How working with clients' traumatic material can have serious repercussions for practitioners
In the last twenty years, the mental health field has increasingly become interested in the potentially harmful impact of working closely with those who are traumatised. There is now a growing amount of literature which focuses on the theoretical and clinical implications of trauma work and empirical evidence is emerging documenting its negative psychological effects among help-givers, including counsellors, disaster relief workers, police and medical personnel, and mental health professionals (Follette et al 1994; Sloan et al 1994; Weiss et al 1995).
Treatments for PTSD often involves elements of exposure work, such as prolonged exposure therapy (Foa et al 2007), cognitive processing therapy (Resick et al 2008) and to a lesser extent eye movement desensitization and reprocessing (EMDR), as it is regarded as information processing (Rogers and Steven, 2002). These therapies are examples of techniques used in the treatment of PTSD (Ponniah & Hollon, 2009) and typically involve patients’ describing their traumatic experience(s) and clinicians listening to the trauma narrative. This vicarious exposure to traumatic material may significantly affect clinicians both personally and professionally.
Defining Vicarious Trauma
Vicarious trauma is a natural pervasive change resulting from the repeated exposure to experiences and feelings of a traumatic event experienced by another person (McCann and Pearlman, 1990). It has been recognised for over twenty-five years (McCann and Pearlman, 1990; Pearlman and Saakvitne, 1995) although it has been referred to in other terms, such as "empathic strain," "secondary victimization," or "compassion fatigue" (Lindy 1988; Figley 1983). Other related concepts include: secondary trauma; secondary survivor (Remer & Elliott, 1988), secondary traumatic syndrome and secondary traumatic stress disorder, burnout and traumatic countertransference. The terms allude to the negative impact of working with those traumatised and show that indirect exposure to trauma may lead to ill health (Killian et al, 2017).
McCann and Pearlman (1990) coined the term vicarious trauma (Rasmussen, 2005; Pearlman & Mac Ian, 1995). They theorised that it is an interactive, cumulative, and inevitable process, distinct from burnout or countertransference (Harrison and Westwood, 2009). Pearlman and Saakvitne (1995, p.279) argue that “vicarious traumatisation is a process through which the therapist’s inner experience is negatively transformed through empathic engagement with clients’ trauma material”.
Although vicarious trauma could occur as a result of one person caring for another who has been traumatised, researchers argue that counselling seems to differ from other professions because empathy is a major tool used by therapists in the counselling process (Dunkley & Whelan, 2006; Rothschild, 2006). The reasoning is that therapists are particularly vulnerable because empathic engagement intensifies vicarious trauma leading to pervasive and enduring alterations in cognitive schema that affects the worker’s frame of reference (Schauben & Frazier, 1995). Whether these changes are destructive depends on how much the therapist is able to engage in his/her own process of integration and transformation of clients’ horrific traumatic material (Harrison and Westwood, 2009).
In her book Trauma and Recovery, Herman (1992, p.140) states, “trauma is contagious…When a [support person] experiences, to a lesser degree, similar terror, rage and despair as the victim, the phenomenon of traumatic counter transference or vicarious traumatic counter-transference or vicarious traumatisation occurs.” In other words, anyone who cares for a person who is traumatised is vulnerable and can suffer from the same symptoms as the person being helped.
The Effects of Vicarious Trauma
McCann and Pearlman (1990) argue that exposure such as hearing a person’s material about a trauma experience, can eventually alter the listener’s cognitive schemas which mediate their experience of reality. Saakvitne also argues that the self is disrupted so negatively that it affects “self-capacity, frame of reference, realms of perception, memory, basic beliefs and psychological needs” (2002, p.447). Essentially five areas are particularly susceptible in those supporting traumatised people. These are: safety, trust, esteem, control and intimacy (Pearlman & Saakvitne, 1995; Trippany et al, 2004).
Moreover, vicarious trauma is distinctive in that empathic engagement with clients negatively transforms the therapist’s inner-self as a result of clients’ traumatic material (Pearlman and Saakvitne 1995; Chouliara et al. 2009; Dunkley & Whelan 2006; Van Deusen 2006; Trippany et al. 2004; Sexton 1999). Vicarious trauma also invades the counsellor’s family, social, professional and spiritual life as well as their values and morals in terms of how they view others (Adams & Riggs, 2008).
In the words of McCann and Pearlman (1990):
“…It is our belief that all therapists working with trauma survivors will experience lasting alterations in their cognitive schemas, having a significant impact on the therapist’s feelings, relationships, and life” (p.136).
Other effects of vicarious trauma include transforming the counsellor’s identity, worldview and spirituality, as these are the basis upon which therapists view, experience and make sense of their worlds (Baird & Kracen, 2006; Eidelson, D’Alessio & Eidelson, 2003). According to Neumann and Gamble (1995, p.334), counsellors may start to view their worlds through a “trauma lens”, which may lead to numbness, disconnection and withdrawal from other people (Dunkley & Whelan 2006a). Rothschild (2006) suggests that counsellors defend or protect themselves from strong distressing emotions by dissociating from body senses and becoming more cognitive - thinking rather than feeling when confronted by distressing emotion. At times, a therapist may even question their own competence and the reason for their choice of profession (Herbert & Wetmore 2008; Herman 2001).
Vicarious trauma can lead to the counsellor grieving for the loss of their old world and, as part of the bereavement process, the therapist can have feelings of sadness, anger and bewilderment. They may develop issues of trust and question the safety of others as well as becoming suspicious of those people who they would otherwise have trusted and they may become cynical (Canfield 2005; Neumann & Gamble 1995; McCann & Pearlman 1990).
