Matrix of Clinician Distress - Part 3

Burnout, Compassion Fatigue, and Moral Injury Are Just Part of the Storm System. Let's Look at Grief and Trauma.

(The entire Matrix of Clinician Distress series is available in article and podcast format - see footnote for more explanation on how to find.)1

Grief and Trauma – Exploring the Fuller Clinician Distress Map

We continue our series on the matrix of clinician distress.

In the first piece, I posed an overall scenario representative of what a lot of clinicians are experiencing. It contained a mix of elements of three of the most often talked about phenomena affecting healthcare clinicians. In fact, I chose those three in part because I’m working on a national presentation on burnout and even more significantly, a journalist who’s been following the clinician crisis for some time asked my input, specifically on compassion fatigue. I thought it’d be good to recap our discussion for her reference. Those were the three syndromes being addressed in her current research.

So I started writing, hoping to flesh those out further in as succinct a way as possible. As you may have discovered, ‘succinct’ and ‘me’ are close to an oxymoron.

As I was trying to further flesh out these elusive concepts, I kept coming back to this notion of how they’re related – ah ha! they’re all manifestations of distress. And the more I thought about it, the more apparent it became that we’re missing the boat on just fixating on burnout, that there’s a much larger storm system of distress that’s afflicting so many in healthcare. My coaching and consulting work has predominantly been focused on physicians, but I wanted to expand the territory of distress here as I believe that these distress syndromes affect all of us in clinical healthcare.

Concurrently, I was working on another framework iterating what’s eating physicians and I started assembling a tick list of stuff, a veritable shopping list of hassles that docs are weighted down by. Keep your eyes out - it’s a doozy. You might want to refill your Xanax and Prozac while you’re at it, or get back into anger managgement.

In the 2nd part, we delved into that presented typical scenario and explored the ubiquitous “burnout” syndrome, its close relative “compassion fatigue,” and the recently articulated though more elusive psycho-philosophical syndrome of moral injury. While these are now in lots of people’s minds, even these three don’t really convey the full picture, and in fact, their incidence may not even be the top three.

In this piece, turns out the 3rd of 5 articles (who knew there was such a flood of distress? I didn’t until I began drafting it), we’re going to explore additional syndromes that are often conflated with burnout but actually constitute separate components of the clinician distress matrix. We’ll look at grief and the trauma-related stress syndromes.

And then in the subsequent piece (Part 4), we’ll explore the two more prominently occurring clinical mood syndromes – bona fide “disorders” – that need to be considered in the overall landscape of clinician distress.

It’s vitally important to distinguish amongst all of these syndromes, seeing them as discrete phenomena which may occur concurrently with their unique tributaries of causality and manifestations, so that you, whether the affected clinician or the one who treats / coaches, can begin to make sense of what the distressed clinician is experiencing.

Grief

For convenience purposes only, I’m here labeling grief as a syndrome. Conventionally,  that’s what most people equate with the emotional response to the loss of a significant other person in their lives.

More precisely, this complex of psychological manifestations in the context of loss is known as bereavement. The most appropriate term to describe the emotional reaction accompanying bereavement is grief.

Grief is simply deep sadness in the context of personal loss.

Bereavement is a normal, healthy human process, as is the accompanying emotion of grief.

In effect, bereavement is a unique type of stress reaction in the context of the experience of loss of another with whom one was significantly bonded. It is a “loss reaction.” Or put in another way, it’s a unique category of stress reaction occurring when the stress event is one of loss.

When a loss reaction occurs, just as we’ll see in the traumatic stress reaction, associative and emotional memory inevitably recall past losses. In doing so, they bring the packaged memory of the totality of their prior bereavement experiences into the present. Thus, in any bereavement, past grief is awakened and combined to some degree with present grief. And this cumulative experience is almost always experienced as one major grief response until that time that one is able to disaggregate them and return the prior memory experience package back to its memory storage.

The Contagion Of Suffering And Loss

Bereavement is not just about the immediate loss of the other, but about the loss of their cumulative presence over time, with all of its memories of significant events (both good and bad). Further, bereavement may entail recalling and feeling, even empathically experiencing, the lost one’s struggle as they grappled with dying. If it entailed suffering, then witnessing that suffering and being helpless in its presence can rise to the level of psychological trauma. Thus the concept of traumatic grief.

