Dr.

Norieta Calma-Balderrama // August 17, 2016

Principles and Perspectives

Stress, Burnout and Secondary Trauma

I. Stress
Unspecified demand made on the body
Circumstance with which a person finds difficulty in coping
Is normal but can also be harmful to the body and mind
It can be acute or chronic
Can damage the cardiovascular system
If not controlled, it produces hormones that weaken the immune systemcough and colds, hair and face
Distress state of acute or extreme stress
Causes can be prevent/reduced
We could learn ways of coping with stress

A. When Coping Mechanisms Fail

Cannot get away no flight
Cannot get control of the situation no fight
Does not make sense no meaning leads to sense of loss

B. Effects of Stress
1. Mental distress
2. Physical complaints
3. Changed behavior
4. Relationship difficulties
5. Work performance deterioration

C. Stress Response
1. Starts in the Brain

Hypothalamus, amygdala and pituitary gland go on alert

Exchange of information, signal hormones and nerve impulses to the rest of the body for fight or flight (sympathetic response)
o When emotional part of the brain is not working, you cannot think clearly

Day before exams or boards should be relaxed for cortex to function well

When you are angry or stressed, take a deep breath and relax. Excess cortisol does not help in decision making.
2. Adrenal glands react by releasing epinephrine which makes the heart pump faster and lungs work harder to flood body with oxygen

Release extra cortisol and other glucocorticoids (help body convert sugar to energy)
3. When the threat passes, epinephrine and norepinephrine levels drop but if danger comes too often they can:

Damage the arteries

Weaken the immune system

Loss of bone mass

Suppression of reproductive system

Memory problems

D. Signs and Symptoms of Stress

1. Mind

Anxiety, irritability becoming angry quickly, poor concentration

Worry thinking of same things again and again

Grp 10: Agdamag, Amigo, Colinares, Domingo, Gonzales, Kaw, Loyola, Malinit, C. J. Manalo, Rufino, Salud, Valdez, Villa-Abrille

1/9

2. Body

Tired headaches, somatic pains, poor appetite, vague pains

3. Behavior

Problems with sleep, daytime sleep

Over activity

Restlessness

Alcohol or drugs to relieve tension

o May be a form of coping with a lot of problems or stress and trauma
o Growing problem in the Philippines major cause of violence

Difficulty concentrating
4. Relationships

Arguments and disagreements

Over dependence on others for decisions and support

5. Work

Poor concentration/performance

Arguments/disagreements/tired

E. Stress Management
For doctors
Understand yourself better by asking the following questions:
Why do I want to be a doctor?
What do I get for myself from helping others?
How might my personal needs affect my ability to help others?
Questions may be your driving forces
For yourself
What strengths do I have that will allow me to be useful in helping others?
Ask if you need help and if you can help others
How can you be compassionate/kind to yourself?
I want to manage properly the things that I have to do.
Im happy with who I am.
Important to help yourself.
It will not be helpful if you yourself need help
Doctors tend to forget themselves and give 100% to other people
If you give 1 to others, you give 1 to yourself
Do you need help?
Understand your own needs following a difficult experience by asking:
Have you had chance to talk with other about your difficult experience?
Are you able to recall what happened to you without crying or getting angry?
Do you have a chance to relax after your work?
Are you usually happy, kind, and caring with you family and people you work with?
Can you help others?
Do your thoughts often wander or you are not concentrating on what is being said to you?
Do you feel bored, tired, irritable or restless when talking/listening to people?
Do you get overly involved in other peoples problems?

Help beyond what is necessary

Social workers adopt/bring home street children

Stress, Burnout and Secondary Trauma

2/9

o
o

Know boundaries: what you can and what you cannot

Do you feel it is a heavy burden on you to help others?

Helping others
The most important goal is to help people to help themselves
Helping people with mental health problems
1. Setting safe, quiet, private, helping
2. Build up trust relationship grows
3. Listen attentively
4. Probe for information
5. Provide comfort and support
6. Encourage self sufficiency
7. Assess the problems
8. Develop a plan of action
9. Follow-up

F. Core Values for Effective Helping

1. Acceptance of how they feel
2. Nonjudgmental approach
3. Confidentiality
4. Acceptance of expression of feelings
5. Acceptance of self-determination and child participation
6. Valuing of individual difference
7. Valuing of sustainable community ownership of service programs
*Make sure you have friends outcome is better if you have friends to talk to

G. Horowitz Ideal Course of Recovery

1. Perceive the event correctly
2. Translate perceptions into clear meaning
3. Relate meaning to current belief, attitude or meaning
4. Revise memories, attitudes and/or belief systems to fit new developmental line
5. Decide on appropriate action

H. Interventions
1. Psychological intervention

Self-awareness/expressive therapy:
1. Journal writing
2. Art/drawing
3. Drama/dance
4. Play
5. Circle of friends
6. Mind/body interventions (exercise to relaxation, fun, meditation)
2. Relaxation exercises