According to Brady et al (1999) and Sexton (1999), counsellors who are spiritual are not spared, and may be particularly vulnerable. They may find that they become despondent as their hope, creativity, compassion and ability to love become affected so that they feel isolated, disconnected, pessimistic, experience inappropriate anger, insecurity, cynicism, relational difficulties, emotional and/or physical withdrawal from society (Harrison & Westwood 2009; Herman 2001). Etherington (2000) theorised that a consequence of a therapist’s loss of spiritual conviction may lead to them doubting whether they now have compassion, putting tremendous strain on their spiritual core and purpose in life as well as the possibility of becoming faithless (Canfield, 2005), which can lead to a feeling of emptiness from the loss of spirit and meaning in their lives (Meyer and Ponton, 2006). A possible consequence, as Canfield (2005) asserts, is that clients who bring traumatic material may cause counsellors to over-identify with them rather than keeping a professional distance.
Symptoms of Vicarious Trauma
As vicarious trauma affects each person differently in a way that is “unique”, the symptoms are therefore varied (Herbert & Wetmore, 2008; Marmaras et al 2003). According to Adams and Riggs (2008), the symptoms are very similar to those of post-traumatic stress disorder - stress, depression, intrusive thoughts/feelings, sadness, avoidance. Pearlman and Saakvitne (1995) described how the intrusions are of “sadistic imagery into the therapist’s own inner life” (p.293). According to Neumann and Gamble (1995, p.344), the defining symptom of vicarious trauma is the “flashing” of disturbing imagery that occurs outside of counselling sessions, which can be distressing for counsellors. Dunkley and Whelan (2006a) noticed that this imagery, re-experiencing the graphic details of the client’s traumas, nightmares and intrusive thoughts, add to the therapist’s state of hyperarousal that leads to persistent anxiety, anger and distress.
At one time or another, many people in any profession will find themselves suffering somatic symptoms, such as nausea, headaches, physical numbness and sleeplessness, and counsellors are not an exception (Adams & Riggs 2008; Neumann & Gamble 1995). However, they may also experience physical sensations similar to those of their clients (Rothschild, 2006), including having vivid dreams and becoming avoidant of situations, places and activities linked to their client’s traumatic events (Sommer 2008). As a result, therapists experiencing vicarious trauma feel exhausted and drained of energy (Herbert and Wetmore 2008). Often the symptoms are not often initially associated with vicarious trauma, making the counsellor even more vulnerable to its effects.
Symptoms of vicarious trauma are not limited to somatic effects, as they can also present in the counsellor’s approach to the clinical work (Meyer and Ponton 2006). For example, the counsellor may engage in rescue attempts or try to control the client, or commit boundary violations; the framework within which the therapeutic alliance occurs with clients may become blurred or crossed. This may confuse the client in terms of the roles and expectations they experience, and it may lead to problems for both the treatment and potential professional liability (Gutheil and Gabbard 1993).The distress reported by psychotherapists working with trauma may be aggravated by fact that almost a third of them experienced childhood trauma (Brady et al 1999; Figley 1995; Kohlenberg et al 2006; Pearlman & Mac Ian 1995; Pope & Feldman-Summers 1992).
Any traumatic experience has the potential to evoke feelings of anxiety, threat, helplessness and stress which could disturb the very foundation of a person’s existence (Kleber et al 1992). During a counselling session with a client who has been traumatised, it is almost impossible for the counsellor to be unaffected by the fact that s/he is a witness of the client's traumatic narrative, as well as the transference-countertransference enactments. For over 20 years, there has been great interest in conceptualising the effects of counsellors' empathic connection with their clients. The secondary traumatic stress counsellors experience causes symptomatic reactions similar to the symptoms of post-traumatic stress disorder in their clients. This can lead to emotional exhaustion called compassion fatigue (Figley, 1995). Eventually, the accumulation of the psychological assaults on the counsellor can lead to distortions of trauma-relevant cognitive schemas concerning control, intimacy, safety, self-esteem and trust - resulting in vicarious traumatisation (McCann and Pearlman 1990; Pearlman and Saakvitne 1995). It is interesting to note that secondary traumatic stress reactions are often linked to the counsellor’s countertransference reactions and are viewed as the effect of the interaction between the client's material and the personal make-up of the therapist. However, the trauma specificity of the counsellor’s reactions to the client’s material is still unclear (Sabin-Farrell and Turpin 2003).
Trauma practitioners are trained to work with psychological trauma and know about the importance of self-care to reduce the possible risk of the negative effects of their work. However, anyone who has a significant relationship with a survivor of trauma may potentially be at risk (Trippany et al 2004). An area of concern is untrained managers in organisations whose staff work in environments with a high risk of exposure to stress and violence. Often it is easy to dismiss the effects of traumatic events on a person's emotional well-being and therefore hold onto the negativity. Holding onto the negativity for long periods of time can result in detrimental effects, as outlined above. An example would be a manager who witnesses and hears about the impacts of trauma on his/her staff, particularly if the manager has to support more than one member of staff being impacted upon by trauma at the same time.
In summary, although the existing empirical literature is sparse and has largely focused on mental health clinicians who treat traumatized clients, there is enough preliminary evidence to suggest that working with traumatized people can have a negative impact on trauma workers in general (McCann & Pearlman 1990). It is noteworthy that vicarious trauma is a normal response to working with traumatised people and is not a result of deficiencies in clinicians (Pearlman 1999; Pearlman & Mac Ian 1995; Pearlman & Saakvitne 1995).
Tanya Dorrell is the Senior Counsellor at Transport for London’s Counselling Service.
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