1. Introduction

When we sit in front of a patient and conduct an assessment, the data-gathering process will be unique in the sense that no one will take the same steps or enter the same doors - the patient’s statements - to further the exploration. It becomes a co-construction between the interviewer and the interviewee. Each patient’s story becomes a foreign land even though some elements sound familiar. We can go from disbelief to stupor, from horror to awe. The awe is usually what keeps us going, what makes us wanting to continue to work in the trenches of medicine, including human psyche. Despite all the potential depletion the role of physicians entails, there is an amazing source of replenishment and growth that occurs as well, in our patients and in those whose role is to support them. We might have the feelings we live vicariously through our patients, witnessing their strides and feeling the pains and the joys as if they were our own. We may suffer as if the evil had been done to us, too. The unfolding of their lives can go in various directions and be a proxy for our own meaning to life; a vicarious living, full of vicarious wounds, but also full of creative possibilities.

2. Terminology

The expression vicarious trauma can be confusing and ambiguous, especially because trauma implies an experience of toxic stress, which is what people seek to avoid, yet people tend to use "vicarious trauma" and "secondary trauma" (or secondary traumatic stress) interchangeably. However, vicarious trauma is not necessarily a bad thing and it can be transformative, as opposed to "secondary traumatic stress," which can encompass posttraumatic stress disorder (PTSD) symptomatology in the person close to or working with survivors of trauma (National Center for PTSD). (See section Know Yourself, topic Compassion Fatigue, Vicarious Trauma, and Burnout on definitions.) An expression that is more and more frequently used in the wellness vernacular is vicarious resilience, which is more positive terminology and probably a more fitting expression. Once the trauma has occurred in a patient, whether we have secondary traumatization from hearing about it or not, we can all benefit from vicarious resilience (e.g., indirectly experiencing the patient’s own resilience through some kind of mirror-neuron process, or our own that is boosted from hearing a story resonating with our past or connecting us to the suffering of the whole of humanity). It can be a general process taking place through time, after having heard many patients’ stories, or it can occur after one powerful therapeutic process with a particular patient. In order to access that ability to bounce back, people have usually some innate resilience factors such as dispositional mindfulness, interpersonal support or self-care tools (see toolkit and other self-care strategies elsewhere in this e-learning tool), which in turn make it easier for the clinician to see the positive in most stressful experiences.

In summary, vicarious resilience is about:

• Drawing strengths and inspiration from patients’ lives instead of compensating the stress of work through other activities;
• Discover something positive within that stress;
• Maintaining a sense of purpose and meaningful duties in our day-to-day responsibilities.

3. Practical strategies

Ways for each organization to enhance vicarious resilience:

• Teach the concept during lectures and its advantages for both the patient and the clinician; attending physicians and residents can also teach medical students during their rotations. The earlier the concept is disseminated during the training years, the more likely trainees will benefit from this since they might seek those experiences instead of avoiding the encounter with traumatized people.
• Integrate vicarious resilience within the cultural humility experience.
• During team meetings, have at least one person sharing a “success” story about a clinician’s positive transformation from working with a patient with a difficult story. For instance, how did a particular patient change the clinician’s beliefs or attitudes? How can the clinician use the new wisdom and resilience in his/her life and also in the work with patients sharing similar struggles?
• Encourage patients and their providers to share their stories through art, documentaries, and writing (e.g., memoirs).
• Integrate techniques such as “meaning-making” or a parallel chart: beyond the explanatory model (often superficial), one should attempt to create meaning about the patient’s adversity. How did trauma impact the patient’s personal tale, and how could it impact the world in a positive way?
• View this as a positive feedback loop: the more resilient a patient appears to us, the more likely we will emulate this, which in turn can positively affect all our patients’ resilience factors (see Figure 1).
• Emphasize the psychotherapist’s and physician’s role in fighting social injustices: by being trauma-centred and treating all patients as equals, by caring about those we treat, we convey a powerful message of self-worth. Whoever is sitting in one’s office: the rich, the poor, the celebrity, the stigmatized... all are equals and treated with the same respect and admiration for their inner resilience. Then, they leave the office or the room empowered, with a more confident, integrated, and resilient identity.