Breathing exercises
Stress, Burnout and Secondary Trauma

3/9


Progressive muscle relaxation

Regular repetition of words (self-statements)

Meditation

Massage
3. Remedial action

Traditional treatments

Religious or spiritual

Problem solving techniques

Behavioral therapy/counseling

cognitive therapy

Group therapy recreation groups activity groups/treatment groups

Referrals/networking

II. Secondary Stress

Common among doctors
High emotional cost; overlooked
Lead to burnout
From exposure to reality that is beyond ordinary comprehension
NEED: provision of care for doctors suffering from secondary trauma

Caring for the Caregiver/Doctor

Secondary traumatic stress factors
Hearing stories energy sapping feelings (e.g. cruelty and sadistic atrocities)
Hearing becomes violent attack on own sense of integrity and worldview

III. Burnout
Unlike secondary trauma, stress emerges gradually occurs when stress intolerable level emotional exhaustion
Definition according to Pines and Aronson: state of physical, emotional, mental exhaustion caused by long term
involvement in emotionally demanding situation
Physical feeling tired
Emotion depressed, hopeless
Mental exhaustion disillusionment, resentment towards people

A. Interventions
1. Support

Give time to leave burdens, renewal

Admit may be perceived as admission of ineffectiveness choose to abandon work

A problem is just a dot in your life, dont let it grow larger over time
2. Concentrate on the here and now, focus on todays problems and not yesterdays problems.
3.Recognize limitations no one can solve all problems
4. Say NO to overloading demands
5. Support groups sharing
6. Maintain balance in professional/personal lives have fun, laugh, retain faith and hope
7. Maintain physical and emotional health exercise, play, diet, rest
8. Make sure one has dealt with own trauma of past abuse
Stress, Burnout and Secondary Trauma

4/9

B. Organizational Support
1. Opportunities for debriefing
2. Providing consultants/supervisors who will bring new insights/expertise
3. Forum for regular feedback
4. Clear policy guidelines
5. Sharing responsibility and supporting doctors/caregivers

C. Stages of Burnout*
1. Honeymoon realizing but not taking action
2. Disillusionment despite efforts one is unable to cope or control things around
3. Brownout on and off; appear to function well but in escapist behavior; less productive and indecisive
4. Frustration ignoring the signs; negative feelings manifest as anger; less enthusiasm; cynicism; detachment

At this point seek the help of mentors

5. Despair despair or clinical depression occurs; feelings of failure, pessimism, self-doubt, loneliness, emptiness, desire to
run away and ignore

Usually need professional intervention

Mnemonic: Hoy Di Ba Fun Dito?
*Will be asked in the exam!!!

D. Sources of Burnout
Lacking sense of accomplishment or meaning in your work
Being under constant, strong pressure to produce, perform, meet deadlines, excessively demanding indifferent to personal
sacrifice
Doing same work with little variation
Working with group that shows little progress
Low morale, lacking trust between supervisors, tension among staff, lack of support from colleagues
No opportunities for self-expression or taking initiative in trying new approaches; experimentation and change discouraged
Having to deal constantly with unrealistic demands
Lack of supervision, continuing education or training
Unresolved personal conflict outside of job situation like marital or relationship problems, financial or family problems
Giving great deal of yourself but not valued
No distinct identity of your own in your work situation
Strong sense of being anonymous and squeezes everything out of you
No control of authority over matters you are held responsible

E. Tips
Feel symptoms of burnout
1. Take time to recover then you feel your normal self then it is stress
2. If no matter how much time you take off you do not feel better, then you are probably in stage of burnout

Stress, Burnout and Secondary Trauma

5/9

F. Preventing Burnout
Evaluate goals, priorities, and expectations to see if realistic and if they are getting you what you value in your life
Recognize you can take active control of your life
Find other interests other than work
Think of ways to bring variety into your life
Start projects that have personal meaning. Do not wait for the system.
Monitor stress at work and in your home life
Try using stress/anger meter: 1-10
If 8, stop a bit
Attend to personal health, sleep, diet, exercise
Develop friendships mutual in giving/receiving
Learn to ask what you want but dont always expect to get it
Learn how to work for self-affirmation and self-reward
Reward yourself computer games, retail, ice cream
Find new meaning in your life (play travel, experiences, reading)
Take time to evaluate your work to determine which you should continue
Take new classes, workshops, conferences, and gain new perspective
Manage time, rearrange schedule to reduce stress
Learn limits, set clear boundaries
Accept your imperfections
Form support groups
Learn to do variations (work routine)
Cultivate hobbies that bring pleasure
Be active in professional organizations
Seek counseling as part of personal growth
Learn to look within before making choices
Accept personal responsibility for consequences of choices
Stop blaming the system
Bring new meaning into your work
Additional tips:
1. Understand sources demands of work, personal history
2. Transference build up trust
3. Limitations know limits; flexibility, resilience, ability to say NO
4. Self-awareness/beliefs knowing limitations and boundaries, knowing when to let go
5. Acknowledge situation
6. Remember to take care of yourself physical, emotional, professional
7. Set boundaries and limitations, evaluate goals, priorities, expectations realistic and achievable
8. Improve work environment