In experiencing the grieving of another in this way, it is similar to a vicarious traumatization where we re-live the other’s experience of their trauma in its recounting.

Vicarious experiencing of another’s loss too is associated with sadness.

And depending upon our degree of empathic identification and re-living it with that person in this “once removed” fashion, it can also intensify our own experience of current, recent or remote loss. Just as for the grieving one, it’s not as though one consciously chooses such recall. It comes unbidden. And this is exactly why those doing high-intensity “people work” need to have an opportunity to do their own psychological work and have access to support. Both grief and trauma reactions can be so highly charged that for the coach or therapist that their intensity is rightly comparable to a hazardous material requiring a hazmat suit and a decompression protocol.

Mirror Neurons And Empathy

In the last decade or so, a new understanding is emerging about the cellular basis for what we might call the “empathic reflex.” There are specialized neuronal cells in our brains that are messenger nerve cells. They take what we see happening to another and translate it into our own bodily experience. It’s essentially autonomic “experiential empathy.”

You may have wondered why you flinch at an explosion on a movie screen, or jerk your head away when the character, likeable or not, on the screen gets a bared-fisted hook to the face. It’s as though you experience it concurrently. That’s the wonder of mirror neurons, actually discovered by monkeys.

Well, not literally. The astute animal lab assistant in Italy who discovered this took note of a caged monkey intensively watching him as he opened his backpack. When he pulled out a banana and began peeling it and then put it to his mouth, the monkey, staring intensely at the banana, mimicked his very movements! But the monkey wasn’t trying to be a mimic (as far as we know). So intense was the perceiving, he was vicariously eating the banana.

Grief - My Own, and My Engagement With Others

Clearly, clinicians experience grief like any other emotionally sensate human. They have families, and loved ones in their circle of friendship. And as the work in healthcare can be so intense and prolonged beyond that of conventional 9-to-5 non-“people work” jobs, a significant bond often develops among clinicians. A similar bond develops between clinician and patient, especially those one works with over a sustained period. After all, it is health CARE, and the most important healing ingredient is exactly that – care.

When you care, you become more attached to that person. You are more engaged with that person than the rest of the people in your acquaintance circle. And by this very nature, you are susceptible to the experience of loss.

To love at all is to be vulnerable. Love anything and your heart will be wrung and possibly broken …. The only place outside of heaven where you can be entirely safe from the dangers of love … is hell. [C.S. Lewis*2]

Our scenario in part touched on the experience of a clinician experiencing grief due to the loss of a colleague and also of patients.

Let’s look at this more deeply. As a clinician providing healthcare, I thus experience three clusters of grief - that from my own loss of my colleague; my loss of my struggling-to-breathe patients; and that sadness which I feel for the families and friends of my dying patients, i.e. my empathic grief.

Given the immensity of loss worldwide, the sheer awesomeness of the devastation caused by this highly dangerous virus that has turned the civilized world into an emergency room, it is likely that we experience a collective grief. But it’s one I suspect that we can’t yet articulate as we’ve not fully become aware of the collective unconscious. This was Carl Jung’s mind-blowing hypothesis, one so radical that Freud himself had to distance himself from it, preferring to focus on the existence of the individual unconscious mind with all of its wild capers. That was, he thought, already too radical for the supremely rational Victorian mind and sexually repressed bodies to take in. A collective unconsciousness – with no boundaries?!3 Good lord, he must’ve thought, we have a hard enough time keep our one unconscious mob contained!

Two Types of Clinician Grief-based Sadness

Immediate Grief At Our Own Loss

This is the clinician’s own experience of the loss of someone. If we have currently lost a dear family member, friend or colleague to Covid, our grief is that of losing a loved one; we grieve for our loss and the fact of their loss. Likewise the loss of a dear patient under our care, we experience grief.

