PERSONAL ESSAY

Lawyers and Secondary Traumatic Stress, or: On the dispersal of brain matter in a Kentucky trailer

The photo of the victim was stuck in an unmarked manila folder. It was our duty to stare at it, to not look away

By Dan Canon

Published January 22, 2022 7:30PM (EST)

Desk at night (Getty Images/CTRd)
Desk at night (Getty Images/CTRd)

Note to our readers: This story contains graphic descriptions of violence.

When a man's head has been blown off with a shotgun, you'd expect there to be more of a mess. But a 12-gauge to the temple, at close range, can be surgically precise. I was a third-year law student, still in my 20s, when I learned that. Our clinic director gave us a foot-thick, plain-brown expandable file and told us to "turn over every page." The photo of the victim was stuck in an unmarked manila folder, shuffled into a stack of ordinary-looking paper. At first it looked like an error in printing; like someone had taken a picture of a shirtless man, sitting upright in a wheelchair, but somehow cropped out the top half of his head. Even the bottom of his face, the nostrils, the graying mustache, the mouth still open in surprise, was intact beneath a sharply defined line that divided what was left of his skull from the rest of his trailer.

An image like that is not immediately shocking. You may have made an educated guess that what you're looking at is horrific, but you don't know why. By the time you comprehend it, you're already immersed in it. You can't pretend you didn't see it. Nor do you have the luxury of flipping to the next page or slapping the file shut; you must carefully examine every detail of the scene for your client's sake. When you do, you begin to understand why there is so little visible disarray in such a violent photo. It's because the force applied to the matter in question was so great, and the matter so willing to yield. What would otherwise be large clumps of organic material have been broken up and dispersed into a barely perceptible red mist that has settled onto surrounding surfaces without betraying what it used to be: hair, eyeballs, an earring, the stored memories of a grandfather caught up in rural Kentucky's extensive drug trade. Through an accident of physics, the gore is presented in a way that makes it bearable to the casual observer.

Over my career, I've seen a lot worse. Murder victims soaked in blood, brains scattered on the floor, eyes bulging out. Countless people twisted up, deconstructed, and otherwise dehumanized by police. Kids with their faces burned off, kids wedged under truck wheels, kids with baseball-sized bullet holes in their chests. Video of diabetic mothers dying, sometimes quickly, sometimes not, on the floors of jails and prisons. I once took photos of my partner holding a desiccated, splotchy rubber glove that was retrieved from the stomach of a nursing home resident months after someone rammed it down her throat. I even represented an honest-to-god axe murderer; I will spare the reader the details of that file. These images no longer bother me any more than my first look at the half-headed man in the trailer.

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To be an American is to be surrounded by trauma all times. This may be a difficult fact to process for those of us who grew up in the sanitized bubble of the suburban middle class, but it is undeniable. Equally undeniable is that in the 21st century, most of us from that bubble are mercifully shielded from the worst of our violence. Bloodshed on American soil is thought to be a thing of the past, an anomaly when it happens in a school or at an office building, a news story that might take up 30 seconds of our workweek. For the most part, our children don't die, our limbs are not amputated, our parents pass peacefully under layers of rubber and plastic. Even in a global pandemic, with hundreds of thousands of people dying everywhere, most of the dying is done where not even the deceased's family can see it. Bodies are placed under sheets, slid into boxes, and safely stored underground or burned in giant furnaces. You might only see a few dead people in your life, and in the unlikely event that you witness the moment of someone's death, it probably won't be as traumatic as, say, a shotgun blast to the head.

The sterile myth of a gore-free existence persists in our fiction, too, in the realm of cop dramas, action movies and video games, where you might see death and blood, but in a way that is both fleeting and sensationalized beyond belief. The altogether incredible on-screen depiction of bloodshed provides little more than a pinprick to the eggshell in the brain. Credible accounts of carnage and despair, on the other hand, can crack it at the base, allowing reaction fluid to slowly leak out. And so we've developed the good sense to steer clear of such accounts when we can, slapping the file shut before we've got a head full of god-knows-what. This freedom from trauma is an under-appreciated luxury of the 21st century, a convenience of modern living, like refrigerated food or indoor plumbing. Rubbernecking delays, in which motorists hope for a glimpse of a mangled corpse, could only occur where such a sight is a novelty.