4. The most important role of your life

We, physicians, have one of the most captivating, mythical, and romanticized jobs. We hear stories. We act as healers. But often we feel trapped in our own emotional responses. How to resolve this? How to gain strength and resilience to continue to work effectively with wounded patients and make a difference? We create an interaction or “life scenario”, a new, more adaptive script with the patient, for the patient. We view each patient as co-director because they have inner strengths that can break the shackles of their trauma.

Using the framework of vicarious resilience in medicine means progressing, transforming, from being the spectator to actor to director. Ultimately, we should aim to become not only spectators of others’ lives, or actors from one life to the other, but director of our own life dynamics, oscillating between the three states when appropriate to context instead of when forced to do so by triggers or malevolent forces.

The three stages of empowerment, using the performance arts analogy, consist of the following:

Stage 1 - Spectator

Being the spectator is an essential role in certain interactions (e.g., when someone needs a compassionate ear). It can be a neutral, comfortable or uncomfortable experience, none of which is a bad thing as long as it is transient and tolerable. However, being forced to be a voiceless, helpless spectator, or feeling trapped in the victim role (as in traumatic experiences) can be disempowering, and moving towards the two subsequent stages described below will help healing.

Image credit: pixabay

Stage 2 - Actor

Most people feel in control when they go about their lives with the persona they think they have more or less chosen (e.g., physician, teacher, spouse, parent, daughter, son). With such roles in society usually come specific and often implicit scripts or sets of rules that maintain the balance within a complex system. Yet, under duress a solid actor can lose that balance and experience distress, emotional paralysis and, hence, feel more like a spectator. It is important to develop awareness of changing roles and scripts throughout the lifespan to adapt to developmental challenges and move towards a more integrative, transcending step, such as sitting in the movie director’s chair.

Image credit: pixabay

Stage 3 - Director

As opposed to the actor being told what to do, the director is like a conductor and aims at integrating various levels of contributions to ensure a cohesive, harmonious performance. The movie director keeps the global picture in mind and wants to maximize everyone’s contribution to attain a broader goal. At times, the spectator of the actors is asked to give them feedback and, at times, the actor tends to model self-development and a thriving existence and, thus, the director will have a versatile role that integrates the trauma story in the overall life narrative. Working behind the scenes allows to see the whole forest instead of just a few trees and integrate various perspectives. The stage of ego transcendence makes it easier for the director to no longer crave admiration from being frequently on stage. The director acts like a coach and draws satisfaction from his team’s work and performance; he/she seeks individual and collective growth. The director’s ultimate goal is to ensure everyone in the troop develops the ability to sit in the director’s chair to co-direct trauma-centred therapy, work-family balance, and general life goals.

Image credit: pixabay

Table 1 summarizes the three stages of empowerment using the performance arts analogy.

Key points

• Vicarious trauma is not the same as secondary traumatic stress; the former refers to transformative, inevitable and not necessarily pathological changes from working with survivors of trauma, while the latter describes professional workers' subclinical or clinical signs and symptoms of PTSD that mirror those experienced by trauma patients, friends, or family members (National Center for PTSD).
• Resilience is multidimensional and includes innate aspects, self-care strategies, and interpersonal elements (e.g., support system, psychotherapeutic relationship).
• Vicarious resilience helps buffer compassion fatigue and is a desirable phenomenon during the processes taking place in the clinical encounter. It is about drawing inspiration from our patients who have overcome adversity.
• Vicarious resilience creates a positive feedback loop. Healthcare providers should stay alert and ready to access this renewable source of energy.

References

• Mollica RF. Healing Invisible Wounds: Paths to Hope and Recovery in a Violent World. Nashville, TN: Vanderbilt Univ Press; 2008.
• PTSD: National Center for PTSD. Working with Trauma Survivors: What Workers Need to Know. U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/professional/provider-type/responders/working-with-trauma-survivors.asp. Accessed 6 Oct, 2018.