Let us recognize also that while grief is a state of emotion, a variant of sadness, grieving is a process. It is the process of enabling and voicing grief. And it is a process that has its own timeline of completion. Just as physical wound repair is the process of tissue healing, so too grieving is a process of emotional healing from loss.

Two Types of Sadness at Others’ Loss

Empathic Sadness

As we know what it is to lose someone and we have experienced that sadness, we vicariously experience the patient’s family’s experience of grief. That vicarious experience may also awaken our own, perhaps still raw, grief. Our empathic experience, truly a form of emotional intelligence, serves to inform us more deeply of the dimensions of emotional experience of another.

Sympathetic Sadness

Not all felt sadness is empathy-based.

In heartfelt sympathy, we feel deeply for the bereaved - we see and “feel their pain” closely; but our response is not so directly rooted in our own experience of loss (though it is nearly impossible that it doesn’t stir memories of our own).

As clinicians, this is the type of sadness we most often manifest (and feel) and in fact convey in words and gestures to the grieving other.

The two are very closely related, the former activating our own lived experience of loss; the other recognizing the power of the other’s loss and recognizing the immensity of their grief, and feeling sad for their loss. But in the sympathetic variety, we do not experience it as though it comes from a place of intimately connecting with our own loss. The difference, I believe, is rooted in the degree of personal experience of bereavement that is mobiized.

Dimensions of Affective Engagement

Let’s take a closer look at the varieties of a clinician’s “expression” of sadness and concern. It can range from remote to intimately close.

Affective acknowledgment or “verbal restatement of affect.” This is where I make note that I see, hear, sense your feeling of sadness.

“You seem sad.” “I see how sad you must feel.” “Something tells me you’re hurting.”

Compassion - Here I have a gentle, loving appreciation of the impact of your loss; this is not sadness per se as much as it is gentleness and kindness in the presence of another’s loss, a respectful tenderness, with your offering supportive sentiments for the other and wishing endurance for them to manage their loss. By its nature, it is more love-based than it is sadness-based.

Sympathy is the expression of sadness for their loss as I recognize the power of that loss for them as I know the power of such loss. Sympathy is a blend of compassion as well as some degree of experiencing the feeling of sorrow. It is a humanitarian sorrow, one born of the shared experience of loss.

Empathy is the deeper inner experience to some level of the sadness that another feels, generally through a shared experience of personal loss, one that evoked similar sadness in me. In a way, “I feel your sadness because of the sadness it awakens in me.” By “sharing” I don’t mean overt sharing of each other’s story (though that may occur in some fashion). Rather, that there is a life experience of loss that we have in common, and if your experience is similar to mine, I know - really know in the marrow of my limbic system - your experience of the immensity of that loss.

You’ll note, these are levels of affective arousal and engagement around the theme of loss and its stress reaction.

Admittedly, this is my own idiosyncratic triaging of “levels of affective engagement.” But over the course of my career, this understanding has resonated and its truth become more real for me. Again, it’s not hard and fast science, just one coach-clinician’s framework on understanding emotional experience and affective engagement.

Nor is it a value judgment. One is not “better” than the other. There are times when affective restatements might be optimal; other times sympathy; and other times when we can allow our empathy to be manifested through such emotional attunement.

And they may each have their shortcomings. Affective restatement can sometimes seem too detached; likewise intense empathic expression can seem too intense and overwhelming, even burdening to the other.

Intense Loss and Recurrent Loss Can Have Profound Psychological Impacts

Experiencing recurrent loss, or witnessing the recurrent loss and grief of others, almost invariably has a cumulative effect on us.

Further, single or recurrent loss experienced by ourselves or witnessed by us as experienced by others can reach a degree of anguish that experiencing or witnessing such loss can become psychologically traumatic. And we may experience an exponentially powerful, sometimes disabling grief.

One either has to find a way to manage this and make sense of it with the help of others, or one needs to step away from the now nearly toxic degree of sadness.

Knowledgeable support services are vital to help a clinician (and to help coaches and therapists too) navigate this experience. Without support, and assistance with framing it, making sense of it, learning to cope with it, one is prone to a clinical mood disorder. That mood disorder can reach such intense proportions that one may experience a major depressive episode even with psychotic symptoms. We’ll discuss depression in clinical mood syndromes below.