American lawyers are a part of a strata of workers who dare not turn away. We, along with therapists, social workers, journalists, healthcare professionals and schoolteachers must fling ourselves into varying depths of human suffering if we wish to maintain our professional reputations (and pay the rent). Like many attorneys, I have an affirmative duty to stare at artifacts of violence in an attempt to derive some sort of deeper meaning from them. Could this be something different than the witness, the other side, or the judge said it was? What details seem out of place? Where is the missing footprint/blood spatter/bone fragment? How much money is this injury worth? In the few cases where there are no photos or videos, a thorough advocate must still conduct searching inquiries into the worst imaginable tragedies. For us, it is not enough to know that someone's father was crushed to death in a freak accident; we must ask pointed questions about who he called out for, what his last gasps sounded like, how long they lasted, whether he sounded afraid, how afraid?

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For all the questions that arise in examining the bits of carnal waste scattered outside the gates of the American legal system, one rarely asked is: "What is this doing to me?" As a general rule, we lawyers are good at assessing damages to others. We are not good at evaluating the psychological harm that we may have inflicted on ourselves by over-consuming the graphic details of humanity's worst hits.

I had already been in practice for about ten years by the time I first heard the term "secondary traumatic stress." STS, often called "compassion fatigue," was identified in the early 1990s, and affects anyone who works closely with trauma survivors. It can be defined as "the stress resulting from helping or wanting to help a traumatized or suffering person." In the legal context, secondary traumatic stress especially affects those who work in the criminal and family law spheres, though I suspect that anyone whose office regularly hosts sobbing, grieving clients is at risk.

STS causes the part of your brain that sympathizes with the misfortunes of others, if overexposed, to white out. The possible side effects of a trauma-rich diet can include irritability, depression, insomnia, destructive or reckless behavior, and — every lawyer's favorite — substance abuse. There's also "intrusive imagery," which means muddled ghosts of what happened to other people will flit before your eyes throughout the day, only it's your mother on the autopsy table in the middle of dinner, it's your kid flattened by a tractor trailer while you're standing in the coffee line. Some of the literature casually mentions "detachment or estrangement from others," and "inability to experience positive emotions" as potential results. At the very least, your ability to care about stuff that people should care about is severely compromised.

I have not been, and will likely never be, formally diagnosed with STS, but these symptoms are familiar. After almost two decades of near-daily exposure to tales of trauma, my response to a family-shattering car crash in an adjoining lane usually isn't rubbernecking, but more like "hurry up assholes, who gives a fuck about this shit, I've got somewhere to be." Fun isn't as much fun, sorrow isn't as sorrowful, and while I don't often think about killing myself, it's mostly because the idea of suicide, like most ideas, just isn't that exciting. Maybe after a few drinks.

Thirty years after the formal identification of secondary traumatic stress, lawyers can still go their entire careers without hearing of it. The term "compassion fatigue" only appears in seven cases out of the billions decided by American courts in the last thirty years. "Secondary traumatic stress" appears in only three. A handful of journal articles have discussed its impact on the American legal profession, but for the most part, it is simply not part of our standard lexicon. Universities continue to ignore its existence, even when they should know better. The American Bar Association, tasked with issuing volumes of rules governing every aspect of legal education, does not require law schools to discuss the effects of vicarious trauma, nor to cover any topic pertaining to mental health at all, and so most of them don't. We still neatly package misery for students, leaving it as something to stumble upon as they leaf through files, as if it's as ordinary as a rule of civil procedure or a trespassing statute. When they're not looking directly at it, they're poring over dry, clinical descriptions of suffering and death, discussing it as matter-of-factly as one might talk about the chemical makeup of Oxycontin.

Compassion fatigue's better-known cousin is post-traumatic stress disorder (PTSD), a condition first identified by the American Psychological Association in 1980, but acknowledged by the scientific community long before. By now, PTSD is a household term. The condition, which affects an estimated eight million Americans per year, is defined by the APA's Diagnostic and Statistics Manual (DSM 5) as:

Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

There is no separate diagnosis of secondary traumatic stress or compassion fatigue in the DSM 5. One might reasonably assume that that's because the definition of PTSD already includes it in items (3) and (4). But nearly all the relevant literature, which by now encompasses thousands of books and peer-reviewed articles, addresses the pathology and treatment of (1) and (2) only. Number (4), where lawyers live, has been relegated to a handful of academics and the specialty journals who will publish their articles.

RELATED: You can "see" PTSD in a person's eyes, researchers find

As such, STS remains a relative unknown. Those of us who intimately meddle in other people's trauma are not thought to be victims of PTSD, and STS is not on the tip of America's tongue, so many of us will never have a name for what we're experiencing. The closest we can get to a diagnosis is "overworked," "stressed" or maybe "depressed." A 2019 article in the journal Traumatology reveals not only that we don't know how to measure secondary traumatic stress, but we don't really even know how to diagnose it. The select few of us who are able to get a bona fide diagnosis are left without a competent treatment, because we don't yet know what one looks like. The pithy advice to engage in "self-care" seems to be the best we can do, and research shows that that oft-heard admonition just doesn't work.

