The High Cost of Caring

Careers that demand empathy, vigilance, and compassion can leave workers drained and traumatized. As researchers discover the true toll of emotional labor, employees are finally getting the help they need to stick to their calling.

By Diane Cole, published November 7, 2017 - last reviewed on November 7, 2017

"You don't talk about this to others. You don't want to spill out these images you've seen. This is my pollution. I'm not going to pollute anyone else."  – BRENDA CHAMBERLAIN (Photo by Matt Nager)

Six years ago, Brenda Chamberlain found herself slowly unraveling. She experienced dizziness, headaches, and infections, along with what she came to call "PTSD moments." She would walk her dog and suddenly find herself just standing on the street corner sobbing, or watch her niece's dance recital while crying in the dark, leaving her future husband sitting beside her bewildered, not knowing how to help. 

By that time Chamberlain had been working for Microsoft for about five years, first as a contractor and then on staff. She began by managing, from her office in Redmond, Washington, teams of "content moderators" in the Philippines tasked with clicking through online images to weed out offensive material, including depictions of nudity, violence, and sex acts. When the moderators weren't sure what call to make, they would pass the decision on to her—exposing her to disturbing images she describes as "pollution." 

By the time she left the company, she was part of a team focused on online safety policy and online child safety, a role that included representing Microsoft on the Technology Coalition of the National Center for Missing and Exploited Children, to which her team sent any and all content involving suspected child pornography or abuse. The mission, Chamberlain says, "was very hopeful and aspirational—to eradicate online child solicitation and sexual exploitation," and she likened her role to that of a first responder. If it helped lead to an arrest, she says, "every bit of evidence we could gather and turn over, that is a child we saved. That's why I was doing this." 

The group became especially tight-knit, she says, "almost like veterans," and they shared with each other a kind of unspoken ethic that "you don't talk about this to others. You don't want to spill out these child porn or child abuse images you've seen." The mindset, she says, was that "this is my pollution. I'm not going to pollute anybody else."

But the cumulative impact of the subject matter was taking a toll. Increasingly, team members leaned on one another for support. They'd go into each other's offices, shaken by the images they had seen, and share worries about how their work was manifesting in weight gain, drinking, and lashing out at loved ones. "When you're in that place, you're getting through the day, you're not aware of what would probably be called a state of hyperarousal, a state of emergency, because the images were states of emergency for the kids involved," she says.

Team members asked for, and received, group and individual therapy to help them cope, which Chamberlain says helped. Whenever the National Center for Missing and Exploited Children informed the team that evidence they'd collected had led to a perpetrator's arrest or conviction, they celebrated and shed happy tears. It happened only a handful of times a year, but it affirmed the importance of the work. 

In the end, though, she says the rewards were not enough to quell the emotional overload. Sharing time with her partner made her realize how isolated and constricted her own life had become. "Living alone with my dog and cat, I could control my environment so that it was very serene." She would typically spend two or three hours a day decompressing with yoga, meditation, quiet time, or walks with her dog. But as she devoted more time to her relationship, she had less opportunity to let go of the workday's stress. "I knew that to prioritize the relationship, I had to quit the job because I couldn't devote time to the self-care that allowed me to continue doing it."

Today, she and her husband manage a horse ranch in western Colorado, and she has become a certified mental-health specialist in equine-assisted therapy. For about a year after leaving Microsoft, she says, "I felt like a freak. I felt very polluted. I had extreme hypervigilance, a very low tolerance for stress, and was on edge all the time. It was like a cheese grater going over your skin or your nerve endings." Those feelings have abated, but Chamberlain believes the job changed her forever. "I am still very, very careful about what kind of stimuli I expose myself to, and I still feel like I have to focus on self-care. When I don't get that, I become irritable, isolate myself, and start feeling as if I'm coming down with a cold." 

Chamberlain still believes in the value and importance of her work on the web's dark underside. "This work can be done well and long-term with the right kind of program in place. And despite the changes it wrought in me, I still consider it to be one of the most amazing experiences of my life," she says. "People who do these jobs have a true passion and sense of mission. If companies devote the resources to support, I think it is absolutely possible to do the work well without breaking hearts." 

Living With Secondary Trauma

Everyone hits the wall at some point, wondering why the job won't just stay at the job. But some careers take a higher emotional toll than others. Many professions require putting on a happy face to the outside world, regardless of how we're feeling on the inside. Emotional labor is the term used to describe the effort needed to manage that discrepancy, says Robin Stern, associate director of the Yale Center for Emotional Intelligence. For workers in many fields, the daily demands of appearing calm and even-keeled in the face of difficult or angry interactions with customers or coworkers can leave them stressed and depleted. 