Now we turn our attention to another powerful source of stress, examination of which I believe we (healthcare clinicians as well as coaches and therapists) have been severely inattentive.

Trauma-Related Stress Syndromes

Now, let's look at fright. It's an automatic, i.e. autonomic nervous system-based, reflexive response to threatening-type stress. Such intense threat invokes fear, which is the conscious emotional experience of the fright response. The emotional state of fear combined with the body’s physiological fright response cascade can literally overload the brain’s circuits and activate a neuronal ‘failsafe’ bypass circuit, putting the brain in emergency operation and virtually shutting down the customary cognitive processes we associate with thinking. In a way, the brain (hardware) and mind (its software) concurrently go on autopilot and into emergency mode.

DSM5 significantly rearranged the core components of both short-term PTSD (the acute stress reaction) and the longer persisting variant we’ve known as PTSD.4

The Acute And Post Acute Trauma Stress Reactions Are Nearly Identical

For practical purposes, except for the onset and duration parameters, both the acute traumatic stress reaction and PTSD are nearly identical. One way to phrase this is that the acute traumatic stress cascade is what happens during and immediately after the stress event, and may continue over the course of a limited ongoing period (up to a month).

The post-acute traumatic stress response is what persists beyond that acute event window of time. And, practically speaking, what distinguishes a “response” from a “disorder” is the degree of impairment of actual function in the various domains of one’s life. In essence, “response” morphs into “syndrome” which can morph into a clinical “disorder” (i.e. a bona fide illness) based on symptom intensification and their degree of impact on function.

The key point here is that these are stress responses to a particular type of stress event, a psychologically traumatic event.

When a person directly experiences or directly witnesses a powerful event that causes them to feel fright or horror, that event may be said to be of a psychologically traumatic nature. It’s a blow to one’s sensibility and evokes a predictable cascade of physiological responses.

Your physiological reaction to that experienced event caused you to activate the fright response cascade and to feel fear about your own safety or helplessness. One may have a similar fright cascade in witnessing others experience a life-threatening or horror-evoking event. (I include horror here because I see it as a shock to one’s sensibility and such is essentially an assault on one’s fundamental worldview schema, their way of understanding and going about living their day-to-day reality.)

Your emotional response could cause you to feel horror, or severe disgust and revulsion. Since "fear" is an affect generally requiring conscious recognition of emotion, (e.g. “I feel afraid”), you may not get to that level of conscious awareness of your fear emotion. In a traumatic event, you may be cognitively, emotionally and physically frozen – immobilized. That's the high voltage power of the fright cascade.

Your experience of that event happening to you or witnessing it happen to others may overwhelm your capacity to consciously respond and may cause a “freeze” response in which you become immobilized.

After the psychologically traumatic event and for a sustained period, you generally feel “aftershocks” of the event. These take various manifestations, amongst them:

Re-experiencing

You re-experience the event in the form of an unbidden flashback;

You have restless sleep and dream about the event;

You brood about and are preoccupied by the event.

Hyper-arousal

Your awareness is heightened about your environment in anticipation of a repeat traumatic event;

You have a startle response;

You are restless, continuously on edge, or may have difficulty sleeping;

You unconsciously impose your interpretation of ordinary events in the framework of a traumatic event.

Avoidance

You avoid situations in which you might directly be harmed or which may provoke your recalling the event and thus generating a virtual re-experiencing of the original event;

You alter your life routine to create a virtual capsule around you so as to avoid re-experiencing the traumatic event.

Remember, the power of the traumatic event generally overloads cognitive processing. As a result, it induces a trauma event-related stress response cascade consisting of the above characteristic cluster of symptoms.

Note here that what is being underscored is that a traumatic stress event has a unique cascade of manifestations, fundamentally based in the "fright" response. Non-traumatic stress events or “ordinary” chronic stress do not evoke such a fright response. This is not to say that non-traumatic events are of less severity or impact; major life stresses too can have immense psychological impact. But their presence may not evoke that trauma-invoked fright response and thus may not have these particular manifestations, e.g. recalling past freight experiences, re-experiencing, avoidance, hyper-arousal et al.

