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Each individual, she says, manifests vicarious traumatization differently. Early on, some people notice physical symptoms. “The first signs are usually very, very minor,” she points out—a tingling in the hands, a twitch in the eye. Alternately, someone may notice one day that they have stopped doing things they once enjoyed. “Maybe they haven’t been to a movie in a long time,” Murray says, “or they’ve stopped exercising, or drastically shifted their eating.” Another red flag is reduced productivity at work. “Paperwork is a big thing,” she says. “They find they just can’t keep up with things.”

One of the strategies Murray learned in training and has passed on to her own supervisees is cognitive reprocessing—reframing a distressing situation in a more positive way. It can be applied to everything from getting caught in a traffic jam to dealing with a particularly heart-wrenching care situation. “If you are seeing this really depressing case, you may think, ‘Oh my God, I can’t do anything,’ and start feeling very helpless and hopeless and sad, and as a result, not be very effective,” she points out. Mentally restructuring the situation to acknowledge the challenges and your own feelings of sadness subtly shifts your emotional state, she says, and restores balance. “You can see this person has a not very great life, but you think, ‘I’m here and we’ve got services, we’re moving in the right direction.’ Now, I feel a little more hopeful. I’m still sad but the whole demeanor and mentality shifts.”

Over the past few years, Murray has been pleased to see a greater awareness in public health that researchers and care providers need training and support to manage the emotional burdens of their jobs. “Today, there is more awareness among NGOs that they have to train staff on self-care,” she says. “I’ve seen way too many young kids go out into the field thinking it’s this glamorous fun thing, and they are not well prepared and not effective on the ground.” They may do things that are problematic for the country and for the project, she says, like engage in excessive drinking or promiscuity. She has found it helpful to have someone on the outside—“not necessarily a work colleague but someone who knows you well, whether a spouse or a best friend”—who will be likely to notice and comment on little changes in her appearance or behavior. “I had a supervisee once who had a friend who said, ‘You don’t do your hair anymore. It’s always back in a bun.’ It was such a small thing but enough of a change that this person noticed.” In fact, the young woman who’d stopped doing her hair was indeed struggling. Her friend’s comments were the trigger she needed to admit the strain she was under and seek help.

Recognizing and respecting their own limits is also important to health care providers. Rothstein, for example, used to schedule four new ALS patients on Monday, his clinic day. “I can’t do that anymore,” he admits. He now tries to schedule only two new patients. “The exam is nothing,” he points out. “I typically know within minutes of examining them. It’s the discussion part that is really demanding.” That usually takes hours. “You see the full range of emotions and you just have to let someone go through that. Even though I do this all the time, that’s still a stress for me.” When he gets home on Mondays, Rothstein says, he will walk, run, or ride his bicycle to decompress.

Ferrigno has found release in impulsive trips with her children. “Sometimes when my kids were little, in the middle of cleaning the kitchen floor, they’d say, ‘Let’s go to Six Flags.’ The bucket stayed where it was and in 15 minutes the sandwiches were made and the cooler was packed and we were at the gas station getting gas.” She and her husband, a social worker who deals with end-of-life issues too, developed a practice early in their marriage to help deal with the challenges of their emotionally demanding professions. “We made a commitment to each other when we were married that for our own sanity we would take 15 minutes every night together to defuse our day. Even when we had little kids running around, there were days when we literally locked ourselves in the bathroom and put the kids in a safe zone and took our 15 minutes.”

Conversation with colleagues can also help providers manage the emotional demands of their work, including strong emotional responses to particular patients and families. “I have a clinic that’s been together a long time,” Rothstein says. “[The staff] are highly experienced and we’ll exchange stories, talk to one another about the things we see. Like, ‘this one is really tough.’ We agree. There are ways in which we work it out.”

Though rarely discussed in the workplace, religious faith provides grounding and support for some. Ferrigno alludes to a time when her life felt so unmanageable that “the only place I could look was up.” Her resulting Christian faith became the core of her self-identity and informs her work as a nurse dealing with very sick patients. “At the end of the day, I just want to be doing what God has in mind for me. Some folks don’t understand that, and that’s OK,” she says. “But my job is to love whom God puts in front of me.” Rothstein says that he is not religious at all. “I am Jewish, but I haven’t practiced in years.” Though he does not feel an emotional or spiritual need for faith, many of his patients do. When a patient raises the issue, sometimes asking Rothstein bluntly if he believes in God, “I have to sidestep that issue because what I don’t want to do is undermine their relationship with me. They have to trust me, but religion can’t be the basis of that trust.” Instead, he will say, “Clearly, religion is important to you and I think that’s fantastic.” Murray too, finds that the issue of faith often rears its head in her work overseas. “I find it a lot internationally,” she says. “It is helpful to have some kind of comfort dealing with it and talking about it because it comes up so much.”

Whether one is religious or not, working with terminally ill people forces care providers to confront their own mortality. “You can’t do this work unless you’ve dealt with your own death issues,” Ferrigno says bluntly. “People who fear their own death cannot help anyone else.” And Rothstein admits

that his work with ALS patients has caused him to reflect on his own life. “My wife and I were not fortunate to have kids and I see what that’s like [for patients]. It’s your kids who are going to be there for Mom or Dad. Patients can hire aides, but it’s the loving, caring person who can smooth out the difficult end-of-life issues.”

It is impossible for people like Murray, Ferrigno, and Rothstein to build an impenetrable emotional wall separating themselves from the suffering people they encounter daily. All the while, they face the delicate task of creating enough emotional distance to be effective, while remaining emotionally engaged enough to create trust and offer support and healing. That might seem like an impossible balance, but, Ferrigno says, “pain comes in life no matter how we spend our days. As for career stress, what is high stress to one is joy to another.”

Science writer Deborah Rudacille is based in New York. Her latest book, Roots of Steel: Boom and Bust in an American Mill Town (Pantheon), was released last spring.