internal environment of [practitioners] -- their values and perceived obligations -- are incompatible with the needs and prevailing views of the external work environment” (Epstein & Delgado, 2010). It also “involves a threat to one’s moral integrity. Moral integrity is the sense of wholeness and self-worth that comes from having clearly defined values that are congruent with one’s actions and perceptions (Hardingham, 2004).” The key symptoms are a sense of powerlessness, changed thoughts about the self, and it may lead to practitioners leaving the profession (Epstein & Delgado, 2010).
Loss & Grief
Loss: Loss is losing someone or something; there are death and non-death related losses. Different kinds of loss include primary, secondary, symbolic, ambiguous loss (Sparks, 2020a).
Grief: Grief is the natural emotional response to any change or loss. There are many different types of grief including anticipatory, complicated, and disenfranchised. Disenfranchised grief occurs when the type of loss or relationship with the object of loss is not socially recognized; in short, when particular individuals are not socially viewed as entitled to grieve. Because it is disenfranchised, there may be social stigma and a lack of societal mourning rituals that grieving people can rely on to access social support. Each of these types of grief have their own physical, mental, and emotional symptoms including feeling sad, lonely, angry, guilty, frustrated, depressed, anxious, numb, agitation, sleep and eating changes, fatigue, body aches (Sparks, 2020b; Doka, 1989).
Distinguishing between secondary trauma conditions
While secondary traumatic stress disorder (STSD) and vicarious trauma (VT) are both caused by secondhand trauma exposure, STSD manifests as PTSD symptoms where VT manifests as cognitive shifts. Compassion fatigue (CF) is a broader term that is caused by a combination of trauma exposure and organizational and systemic factors, and encompasses some of the symptoms of STSD, VT, and burnout. CF, VT, and burnout develop gradually; STSD may develop immediately or gradually and may have a compounded effect.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Comas-Díaz L., Hall G. N., Neville H. A. (2019). Racial trauma: Theory, research, and healing: Introduction to the special issue. Am Psychol. 2019 Jan;74(1):1-5. doi: 10.1037/amp0000442. PMID: 30652895.
Doka, K. (1989). Disenfranchised grief: Recognizing hidden sorrow. Lexington Books.
Epstein, E. G., & Delgado, S. (2010). Understanding and addressing moral distress. OJIN: The Online Journal of Issues in Nursing, 15(3), Man. 1. http://dx.doi.org/10.3912/OJIN.Vol15No03Man01
Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Brunner/Mazel.
Figley, C. R. (2002). Compassion fatigue: Psychotherapists' chronic lack of self care. Journal of clinical psychology. 58. 1433-41. 10.1002/jclp.10090.
Freudenberger, H. J. (1975). The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research & Practice, 12(1), 73–82. https://doi.org/10.1037/h0086411
Levine, P. A., & Frederick, A. (1997). Waking the tiger, healing trauma: The innate capacity to transform overwhelming experiences. North Atlantic Books.
Maslach, C. (1982). Burnout: The cost of caring. Prentice-Hall Inc.
Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: recent research and its implications for psychiatry. World psychiatry : official journal of the World Psychiatric Association (WPA), 15(2), 103–111. https://doi.org/10.1002/wps.20311
Nagoski, E., & Nagoski, A. (2019). Burnout: The secret to unlocking the stress cycle. Ballantine Books.
National Center for PTSD. (2020). “Complex PTSD.” US department of veterans affairs. https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp#one
Newell, J. M., & MacNeil, G. A. (2010). Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue: A review of theoretical terms, risk factors, and preventive methods for clinicians and researchers. Best Practices in Mental Health: An International Journal, 6(2), 57–68.
SAMHSA’s Trauma and Justice Strategic Initiative. (2014, July). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. SAMHSA. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
Sparks, D. (2020, Aug. 26). Patient and provider healing: Topics on death, dying & resilience [PowerPoint presentation]. University of Texas at Austin.
Sparks, D. (2020, Sep. 9). Assessment & intervention with disenfranchised grief in practice [PowerPoint presentation]. University of Texas at Austin.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Comas-Díaz L., Hall G. N., Neville H. A. (2019). Racial trauma: Theory, research, and healing: Introduction to the special issue. Am Psychol. 2019 Jan;74(1):1-5. doi: 10.1037/amp0000442. PMID: 30652895.
Doka, K. (1989). Disenfranchised grief: Recognizing hidden sorrow. Lexington Books.
Epstein, E. G., & Delgado, S. (2010). Understanding and addressing moral distress. OJIN: The Online Journal of Issues in Nursing, 15(3), Man. 1. http://dx.doi.org/10.3912/OJIN.Vol15No03Man01
Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Brunner/Mazel.
Figley, C. R. (2002). Compassion fatigue: Psychotherapists' chronic lack of self care. Journal of clinical psychology. 58. 1433-41. 10.1002/jclp.10090.
Freudenberger, H. J. (1975). The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research & Practice, 12(1), 73–82. https://doi.org/10.1037/h0086411
Levine, P. A., & Frederick, A. (1997). Waking the tiger, healing trauma: The innate capacity to transform overwhelming experiences. North Atlantic Books.
Maslach, C. (1982). Burnout: The cost of caring. Prentice-Hall Inc.
Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: recent research and its implications for psychiatry. World psychiatry : official journal of the World Psychiatric Association (WPA), 15(2), 103–111. https://doi.org/10.1002/wps.20311
Nagoski, E., & Nagoski, A. (2019). Burnout: The secret to unlocking the stress cycle. Ballantine Books.
National Center for PTSD. (2020). “Complex PTSD.” US department of veterans affairs. https://www.ptsd.va.gov/professional/treat/essentials/complex_ptsd.asp#one
Newell, J. M., & MacNeil, G. A. (2010). Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue: A review of theoretical terms, risk factors, and preventive methods for clinicians and researchers. Best Practices in Mental Health: An International Journal, 6(2), 57–68.
SAMHSA’s Trauma and Justice Strategic Initiative. (2014, July). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. SAMHSA. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
Sparks, D. (2020, Aug. 26). Patient and provider healing: Topics on death, dying & resilience [PowerPoint presentation]. University of Texas at Austin.
Sparks, D. (2020, Sep. 9). Assessment & intervention with disenfranchised grief in practice [PowerPoint presentation]. University of Texas at Austin.