The demarcation here, born out of the traumatic stress literature which was heavily influenced by observing the emotional impact of the traumatic violence experienced by combatants, is important in two respects:

  1. Certain events are likely to cause a uniquely characteristic cascade of reactive manifestations that, when the event is identified and meets the general sense of a traumatic event, one is likely to see symptom expression from among this clustering of customarily trauma-associated fright symptoms; and

  2. Conversely, when one (especially as a clinician-treater or coach) sees or “picks up” on one’s diagnostic radar certain symptoms, especially when they are occurring as a cluster, one should be highly suspicious that one may be dealing with a stress syndrome uniquely related to an original traumatic event.

Reasoning in this way, and perhaps this is true of all diagnostic reasoning processes, is beneficial for several reasons, two of which are particularly key:

  1. Once you as a diagnostician hypothesize the presence of a named syndrome, you are then compelled to explicitly explore for the presence of other symptoms often occurring in that cluster. (And by explicitly, I don’t mean overtly, or in a rote checklist manner, or intrusively. Rather, one is to have a heightened awareness and alertness for their presence.)

  2. Once you are confident that the symptom aggregation fits that syndromic clustering, you are now able to orient yourself toward the most appropriate, well-informed remedy. The treatment approach to trauma-related stress is different than that you might select for non-traumatic stress or a mood syndrome etc. And like antibiotics to certain bacterial infections, some classes of antibiotics work for one type of infection and not another, I.e., not all antibiotics work on all bacterial infections. One has to be intentionally selective in choice of therapeutic interventions as pursuing the incorrect one either doesn’t work while the patient continues to suffer or even gets sicker; or the ill-chosen remedy itself harms the patient further.

While definitional criteria for an acute stress reaction have varied over the course of the diagnostic classification manual, it’s fair to summarize the elements that have stayed as part of the classification.

The Two Main Variants of the Traumatic Stress Syndrome

Acute Stress Reaction / Disorder (ASD)

The symptoms listed above happen at the time you experience a traumatic stress event and/or may become prominent in the immediate and short-term period after the event.

When these symptoms are manifesting within the first 30 days of the original traumatic event, they constitute the syndrome known as Acute Stress Disorder. This temporal demarcation was made as studies seemed to suggest that most traumatic stress symptomatology resolved or at least significantly lessened during this period.

Post Traumatic Stress Syndrome / Disorder (PTSD)

When the symptoms persist beyond 30 days from the original event or even emerge more prominently 30 days after the event, the syndrome is now properly considered to represent PTSD.

It is held that PTSD can occur without the symptomatology of an acute stress disorder preceding it.  I don't know what the literature says on this to support this. It seems unlikely and I’ve not observed it in my practice.

It is also held that PTSD can newly manifest after a prolonged interval since the initial event. This is known as delayed or late-onset PTSD. This is entirely plausible as a variety of “containment mechanisms” may have kept the acute traumatic stress syndrome at bay.

The prospect of encountering a lethal disease from which one could die, and having an intense fear reaction accompanied by experiencing a cluster of the symptoms of the acute stress reaction, would certainly seem to qualify as sufficiently traumatic and properly warrant its proper categorization as ASD or PTSD.

Why’s All This Fine “Symptom Checklist” Detail Important?

Because the “treatment” for burnout (and for that matter for each of the other syndromes) is different from the treatment approach to trauma-related syndromes. In fact, the very approach to interview of the person and investigation for the presence of the syndrome and the elicitation of circumstantial detail pertaining to traumatic events is dramatically different.

In trauma, the treater (here, including both therapists as well as coaches) must tread lightly, sensitively, as intrusive, matter-of-fact questions can be experienced as assaultive and not only cause pain and retreat but actually cause reactivation of the entire cascade as though the traumatic event were newly occurring (e.g. engendering a flashback).

It’s also important as healthcare is so laden with patients’ traumas and sometimes even physically violent danger to the clinicians themselves.

