This post is part of a series “Healing in the Wake of Community Violence: Lessons from Newtown and Beyond,” based on an event of the same name hosted at Harvard Law School in April 2017. Background on the series and links to other blog posts are here.
When a horrific violent event occurs, the community’s thoughts and efforts to help naturally extend out to the injured and traumatized survivors and the loved ones of those killed. However, the effects of such traumatic events ripple out beyond those so directly impacted. According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013), the definition of trauma includes not only direct exposure to actual or threatened death or serious injury, but also witnessing such an event or experiencing repeated or extreme exposure to aversive details of such an event. Under this more comprehensive definition, the circle of affected individuals in the wake of community violence widens to include professionals and community leaders who are tasked with tending to the safety, medical, emotional, instrumental, and spiritual needs of those wounded. These “helpers” include first responders (e.g., police officers, emergency medical technicians), medical and mental health professionals, case workers, and religious leaders.
First responders and medical personnel may be at particularly high risk for “vicarious traumatization” in the aftermath of community violence. Research documenting the neurobiological impact of trauma informs our understanding of how these helpers may be negatively impacted while tending to victims of violence. When humans are confronted with a threat, the autonomic nervous system (ANS) is immediately activated, stimulating a flight, fight, or freeze response. The hypothalamic-pituitary-adrenal (HPA) axis releases the stress hormone cortisol to prepare the body to cope with the threat. Several brain areas are activated (e.g., amygdala, prefrontal cortex) to evaluate the source and severity of the threat and to organize a behavioral response. These neurobiological systems interact with each other within and across time, either dampening and terminating or increasing and prolonging the body’s physiological and behavioral stress response.
An individual’s neurobiological response to a given trauma is influenced by many factors, including his/her prior trauma history, current mental and physical health and coping skills, and available support resources. Repeated exposure to new traumatic events and/or to reminders of past traumatic events can shape the functioning of neurobiological systems so that they respond in a maladaptive manner to future threats. For some individuals, this maladaptation takes the form of hyper-reactivity of the stress response, which can be manifested as hypervigilance, rapid and strong responses of neurobiological systems to stressors, anxiety, irritability/anger, and sleep difficulties. For others, maladaptation takes the form of hypo-reactivity of the stress response, including slowed and dulled responses of neurobiological systems to stressors, emotional detachment, avoidance of distressing thoughts/feelings, and difficulty experiencing positive, loving feelings toward others. Over time, these patterns can lead to mental health difficulties (e.g., depression, anxiety, posttraumatic stress disorder, substance abuse), cognitive problems (e.g., concentration and memory impairment), and deterioration of physical health. These difficulties, in turn, can negatively impact work performance, impair social relationships, and lead to poor self-care.
It is important to note that devastating events such as the Sandy Hook Elementary School shooting receive much attention due to their extreme level of destruction and their impact on our shared sense of safety within what are supposed to be protected spaces in our communities. However, for first responders and medical personnel, traumatization may occur over a slow but steady stream of exposure to individual violent events, which often escape the attention of the media and the public at large. For example, police officers may be confronted with multiple threats of violence to themselves and with the witnessing of the aftermath of violence to others within one shift. Emergency room personnel must tend to every injured patient who presents in their trauma center. Exposure to such events are normalized as part of the job, which may lead to neglect of the mental health needs of the helpers and stigmatization among those who seek out assistance in coping.
Helpers may face additional challenges that compound the deleterious impact of trauma exposure. When confronted with a threat to their safety, as in the case of a police officer responding to an active shooting, or with the gruesome effects of violence, as in the case of a physician or nurse treating a shooting victim, they are not allowed to flee or freeze. Rather, they must suppress/overcome their ANS response and move toward and confront the threat. Because these professionals often live in the same communities within which they work, they may know the victims personally, making the maintenance of proper emotional distancing and enforcement of professional boundaries particularly challenging. Because their jobs necessitate coming into contact with violence or the aftermath of violence, they may believe that they are failing if they feel overwhelmed by their job demands and consequently avoid seeking out treatment.
Our understanding of the impact of vicarious traumatization necessitates an organized public health response to the needs of helpers such as first responders and medical personnel. Organizations that employ helpers should be trained to understand and recognize signs of vicarious traumatization and should educate employees on how to recognize signs in themselves. Organizations should foster a culture that promotes self-care, destigmatizes engagement in mental health services, and facilitates access to appropriate treatment. The act of an employee reaching out for help should be framed as a strength, not a sign of weakness or an indicator of incompetence. Helpers need access to treatment by providers who have training in trauma-informed, evidence-based therapies. At the societal level, there needs to be increased recognition of the phenomenon of vicarious traumatization; resources for the training of mental health professionals in trauma-based therapies; sufficient funding for the training of organizations employing helpers; provision of access to and funding for treatment for helpers; and destigmatization of mental health challenges. As a society, we depend upon helpers for support in our darkest hours of need. They need and deserve our support in return.
Watch Michelle Bosquet Enlow’s full presentation, “The Neurobiology of Trauma and Vicarious Traumatization: Tending to the Healers,” on the Petrie-Flom Center’s website.