But when the workday involves engaging with other people's trauma, a job can produce more acute and dramatic symptoms. This overwhelming emotional residue, Stern says, is called secondary or vicarious trauma. The more empathic and open to others' pain the workers are, the more likely they will share those victims' feelings of heartbreak and devastation. The danger is that when they regularly experience this vicarious trauma, they no longer know how to nurture their inner life. "They need strategies," Stern says. "They need to create a regular practice of self-care and nurturing their own soul." For some that may include prayer, mindfulness and meditation, or yoga. For others it could be spending more time with loved ones, walking in nature, reading spiritual texts, listening to music, or taking up a hobby that helps to fuel their inner, spiritual, or artistic self.

Soldiers, first responders, humanitarian aid workers, nurses, surgeons, lawyers and therapists for victims of domestic abuse, and journalists on the front lines of war and disaster are among the workers exposed to stress and images that can't be easily forgotten. They spend their days in constant close proximity to suffering. The inherent value of their roles as witnesses and healers provides a sense of purpose that keeps them going. But while some appear to get through the experiences unscathed, many struggle to find an escape, even once they're back in the comfort of home. 

The toll of some new-economy jobs has only recently begun to be examined by researchers like Sarah T. Roberts, a professor of information studies at UCLA. Roles like Chamberlain's, she says, can offer validation because they involve protecting others, especially children. "These workers are on the front lines in a real way," she says. And yet because the job takes place out of sight of most internet users, the workers' sense of isolation may be particularly acute. Content moderators also often work under nondisclosure agreements that bar them from telling others what they are seeing, a potential roadblock if they want to open up and seek support. 

Even in professions known for acute emotional stress, workers aren't always taught the skills needed to cope, says Cynda Rushton, a professor of clinical ethics and nursing and pediatrics at Johns Hopkins University. Health-care workers, for example, face each patient's pain and suffering—the outcome of which they may not be able to change, despite their best efforts—and then have to move on immediately to the next person in need. This routine can foster an intense sense of helplessness, leading workers to become "angry or hypervigilant or to shut down or numb out so they aren't able to engage," both on the job and in their personal life. To prevent that, Rushton asserts, organizations need to put practices into place that help individuals  develop resilience "before they need it." 

Since 2013, the international humanitarian organization Save the Children has offered its humanitarian responders a free support program that enables staffers to take advantage of confidential counseling sessions to discuss such issues as stress, anxiety, depression, sleeplessness, and witnessing or being affected by a traumatic event. The program is run by the KonTerra Group, which also provides support services to several other humanitarian aid and relief organizations.  

Save the Children also offers field workers preparedness and resiliency training prior to each posting. "These trainings help you understand how to stay safe and deal with negative events that can happen on a deployment, from harassment to an ambush," says Laura Cardinal, the group's senior director of humanitarian response. "There is also security training geared toward women and mandatory counseling sessions."  These sessions, along with a debriefing upon each worker's return home, have all proven helpful, says Cardinal, who in her nine years with Save the Children has herself been deployed to crises in Darfur and the Philippines, among other places.  

News photographer John Moore has witnessed scenes of tragedy and devastation: "I don't think I could live with myself if I imagined I was some sort of vulture." (Photo by Mike McGregor)

Seeking a Shield

Over his 26-year career, news photographer John Moore, 50, has documented conflicts in Iraq and Afghanistan, the aftermath of suicide bombings and the assassination of Benazir Bhutto in Pakistan, the Ebola crisis in Liberia, and famines in Somalia and Angola. "It's a cliche to say the camera is a shield," he says. "There is something to that, but in my case, the camera also provides a sense of purpose. Without one I don't think I could walk away from a scene of suffering without a deep sense of guilt. 

"It's never easy to cover traumatic events, so it's key for me to know why I'm there—to tell a story and make people feel something. I know that not every photo I take will result in positive change, but at the very least I can inform and educate. It is also important to me that the people I photograph feel like I have given them a voice, in some small way, and not feel taken advantage of. I don't think I could live with myself if I imagined I was some sort of vulture." 

Currently a special correspondent for Getty Images, Moore believes that organizational support is extremely important while working in difficult or dangerous areas. "The few studies I know of on the effects of trauma on journalists," he says, "suggest that support from supervisors is key in reducing the effects of post-traumatic stress. So before I even step foot into a potentially risky situation, I've discussed the coverage with my editors at length, and I check in daily while on assignment."

Colleagues also provide support that no one else can, he says. As with soldiers or aid workers, "journalists who cover trauma often find it hard to speak about their experiences with people unfamiliar with that sort of work," Moore says. "With colleagues who have been there, you know that it's okay to discuss as little or as much as you want. It's a safe place." 