In the National Academy of Medicine’s “Exploring Clinician Burnout” project undertaken several years ago, one study examining ICU nurse distress indicated that the symptom clustering obtained from carefully conducted, syndrome-informed interviews demonstrated that the type of distress they were manifesting was predominantly more indicative of the syndromes of ASD and PTSD than it was of burnout.

Thus, the careful elucidation of symptoms through sensitive inquiry will help define the syndrome(s) and thus guide the selection of therapeutic remedies.

As discussed previously but again deserving of mention here, one can have concurrent syndromes. Yes, you can have burnout and PTSD. Yes, you can have moral injury and PTSD and Major Depression and grief. Yes, you can have all of them concurrently.

And as is drilled into all physicians’ heads throughout training, the lack of improvement in the patient’s condition should always lead you to question whether you’ve got the right diagnosis or are perhaps missing something concurrently going on.

Secondary or Vicarious Traumatization

You know how it is when you watch a movie and you're scared out of your wits or moved to tears? That's the power of storytelling that is true to experience. You experience that character’s fear or pain or sadness.

Just as with vicarious grief, one can experience a psychologically traumatic event vicariously. This is especially true of those exposed to witnessing – whether through directly observing another’s trauma or hearing the stories of those who have experienced major life-threatening trauma. Like watching a movie in which we are pulled into another’s experience, experiencing it with them, we can become traumatized by their experience as though we too were witnessing it directly. Such is the power of stories that they can bring the listener to the scene of the traumatic event and have them virtually re-live the experience of the trauma event with the story-teller. Most people may watch an intensely engaging life-realistic movie one or two times a month. Healthcare clinicians “watch” hundreds of real-life movies each and every month.

Ironically, this “being moved” is both the risk and the healing power of empathic attunement.

All who witness the life-threatening traumatic experience of another, whether directly or via intensive re-lived-as-though-presently-occurring story-telling are vulnerable to vicarious traumatization and secondary PTSD.

Now that we’ve covered burnout, compassion fatigue, moral injury, grief, and trauma, we can move into the more clinically significant syndromes, the so-called  “Mood Disorders” of “Major Depressive Episode” and “Generalized Anxiety Disorder.”

If you’re enjoying these articles (I of course mean ‘enjoying’ in a broad sense) and you haven’t yet subscribed to my free Physician Interrupted newsletter on Substack, doing so will alert you automatically when that next article is posted. If you’re only on CPR’s mailing list to which I send out really very sporadic mailings and in which I happen to mention that I’ve written these articles amongst other newsy items like which laws the MRTC is likely violating and how many quasi-freebie curbside consults we’ve done (CPR - The Center for Physician Rights - www.PhysicianRights.net), you may not know that the Physician Interrupted Substack blog mailing list is a separate thing. I may figure out a way to combine them without imposing on either crowd, but it’s too much brainpower to invest right now.

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1

When you click at the very top of the page on the Physician Interrupted title, it’ll take you to Physician Interrupted’s table of contents page which lists all the articles and podcasts published. You can sort them in a variety of ways. As some of the articles were longish, I broke up the corresponding podcasts into more manageable parts, e.g. 6A, 6B etc.

The articles’ titles aren’t exactly descriptive - I’ve put the topic covered in the subtitle which, space permitting, may or may not show up in the TOC.

The podcasts are all identifiable as they have a headphones icon. The content of the podcasts is mostly the same as the article. While I read aloud the content of the corresponding article, occasionally I improv’d a bit. Nothing substantial. Some people prefer the written word; others enjoy a podcast; still others like having both. Some have some cover art; some don’t. I’m still getting the hang of this. I’ll likely go back and prettify things some time hence.

2

Please forgive if it’s not verbatim. I carried it from a newspaper clipping in my wallet for years until it became dust. I share it from memory.

3

Even more radical is the next evolution of that awareness - what if there’s a collective consciousness?! We’ll leave that for a separate reflection.

4

DSM 5 - The Diagnostic and Statistical Manual, version 5, is the official classification of mental syndromes. This classification scheme began as recently as 1980 and was a well-informed attempt to arrive at some consensus on defining and categorizing the variety of syndromes in the "ill psyche" universe, thus "psycho-pathology."