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"It can get messy," said Caringi, when asked to separate the terms. "All of the experts in this field, including myself, are having conversations about how we deal with this nebulous, unclear set of phenomena."
The hallmark symptom of vicarious traumatization is what the literature calls a "change in worldview" around safety, trust, and control. That can mean that the sufferer sees hazards everywhere, in places they wouldn't otherwise occur. And they might find that they start to view other people as malevolent or untrustworthy.
Merrill recalled working with abduction survivors, and they would describe the vehicle their abductors drove. He said that later, when walking around in his neighborhood, he would see a car that resembled his client's description. "It really freaked me out. I mean, it was just a car, but that's the kind of thing that starts to happen to people," he said. "You can start to feel that the world is all trauma all the time, everybody's dangerous, everyone is out to get you."
Caringi, a longtime clinician, echoed Merrill's experience. Early in his career, he was working in Alaska, flying from village to village, dealing almost exclusively with tough trauma cases. At the time, his wife had just had their first child and was preparing to go back to work. "How do you think it went for me, a guy who was seeing trauma perpetrators and trauma survivors all day long, to find someone who was safe enough to watch my baby?" he asked. "It didn't go well."
La Cheim Behavioral Health Services, where Demitra McDonald now works, is a community mental health center in Oakland specializing in treating clients with acute psychological distress from severe depression and psychosis due to chemical dependency. According to the Center for Disease Control's Adverse Childhood Experiences Study, which includes about 17,000 Kaiser patients, there is a strong correlation between an individual's history of childhood abuse and problems with drug and alcohol abuse.
La Cheim sees about three hundred clients a year in its program of structured day services. "People are coming off of catastrophic crises, so there's a lot of trauma, a lot of anxiety, a lot of fear," said Brad Falconer, a psychologist at the center. "It can be a very over-stimulating, overwhelming environment."
The program's director, Frances Raeside, is committed to creating a supportive environment for the staff. She describes La Cheim's orientation as "strength-based," meaning that clients and staff members alike are regarded as resilient and resourceful in the face of adversity. "It's not just helping [our clients] to hold their trauma, it's helping us hold their trauma," she explained.
"This room is constantly alive," said Mical Falk, clinical director, referring to the room in the center that staff members use to seek help from each other after difficult, potentially traumatizing client sessions. "If people are experiencing it together, they are much less likely to be traumatized than if they were experiencing it alone."
Every day, staffers take time to check in as a group and provide mutual support. The center initiated daily meetings of clinical staff members two years ago, and the organization instituted a weekly small group meeting to ensure staff members are coping well.
"The organizational support is everything to this work," said McDonald, who has worked in the field since 2009 and joined La Cheim last fall. "Not a week has gone by since I started when I haven't been asked, how are you doing? Is the workload going all right?" McDonald said that the affirmations and acknowledgment she receives at work empower her and help her provide better care to her clients.
Merrill sees this kind of organizational support as key to a caregiver's longevity. "I believe people can do really hard work long-term if they are supported well," he said.
"If you know there is an occupational hazard, and there are wraparound supports that are reasonable that could be provided by the supervisor or the organization, it's just not responsible not to provide that," he added.
Unfortunately, Merrill said, organizations commonly lack the resources to properly support their employees. "If we're not helping our workers long-term, they're toast," he warned.
After her breakdown in the parking lot, Demitra McDonald knew she wasn't willing to risk losing pieces of herself. She said she turned to practices that were restorative — pursuing yoga and deepening her spiritual life. She consulted with other therapists. "It helped me get my head together," she said.
She learned that she had to foster a strong and clear identity supported by a healthy set of boundaries. "I have to be able to understand where I start and end, and where the client starts and ends," she said.
"It takes a lot of self-reflection, a lot of observation," said McDonald, when asked how she knows where her limits lie. "Ideally, you wouldn't hit the limit. It's like gas in the car. You wouldn't wait until it ran out to gas it. You'd be checking that beforehand. ... As you're noticing that your stores are depleting, you build yourself up."
Jewel Love, a marriage and family therapy intern at La Cheim, said he builds himself up by focusing on the basics — his relationships, eating habits, sleep patterns, extracurricular activities. "I'm just making sure that I'm balancing those areas of my life, making sure that I'm ready and up to par to come here and handle what's thrown my way."