IV. Trauma
Trauma
An event, series of events or set of circumstances that is experienced by and individual as physically or emotionally
harmful or life threatening that has lasting adverse effects on the individuals functioning and mental, physical, social,
emotional or spiritual well-being (SAMHSA n.d.)
Secondary trauma
Results from listening to your patients
Can also come from relationship with patients
Stress, Burnout and Secondary Trauma

6/9

 Having patients in a state of distress

When they are stressed, it may get transferred to you so be resilient
Resiliency
Bounce back
Ability to cope with stress and adversity
People who are resilient see themselves as safe, capable and lovable
Trauma stewardship
The way we do our work of engaging with survivors of trauma, understanding how that work impacts ups, and the
process of making sense of and learning from our experiences (van Dernoot Lipsky and Burk 2009)

A. Be Aware*
Vicarious trauma
Process of change that happens because you care about people who have been hurt and you feel committed or
responsible to help them (Pearlman and Mckay 2008)
Overtime it leads to changes in you psychological, physical, spiritual well-being (Pearlman and Mckay 2008)
Compassion fatigue
Profound emotional and physical erosion that takes place when helpers are unable to refuel and regenerate (Almazar
2014)
*Will be asked in the exam!!!

B. Warning Signs
1. Feeling helpless and hopeless
2. Sense that once can never do enough
3. Hypervigilance
4. Diminished creativity
5. Inability to embrace complexity
6. Minimizing comparing to more dire events; putting suffering in a hierarchy
7. Chronic exhaustion/physical ailments
8. Inability to listen/deliberate avoidance
9. Sense of persecution
10. Dissociative moments cut yourselves from internal experience
11. Guilt, fear, anger, cynicism
12. Inability to empathize/numbing
13. Addictions
14. Grandiosity/inflated sense of importance related to work

Work is the center of our identity

*Stress test: 1-15 you should be in the middle because if 0, not good if you dont care

C. General Care
For doctors
1. Let go of your patients pain carrying the burden does little; that you cannot heal wounds; appreciate the difference
that you make as doctors
2. Relax
Stress, Burnout and Secondary Trauma

7/9

3. Utilize support group mentoring program (College of Medicine)

4. Be happy!
For yourself
1. Flexibility and balance
2. Take decisive actions rather than detaching
3. Look for opportunities for self-discovery
4. Nurture a positive view of yourself
5. Keep things in perspective
6. Take care of yourself and focus on wellness

Review Questions
1.

Burnout stage wherein a person is aware of his/her physical and mental exhaustion but does not do anything about it
a. Frustration
b. Disillusionment
c. Despair
d. Honeymoon

2.

Burnout stage wherein a person is unable to cope with the stress despite his efforts
a. Despair
b. Brownout
c. Honeymoon
d. Disillusionment

3.

A person is running a marathon. As he reaches the finish line, he uses up all his energy and his heart pumps faster.
What hormone is released by the adrenal glands?
a. Epinephrine
b. Adrenaline
c. Both a and b
d. None of the above

4.

Back in 2013, Kobe Bryant tore his Achilles tendon in a game vs. the Golden State Warriors. After the incident, he was
frustrated at the fact that he could no longer play all season. His wife Vanessa had been there for him throughout his
basketball career. She was upset when she did not know how to comfort Kobe because as his wife, she felt responsible
for him and his injuries. What process was Vanessa going through?
a. Compassion fatigue
b. Secondary trauma
c. Vicarious trauma
d. Coping

5.

The following are ways to reduce stress, except:

a. Avoiding vices such as cigarettes, alcohol and drugs
b. Having a healthy and well-balanced diet
c. Sleeping only three hours a day
d. Cutting down on caffeine and sugar

Answer Key: 1. D, 2. D, 3. C, 4. C, 5. C

References
Stress, Burnout and Secondary Trauma

8/9

(1) Pearlman, L. A. & McKay L. (2008). Vicarious Trauma. Retrieved from http://www.headington-institute.org/files/vicarioustrauma-handout_85433.pdf
(2) Burk, C., van Dernoot Lipsky, L. (2009). Trauma Stewardship: An Everyday Guide for Self While Caring for Others.
Retrieved from http://www.bkconnection.com/static/Trauma_Stewardship_EXCERPT.pdf
(3) SAMHSA-HRSA Center for Integrated Health Solutions. (n.d). Trauma. Retrieved from:
http://www.integration.samhsa.gov/clinical-practice/trauma
(4) Almazar. (2014).

Stress, Burnout and Secondary Trauma

9/9