Working in the health care field is hard, especially when it comes to HIV care. Even with treatment advancements and decreased stigma around HIV, receiving an HIV diagnosis is still not easy. Being the person to give this news never gets easy, and often the health care worker doing so is talking an individual through one of the hardest days of their life. Folks at elevated risk for HIV often have past trauma outside the diagnosis that they haven’t processed. When counseling and working with people who are newly diagnosed or new to treatment, individuals often reveal experiences that have caused them high levels of stress, some of which may have led to their diagnosis. Health care workers in the HIV field often get exposed to high levels of trauma over long periods of time and aren’t given the tools to process this trauma. Vicarious trauma, or the ongoing process of hearing other people’s suffering and need, can have long-term impacts on one's physical and mental wellbeing, as well as one’s ability to work within the HIV care field.
As more past trauma is revealed in care sessions with a newly diagnosed patient, the line between empathy and immersion can get fuzzy. Vicarious trauma has a direct impact on a caregiver’s health. Studies have also shown it to be a leading cause in burnout and low retention among health care workers. The longer vicarious trauma goes unacknowledged, the less one is able to care for oneself or for patients. Actively acknowledging and processing the impact of vicarious trauma is an essential part of working in the HIV care field.
Vicarious Trauma and HIV Workers
Informing someone that they have a chronic condition, especially one with as much historical stigma and shame as HIV, is difficult. Workers who deliver the news may feel like they are inflicting pain on their patient through the diagnosis. This feeling can be hard to shake and can cause a response in the body analogous to experiencing trauma firsthand.
“There is something that's so hard about being the person inflicting pain on another person,” comments Carmen Landau, M.D., a family medicine practitioner and trauma-informed care specialist at the Southwestern Women’s Options clinic in Albuquerque, New Mexico. When you experience a trauma like this on an ongoing basis, it doesn’t disappear after you clock out of work. Left unacknowledged, trauma will manifest in the body via mental, and sometimes physical, distress. Chronic stress translates into chronic illness. Folks working in industries where they serve people in crisis mode often report elevated amounts of fatigue, migraines, and bodily pain as compared to the national population. Much of this pain can be attributed to unprocessed trauma from their workplace. This pain then becomes an added source of stress, creating a vicious cycle of stress and pain among health care workers.
Lack of Training Around Trauma
We as individuals aren’t encouraged or given the tools to process our own trauma, let alone the pain we feel from someone else’s. A wide assortment of health care workers, including case managers and community health workers, are trained to conduct HIV testing and counseling sessions. Training courses aren’t standardized across the country, and they typically only run two to three days—and some states, such as Florida, even allow online training. While this increases the number of people who can be trained to conduct testing, it limits the ability to ensure individuals have the tools to both effectively counsel and process what they hear during sessions. With the amount of information that needs to be discussed in this short training period, processing one’s feelings around giving a positive result isn’t given much thought. This can result in health care workers arriving across the table from a patient completely unprepared to give them their results. There isn’t a universal way to give an HIV-positive result, and each person is going to require a slightly different counseling approach. With limited conversations around boundary setting and how to effectively use empathy, counselors may use irresponsible methods such as trauma-bonding as a means of connecting. Lack of training in distinguishing empathy from immersion can convince one that effective counseling means embodying the experience of the person in front of you, yet this is far from the case.
Giving a positive result can feel as if we’ve failed the patient, especially with patients we are more familiar with. HIV health care workers aren’t consistently provided the tools needed to process these emotions, and as this trauma builds, workers create an elevated, and often unattainable, performance standard for themselves. Health care workers may begin to immerse into the patient’s experience and may project onto them the worker’s own experiences or the experiences of past patients. This creates a dynamic in which the worker is trying to “feel the feelings” for the patient, as opposed to providing needed services.
“I as the practitioner become over-involved, over-empathetic, inappropriate with boundary setting or overly rigid, [mentally] checked out, and begin going through the motions without really being present,” says Maisha Davis, director of the Social Work and Outreach Department at Chase Brexton Health Care in Maryland, on what burnout looks like. Being at this heightened state of anxiety for a prolonged time is taxing on the mind and body. A degree of dissociation can form, and health care workers may tend to mentally check out as a means of defending their systems from taking in further trauma. Nearly one in every four health care workers experiences burnout. While not the sole contributor to burnout, vicarious trauma does accelerate it. It also impacts patients.
These past couple years have seen the turnover rate in health care pass 20%, and patients become accustomed to retelling their narratives every few months as their care team members leave. This can frustrate and retraumatize patients, which negatively impacts their health. Patients may also become used to overly involved care team members, and when this isn’t replicated by all they interact with, this can be confusing and further aggravating.
Systemic Barriers to Trauma-Informed Care
Even those who understand the impact that trauma is having in their lives can feel as if there isn’t anything they can do about it. In 2016, it was estimated that as much as 64% of people living with HIV are living with some sort of PTSD, yet at the institutional level many health care programs fail to connect the impact trauma has on both patient health and staff retention. Davis comments, “If you at the administrative level can’t connect it to the bottom line, there’s no vested interest in making it happen. Programs often don’t have the foresight or knowledge to connect trauma-informed care to patient outcomes.”
Even for institutions that do acknowledge the impact of burnout, not much quantitative action is put towards alleviating its impact. Within the U.S., medical assistants, community health workers, and other entry-level health care employees often have limited leave time they can take when sick or in need of a break. For many, when it comes down to getting a complete paycheck or addressing mental health needs, mental health gets put on the back burner.
How to Process
Working in the HIV care field can be incredibly rewarding, and it doesn’t have to mean sacrificing mental health and wellbeing. While it can seem overwhelming, tackling the buildup of vicarious trauma will drastically improve one’s wellbeing and the wellbeing of patients. Acknowledging personal trauma starts with knowing you’re being triggered and the impact it’s having on your life. It’s essential, when possible, to communicate with your supervisor when you are at your limit and the ways in which you desire support.
Many companies offer one-on-one counseling and supportive services through their employee assistance programs. Teletherapy organizations such as Talkspace and Headspace offer additional support and occasionally offer free or discounted therapy services for health care workers. Processing trauma is a life skill, one that requires constant building to strengthen. Every day isn’t going to be perfect, but acknowledging that there is an issue is essential for growing in one’s ability to tend to both your needs and those of others.