Understanding and Managing Secondary Traumatic Stress: A Guide for Families and Friends of Burn Survivors

Family and friends of burn survivors play a key role in the recovery process. However, their support often comes at an emotional cost, exposing them to significant stressors both during hospitalization and throughout long-term recovery.

During hospitalizations, stressors may include prolonged hospital stays, feelings of helplessness, witnessing loved ones go through difficult and distressing treatments such as wound care, time away from work and/or school, and financial stress. Stressors after discharge and between admissions can include adjusting to different roles (caregiver, exercise coach, cheerleader, intimate partner) and workload, frequent worry about potential burn-related complications, and increased responsibility of taking on outpatient care at home.

Some level of stress is a natural response for anyone in these circumstances and often fades over time as the burn survivor and family return home and establish a routine. However, sometimes this response persists or worsens over time and may lead to secondary traumatic stress.

Recognizing Secondary Traumatic Stress

Secondary traumatic stress (STS) refers to “...the stress placed on an individual when they are exposed to trauma descriptions, trauma images, or the reactions and responses of others who have directly experienced the primary trauma.” A traumatic event is one that is very distressing, disturbing, or life threatening, such as an accident, natural disaster, violent crime, abuse or neglect. Traumatic events may feel out of our control.

While the term “vicarious trauma” is often used synonymously with STS, the symptoms are not the same. Vicarious trauma usually builds up over time with repeated indirect exposure to trauma and results in a change in perspective and how someone sees the world. In contrast, experts understand symptoms of STS as existing on a range between normative stress all the way up to a diagnosis of PTSD in the most severe cases. Therefore, even though family and friends may not have been present for the burn injury itself (direct exposure), they can be indirectly exposed and still develop symptoms of traumatic stress.

What Are Symptoms of STS & How Do They Develop?

Symptoms of STS are similar to symptoms of post-traumatic stress disorder (PTSD):

• Intrusive thoughts – flashbacks, nightmares, or emotional/physical distress triggered by reminders of the event

• Avoidance behaviors – about the event or of reminders of the event

• Negative emotions and thoughts – feelings of fear, guilt, blame, shame, and anger; difficulty remembering parts of the event; feeling isolated or detached from loved ones, difficulty experiencing positive emotions; or decreased interest in usual activities

• Heightened arousal – irritability, sleep disturbances, hypervigilance, feeling easily startled, trouble concentrating, or engaging in risky or aggressive behavior

Individuals may also experience fear/worry, decreased motivation, chronic exhaustion, inability to listen, guilt, and hopelessness.

A natural response to distress is to avoid anything that might cause more distress. For example, avoiding social events because of possible questions about the burn injury that might feel uncomfortable or frustrating. Unfortunately, this avoidance can get in the way of the necessary healing and processing of traumatic events. At first, avoidance may bring relief, but eventually it reinforces the fear that those memories or reminders of the event are dangerous or threatening. Avoidance can also grow over time and make it difficult to function normally or participate in enjoyable activities. It is important to notice if these symptoms develop and begin impacting daily tasks at work or at home.

It is also important to remember that people present for the same event may have different memories or experiences of the event. Some individuals may be more at risk for developing symptoms of STS, including those who cope through avoidance or denial of the event and its impact on their life, or have had past unresolved experiences of trauma. However, individuals with strong social support and greater levels of resiliency may have greater protection against developing STS symptoms.

Experiencing STS symptoms is not a sign of weakness or that you are “going crazy,” or even that you necessarily have PTSD. Some individuals may have thoughts such as “It’s not real trauma” or “It didn’t even happen to me, so I shouldn’t be feeling this way.” Experiencing STS does not mean you are a bad family member or friend, or that you are unable to provide support for the burn survivor. Remember that some individuals may be more at risk than others for developing symptoms, which can often be out of their control. Experiencing STS can impact anyone, even healthcare and mental health professionals. The important thing is that you recognize the symptoms, take care of yourself, and reach out to a professional for help if needed.

Strategies for Coping

With so much focus on supporting the burn survivor, family and friends often pay less attention to their own health and wellbeing. Not only is it important to pay attention to possible signs of STS, it’s also important to incorporate time to engage in activities that support your mental and physical health. You are better able to care for loved ones if you are also caring for yourself. Remember the airplane oxygen instructions: in an emergency, you must put on your own oxygen mask before you can help someone else. Healthy strategies for preventing and managing symptoms of STS can include engaging in relaxing or enjoyable activities, regular exercise and sleep, and good nutritional practices.

• Engage in activities that bring you joy and relaxation:

• Call or video chat with a friend

• Go for a walk or do some light stretching

• Listen to a meditation exercise on your phone

• Explore a new part of your town or city

• Listen to music and create a favorite playlist

• Watch a favorite movie or TV show

• Read a book or journal your thoughts

• Cook or bake something you love

• Try a creative outlet (drawing, photography, writing)

• Engage in volunteer work

• Meet a friend for coffee

• Play games or complete a puzzle

Stay Connected with Supportive People

Prioritize staying connected to supportive people in your life. Reach out to people who usually make you feel happier and/or less anxious and who are willing to listen when you feel ready to talk about your experience. When talking with the burn survivor or other individuals present for the event, remember that people can experience and respond to the same event in different ways. Acknowledge and support others’ feelings and experiences, even if they differ from your own. While it is important to communicate with your loved one who is a burn survivor, be mindful of their readiness to talk about the experiences of others related to their injury.

Seek Professional Support When Needed

If symptoms of STS persist or interfere with daily life, consider reaching out to a mental health professional. Ask the providers at your local burn center about support groups, peer support programs, community events, and other resources that family and friends can utilize. Support groups, peer programs, and community events—such as those offered by Phoenix Society—can also be valuable resources.

More intensive support and treatment, such as individual or family therapy, may be needed if symptoms do not resolve over time or if they are interfering with your ability to do important things in your life. A qualified mental health professional can help you to learn healthy coping strategies, process traumatic events, and communicate effectively with friends and family.

STS can be a difficult and overwhelming experience, but it is manageable. By recognizing the signs early, practicing self-care, and reaching out for support when needed, you can maintain your well-being while continuing to be a compassionate support person for your loved one.

Emma Reutimann is a doctoral candidate in clinical psychology at the University of Texas Southwestern Medical Center. She is currently completing her research training at the Parkland Burn Center in Dallas, TX and is supervised by burn psychologist, Kimberly Roaten, PhD, ABPP. She has been working with burn care clinicians over the past two years to complete her dissertation on secondary traumatic stress.

Dr. Kimberly Roaten is a licensed psychologist, a board-certified health psychologist, and a professor in the Department of Psychiatry at the University of Texas Southwestern Medical Center in Dallas, TX. She is also the Associate Chief Quality and Safety Officer for Behavioral Health at Parkland Health and the psychologist for the Parkland Burn Center. Dr. Roaten's research focuses on suicide prevention in healthcare systems and understanding and improving psychosocial outcomes for burn survivors.

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