Traversing the globe from crisis to crisis leaves little room for a personal life. A calling can overwhelm if workers have no opportunity to exhale. That is why people who live their lives against such intense backdrops need strategies to help them decompress. For Moore, who lives in Stamford, Connecticut, that means time with his wife, children, or friends, "sometimes over drinks late into the night." He also meets with a therapist when he can: "I am a big believer in talking through issues with a professional. My travel schedule doesn't always allow for weekly visits, but I get help when I need it—or when my wife points out that it might be helpful!"

"You have to have empathy; you have to care.  That is the reason any of us do this work. But you need a set of tools to help you process the material." – MARGARET L. SATTERTHWAITE(Photo by Mike McGregor)

Stuck in Other People's Shoes

Ironically, the capacity for empathy and compassion that calls many individuals to these careers can feed the symptoms of vicarious trauma, such as sadness, exhaustion, detachment, and anger. Those who help others, Stern says, can spend "too much time" in other people's shoes and forget to step back into their own. They may withdraw from the friends, family, and social activities that once gave them pleasure to focus ever more intently on their work and those they are helping. They may not even realize how isolated they have become until they receive a wake-up call like an illness or a partner threatening to end a relationship.

"There is always a risk when we care, because caring means to suffer with someone," Rushton says. "But we have to be mindful of our own capacities, needs, and limits. We need to care for ourselves so we can care for others." 

New York University law professor Margaret L. Satterthwaite, 48, a longtime human rights field worker, recalls how several weeks immersed in interviewing victims of sexual assault or torture would seep into her daily life. When she returned home after seven weeks in Haiti listening to people's stories as a human rights investigator for that country's National Truth and Justice Commission, she felt a deep aversion to even thinking about the experience, even though it had been meaningful and emotionally fulfilling. "I started doing some journaling to try to figure out this dual response: It was great but I can't think about it," she says. "I realized I felt like a weighted down sponge that can't take anything more in." At that point, she was finally able to begin opening up to friends and family, finding the support that helped her understand the emotional content inherent in the work. 

"We want to have human responses; that's a good thing," Satterthwaite says. "You have to have empathy; you have to care. That is the reason any of us do this work. But you need a set of tools to help you process the material." Satterthwaite has brought attention to these issues in her research, working to create a scholarly literature that was missing early in her career.

The need is clear, she says, especially as technology adds new emotional hazards to her field, such as coping with repeated viewing of video evidence of abuses and violence. "You need to know who is responsible for the violations, and often the only way to do that is just to watch the video for what uniform or what rifle or what words individuals are using. You might have to watch this 50 times, taking in this horrible thing over and over again." 

"It is inevitable for anyone in this field to take things home.  But now I recognize when I'm stuck in a loop of rumination." – ANTHONY BACK (Photo by Patrick Kehoe)

Without training or preparation, workers can be overwhelmed by a sudden rush of emotions. If left alone to discover their own self-care strategies, they tend to find the learning curve can be steep and the journey lonely. "There is a set of resiliency skills that you need in the helping professions," says Anthony Back, 57, codirector of the University of Washington's Center for Excellence in Palliative Care and a professor at its Fred Hutchinson Cancer Research Center. "They relate to how you deal with your emotions when things are running away with you. It is inevitable for anyone in this area to take things home. But now I recognize when I'm doing that or when I'm stuck in a loop of rumination."

Earlier in his career, Back, who graduated from medical school in 1984, had to learn those skills on his own. "When I was a young oncology fellow," he says, "I remember telling this older gentleman that he had lung cancer, and he started to cry. I was taken aback. Here was a tough Vietnam War veteran who had seen all kinds of terrible stuff, and he started to cry, and I just didn't know what to do. I felt guilty. What had I done to make him cry? My mind was going around in circles, and I ruminated about it for days. He was going to die soon from this very aggressive form of lung cancer, and I was convinced that I had made it worse for him." 

After two more similar experiences, the guilt-ridden young doctor was sure that "I must not be doing the right thing for patients," he now says. That's when he sought out a therapist, who reassured him that both he and his patients were exhibiting normal reactions. "But I had to learn that outside of my work because nobody within medicine was teaching us that different patients can have a huge range of emotions or that there are times when crying might be a sign that something more might be needed from the physician." Back has since made meditation a part of his self-care regimen and says he counts on the support of peers. All of it has made a difference at home, he says. 

"Early in my career I'd have a difficult case where a patient didn't do well, and I'd be distracted over dinner. My partner would say, 'You're thinking about something.' I'd say, 'No, I'm not!' And that was the end of the conversation, except that then I'd start to feel guilty about making my partner miserable. It was compounding: I'm not a good partner, I'm not a good doctor, I'm not doing anything right. You can see how easily that can spin into burnout.

"I still have those times over dinner when he says, 'You're thinking about something.' But now I take a deep breath, and I tell him about it and get it out of my system," Back says. "I don't ask him to be my therapist or ask him, 'Did I do the right thing?' I just explain what happened, and, through the telling, help pinpoint what may have gotten under my skin. After that, I will often realize that I can now let this go, or that there might be something more I need to think about, write about in my journal, or talk to someone about. I recover more quickly, and there is less residue." 

