Secondary Traumatic Stress – An Assault on Caregivers of Persons with Brain Injury

Secondary Traumatic Stress – Caregiving families at risk after brain injury

By Janet Cromer, RN, MA, LMHC

Healthcare professionals have become much more aware of the toll that working with people who have been physically and emotionally traumatized can have on their own health and well-being. Many hospitals now provide resilience training for staff to learn essential ways to care for themselves and avoid burnout and compassion fatigue.

But what about the family members who provide intensive care at home for months and years after a loved one suffers a brain injury and/or PTSD? A mother might think she is going crazy when she gets a headache at the thought of entering her comatose son’s hospital room. She can almost hear the sound his buddy described of his car hitting the tree as they returned from a party. The husband of a brain injury survivor might lay awake at night to avoid the nightmares of the automobile crash that injured his wife. The wife of a wounded service member might call her friend to say, “I can’t take one more night of walking on eggshells so I don’t set off his flashbacks and angry yelling.”

What is secondary traumatic stress?

All of these caregivers are at risk of developing a secondary traumatic stress response (STS). The examples may seem graphic, but that’s because STS is an assault on the senses and emotions. It is closely related to post-traumatic stress disorder (PTSD) , just one step removed. The criteria for PTSD state that the person must have experienced or witnessed an extremely traumatic event. Then the person must develop persistent symptoms that feel beyond his control without treatment.

Secondary traumatic stress happens when a responsible and caring person is exposed to the sights, sounds, smells, or stories from the injured person and feels responsible for diminishing his/her suffering. Secondary traumatic stress occurs in degrees of severity along a continuum from a brief acute response to a longer-lasting, more serious disorder.

A central feature is that you frequently experience a high stress level called hyperarousal. This response can have physical and mental health consequences, and interfere with your family and caregiver responsibilities. STS also makes you more vulnerable to burnout and compassion fatigue.

Common ways that caregivers become traumatized

You were in the same accident or witnessed the event that caused the brain injury. For example, my husband suffered a heart attack and cardiac arrest on an airplane. A doctor, who was also a passenger, started CPR as I watched the color drain from Alan’s face. It took almost an hour of CPR before Alan returned to life. For weeks, when I tried to sleep, I saw Alan’s face turn from white to blue to black. Eventually I was able to use a cognitive therapy technique to replace the disturbing image with a mental picture of Alan’s smiling face, and remind myself that he was making progress in rehab. Of course, a caregiver in this situation might also have PTSD.

You have the shocked reaction anyone would have to seeing a loved one comatose, with part of his skull removed to relieve swelling, bandaged, and unrecognizable. No one can tell you his chances for recovery, yet the staff starts teaching you dozens of treatments you’ll need to do at home. Meanwhile, your children and job need attention.

You live with a survivor who has PTSD or mental health problems with unpredictable and frightening symptoms. If he/she hits you or screams accusations or orders, you are at even more risk of STS. We hear about this happening with some wounded service members, but the danger has no age limit. I remember an eighty year old man in a support group that I facilitated admitting that his wife, who’d had a stroke, often hit him so hard that he fell down.

You are expected to perform treatments way beyond your ability. As survivors are discharged from rehabilitation earlier and with complex injuries, this is becoming a very serious national problem.

You care for someone who cannot or will not participate in treatment.

What can be done about secondary traumatic stress?

Self-care and education are essential to nurture yourself. Here are a few tips.

  • Learn about PTSD, secondary traumatic stress, and compassion fatigue. You are not crazy or weak. Your responsibilities and circumstances would overwhelm most people. Watch for symptoms such as nightmares, reliving the accident, numbing, and avoiding seeing or listening to the survivor.
  • Your safety and that of your family must be the first priority. Have an emergency plan. Tell your case manager or treatment team if the survivor’s behavior is out of control.
  • Practice a way of calming and centering yourself every day. Even ten minutes of relaxed breathing, meditation, prayer, or journaling can help. Counterbalancing stress is the key.
  • Tell someone you trust about distressing symptoms. There are several effective treatments available, and ways to manage the intrusive or numbing symptoms.
  • Get support in several ways. Join a support group, participate in community or online educational programs, and look for respite and retreat opportunities.
  • Talk to a case manager, visiting nurse, or therapy staff about getting the help you need at home. Don’t suffer in silence. Your mental and physical health are too important. STS sometimes contributes to neglecting or avoiding the sick person because the caregiver is exhausted and overwhelmed.
  • Take frequent breaks to get out of the hospital or home. Get out in nature, take a walk, stretch out those tense muscles, treat yourself to lunch at a sidewalk café. Distraction can be good medicine. Enjoy a novel, movie, or music and don’t think about anything else for awhile.

Let’s bring caregiver secondary stress responses/disorder out in the open. Sharing your story can raise awareness and lead to earlier treatment and better health.


National Center for PTSD at

Janet Cromer, RN, MA, LMHC is the author of Professor Cromer Learns to Read: A Couple’s New Life after Brain Injury.  Please visit

Recommended Reading

Janet Cromer is also the author of several Tip Cards.

Stress Resilience: For caregivers after brain injury

For caregivers of survivors with brain injury, the ability to reduce and manage stress is challenging, but skills can be learned to increase resiliency. Caregivers can run the risk of burnout or compassion fatigue and compromise their own health and well-being. This tip card helps family caregivers understand the harmful effects of stress and gives strategies to create a resilience plan.








New Normal: For caregivers after brain injury

There is no single definition of “new normal” that fits every family, since each brain injury and each family is unique. This tip card helps family caregivers understand the adjustment process after a brain injury, for themselves and the survivor, with practical tips for moving forward at home and in the community.


4 Responses to “Secondary Traumatic Stress – An Assault on Caregivers of Persons with Brain Injury”

  1. Janet Cromer says:

    Thanks for your comment, Bob. I remember that hypervigilance that is hard to turn off at night. I learned how important it was for me to make time to practice just one technique to reduce stress and slow down my mind. I had piles of resources, but had to give myself permission to make time to practice just one technique to reduce stress and quiet my mind. All the best to you and your family.

  2. Bob says:

    Wow thanks for getting your story out here. If you noticed the time of this reply my mind doesnt stop from my job as caregiver. I wouldnt want to change my job for the world but beginning to feel the effects. I try to talk to family about it but dont want to get them down too. I thank God that I live in a time where so many good resources are available on line to help not feel so alone and get information on how to help as a caregiver. Thanks again and good luck and God Bless you and your family.

  3. Janet Cromer says:

    Hi Rosemary,
    Thank you for your questions. I truly believe that caregivers frequently suffer from secondary traumatic stress but professionals don’t ask about it and caregivers consider the awful symptoms to be part of the whole emotional turmoil. Yes, the treatment, while personalized to the caregiver’s symptoms and situation, is very similar to that for PTSD. That means learning how to decrease the hyperarousal response, learn how to take control of the dreams and memories, and getting much more support and help at home. I always say that treating the caregiver is just one step; Professionals have the responsibility of helping arrange more respite, training, or interventions.

  4. Janet,

    Your article is incredibly informing! I was told I had PTSD fifteen months after my husband’s TBI, but I now know it was secondary traumatic stress response. My question is: does the treatment of these various conditions (STS, PTSD, etc.) change or are the therapies for coping similar or the same? Thank you for bringing this out in the open. Great information for so many caregivers in need.

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