This disconnect has real-world consequences. We send more than 100,000 people, most of them young adults, into the legal profession every year. They, along with the over one million other American lawyers, will make the rules we live by; they will be legislators, they will sit on corporate boards, they will manage public institutions. Most of them will be regularly speaking the unspeakable things humans do to one another before they graduate law school. Before they know what they're wading in, they'll be up to their necks. They may at some point wonder why they feel alienated from their non-lawyer peers, most of whom are safely in a trauma-free bubble with the rest of the general public. They may wonder why they are drinking more, sleeping less and trying to figure out new ways to feel. They may wonder why they can't stay in relationships, or why they yell at their kids so much. Or they may not wonder, because they may not think anything's wrong. All these side effects can seem unremarkable when spread out over time and space. Even something as terrible as a trailer painted with brain matter isn't immediately repulsive if you don't know what you're looking at.

One could be forgiven for not feeling too bad for lawyers with fried compassion circuits. This is what we get paid to do, after all, and most of us get paid pretty well. But STS is a problem that reaches far beyond the legal profession. America's healthcare sector is the largest in the country, with more than 20 million employees and growing. Another four million work in education. There are around 800,000 people who identify broadly as "counselors." Not all of these workers are going to experience compassion fatigue, of course; many of them may stay blissfully insulated from trauma, or at least are spared hearing about it every day. But they are all in the zone of danger. The problem is at least as big as PTSD, and probably bigger; for every one of the eight million Americans afflicted with PTSD, there may be many others who interact with that person and live their trauma vicariously. Most of them — especially those with no background in clinical psychology — won't likely know that their brains are being hacked until it's too late.

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Some research suggests that STS might not only be as big as PTSD, but just as bad, too. A 1995 study correlated PTSD-like effects experienced by female psychologists and rape-crisis counselors with the number of trauma survivors they served: More clients meant more symptoms. A 2006 study of therapists found that the more hours they spent with trauma survivors, the more likely they were to exhibit classic PTSD symptoms. The effects of secondary traumatic stress have barely been studied outside the therapeutic context (and not at all within the legal profession specifically), but one 2011 study found that around 80% of juvenile justice workers experienced symptoms of, and nearly 40% met all the diagnostic criteria for, PTSD.

This essay should not be read as minimizing the experiences of anyone who has personally witnessed and survived a traumatic event. But where we've gone wrong is in focusing on primary trauma to the near-total exclusion of secondary trauma. Even if STS must be thought of as "PTSD-lite," we still face a scenario in which far more people will suffer from PTSD than will ever be formally diagnosed, and most of them won't be thought of as having "real" PTSD. More fundamentally, it's worth asking whether PTSD and STS should be diagnostically lumped together in the first place. After all, the two conditions seem qualitatively different from one another. Lawyers and social workers are not combat veterans or mass shooting survivors. Witnessing a horrific event firsthand is not the same as hearing daily accounts of similar events. And reliving trauma is not the same as having to mold the contours of someone else's worst nightmare into a treatment plan, a short magazine piece, or an argument that will evoke a response in a judge or a jury.

Until we do better at explaining what compassion fatigue is, or at least acknowledging that it exists, millions of workers will learn by being cast headlong into the cesspool the rest of us swim in, and they won't know it until they're soaked to the bone. Nurses will wake up drowning in someone else's fluids, social workers will spit the teeth of their clients, schoolteachers will be seared by the lit cigarettes of their students' abusive parents, and they'll think it's normal, just part of the job, something to walk off, shake off, or drink off. Without intervention, their capacity to care about the things they are supposed to care about will wane, a fact I am sure of after years of sitting in a trailer with no door, next to the empty shell of someone who might resemble my father or grandfather, his head scattered around the room in a manner that is not offensive to me, because I am offended by nothing.

This essay was originally published on Medium, and is republished here with permission from the author.

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Dan Canon

Dan Canon is a civil rights lawyer, educator and author of "Pleading Out: How Plea Bargaining Creates a Permanent Criminal Class." He was lead counsel for the Kentucky plaintiffs in Obergefell v. Hodges, which brought marriage equality to all 50 states.

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Compassion Fatigue Essay Law Mental Health Ptsd Secondary Traumatic Stress Trauma