Such practices have helped Back make himself more available to his patients—and to the new doctors he trains. "Doctors can be big catastrophizers," he says. "We're trained to look ahead at what all the consequences might be. And yet, if you take that on and let your mind run with it in an undisciplined way, you will make yourself crazy. I see some of the people I train catastrophizing nonstop or suppressing all their emotions" in an effort to be heroic or stoic. "But that makes you unavailable. You're thinking, I can't react. And so you don't. But your patient needs you to."

Staying Connected to Home

Jen Simmons, 38, has worked at the Johns Hopkins Hospital surgical intensive care unit (SICU) in Baltimore for 12 years. Recently, she has taken advantage of a new program, designed by Cynda Rushton, to teach nurses at the hospital resilience skills to manage the stress, and distress, that comes with the job. 

Working 12-hour shifts three to six times a week, it's hard for nurses not to take some of the emotion home. "In the SICU we see things beyond what you think the human body can endure," Simmons says. "We see limbs swollen or missing; the volume of blood leaving a body can be enormous. During emergencies, the chest can be open, and you see the heart beating. You see internal organs and bowels." Nurses need to simultaneously focus on any number of tasks to keep patients alive, while at the same time helping their loved ones emotionally process the potentially life-or-death medical decisions they suddenly face. It's natural for nurses to forge bonds with the people for whom they care—and it's tough to witness their suffering at a patient's passing and then go on to the next bed in the unit a moment later. 

"We want patients to get better, and being part of that process is important to us," Simmons says. "When you're focused on people getting better day in and day out but that is not happening, it can be grinding. This is a profession where you give and give. At a certain point you have no more to give. Your cup is empty. But the people who need a drink don't go away, not at work or at home. The people at home aren't fragile like at work, though, and you can take that for granted and forget that your family also needs your attention." 

Simmons has developed routines to decompress, including attending church services with her wife and son. She grew up in a nonreligious household but says she finds herself moved by the sense of community and the time and space the church provides "to quiet down your body and to be still." 

That experience, she says, made her more open to mindfulness and meditation, and she later volunteered to be among the first staffers to take part in the hospital's six-week resilience-building program for nurses. 

"We can't expect people to continue beyond their limits without the support they need to care for their own well-being," Rushton says. "We can't expect them to provide high-quality compassionate care when they are not being treated with compassion and respect by the organization they serve."

Simmons and her wife follow mindfulness practices as a couple now, she says, whether on the phone when she is on a night shift or in bed in the evening, when they each recall the highs and lows of the day. "And then we say something that we're grateful for."

These and other practices help Simmons stay focused on what brought her to nursing in the first place: "At the end of the day, we want to ease the pain and make the patients feel like people." When she feels overloaded, she regroups and takes three to 10 intentional deep breaths. It's the type of simple but effective practice that Rushton says leaders in other high-burnout fields need to share with their teams.

"I would love to think that we can prevent people from hitting the wall by providing mechanisms where these issues are addressed," Rushton says. "We don't need to wait until the house is on fire before we start hosing it down." 

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For Workers Facing Trauma, the Chatbot Is In

Workers who live with secondary trauma may struggle to find help, especially if they are stationed overseas or work late nights. Some organizations now use text-based therapeutic chatbots to help such individuals deal with their issues when face-to-face therapy is impractical, and they've generally been pleased with the results.

Chatbots programmed by artificial-intelligence developer X2 have been deployed to aid nurses and family caregivers as well as Syrian refugees in Lebanon and the workers who support them. The bots' consultations attempt to gauge an individual's concerns and respond with the most effective advice. As the program amasses data on a user, it learns which responses are most helpful and attempts to guide the person to tailored coping mechanisms to spur self-compassion and a more positive outlook.

Everything the bots generate has been approved by psychologists, and therapists overseeing their exchanges are prepared to jump in and take over when necessary, or offer to arrange further consultations with a human. 

In a recent study at Osaka University, a majority of people said they would be more likely to talk about a painful or embarrassing problem with a robot than with a human therapist, in part because of fear of judgment. Early reports on chatbots confirm this: When people know they are not talking to another human, they appear willing to open up more quickly. 

For some, just being able to type instead of talk is a relief. "Call center nurses and others who are constantly on the phone may not want to talk to anybody, because they've been talking all day long," says psychologist Angie Joerin of X2, but they may still need help unwinding.

Typing one's concerns into a text box is not so unlike journaling, a practice proven beneficial by research. "This is a journaling exercise, but it's been upgraded," X2 CEO Michiel Rauws says, and its 24/7 availability can be an advantage for many because "it's easiest to talk about your feelings when you're feeling the feelings." — Psychology Today staff