Motivation and emotion/Book/2016/Vicarious trauma effects on the emotionality of mental health workers

Overview
Case study

Sasha is a 26-year-old female social worker who works at a domestic violence crisis centre. Every day, Sasha works primarily with women escaping severe domestic violence from their partners, many of whom have young children. These women and children are powerless and have had their trust abused by loved ones.

Lately, Sasha has been feeling depressed, irritable and exhausted. She has been having trouble falling asleep and when she does, Sasha experiences vivid nightmares about her loved ones assaulting her. Sasha finds these images infiltrating her mind when she is awake as well. She no longer feels safe around males, even those she has positive relationships with.

Because she is so tired, Sasha has not been enjoying her work and even feels slightly resentful towards her clients for requiring so much assistance. She worries this may be impacting her ability to work as a clinician and is considering resigning from her role.

The suffering of psychological trauma often draws people to seek psychological support and, as such, mental health workers (psychiatrists, psychologists, counsellors, nurses, social workers, occupational therapists) across virtually all settings encounter survivors of trauma (Trippany, White Kress, & Wilcoxon, 2004). Traumas that clients often present with include childhood sexual abuse, physical and sexual assault, environmental disasters and domestic violence (James & Gilliland, 2001). As a result of repeatedly listening to the traumatic narratives of clients, many of which entail details of abuse of trust and powerlessness, engaging in trauma therapy can often cause significant distress to mental health workers (Chouliara, Hutchison, & Karatzias, 2009). Due to this, the term vicarious traumatisation was developed to describe the emotional and cognitive changes that therapists undergo when dealing with predominantly traumatised clients (McCann & Pearlman, 1990).



Vicarious trauma refers to the pervasive changes in core aspects of the mental health worker’s self and the harmful effects such changes result in. Areas affected include the way therapists see the world, interpersonal relationships, spirituality, and themselves (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995; Way, VanDeuson, Martin, Applegate, & Jandle, 2004).

Profound changes in cognitive schemas are a significant element of vicarious trauma, with disruptions to the worker’s schemas associated with trust, intimacy, safety, power, and control often experienced (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). For example, a therapist who holds the belief that the world is an orderly place may have this notion challenged through the narratives that are relayed to them by their client who is a survivor of a heinous assault (Baird & Kracen, 2006).

Further, similarities to Post Traumatic Stress Disorder (PTSD) are often seen in symptoms of vicarious trauma, including intrusive imagery, nightmares, irritability, emotional numbing, avoidance of certain stimuli, increased fear for oneself, and loved ones and difficulty listening to the client's narratives ( Bober & Regehr, 2005; Illife & Steed, 2000; Ortlepp & Friedman, 2002; Regehr & Cadell, 1999; Schauben & Frazier, 1995).

Lead researchers in the field of vicarious trauma, Pearlman and Saakvitne (1995a) believed this construct to be an inevitable experience for all trauma therapists, to some degree, at some stage in their career. According to Pearlman and Saakvitne (1995a), vicarious trauma includes the following:
 * The therapist experiencing similar symptoms to their client, including depression, anxiety, or symptoms of PTSD.
 * Disruption to the therapist's schemas surrounding safety, control, predictability, and attachment.
 * The therapist at times playing the role of a helpless victim to a client's self-destructive or suicidal behaviour.
 * Vicarious trauma manifesting into feelings of cynicism, despair, and hopelessness in the therapist.

Burnout, countertransference, secondary trauma


Vicarious trauma, burnout, countertranference, and secondary trauma (also known as compassion fatigue) all offer explanations as to how mental health workers are affected by their emotionally demanding work (Kadambi & Truscott, 2004). While these terms overlap in many ways, they are not to be used interchangeably. Burnout refers to emotional exhaustion experienced by professionals in a caring role as a result of numerous work related stressors (Figley, 1999; Pearlman & Saakvitne, 1995; Sexton, 1999). Countertransference refers to the feelings, conscious or unconscious, that the mental health worker experiences as a direct result of working with their client (Figley, 1999; Pearlman & Saakvitne, 1995; Wilson & Lindy, 1994). Burnout and countertransference differ to vicarious trauma in the way that they can occur across different settings and with many different clients; whereas vicarious trauma is trauma work specific. Moreover, both burnout and countertransference tend to be a short-term issue that mental health workers contend with, whereas vicarious trauma leads to long-term changes in the individual's way of thinking and living (Cohen & Collens, 2013). Lastly, on a personal level, neither burnout or countertransference leads to long lasting changes in the worker's core beliefs, nor do they cause intrusive imagery or concerns surrounding the individual's safety, whereas vicarious trauma does (Rosenbloom, Pratt, & Pearlman, 1995). Despite these differences, burnout and countertransference share similarities with vicarious trauma. Significantly, all three constructs can lead to a decrease in concern for the therapist's clients, which ultimately leads to a decline in the quality of care provided to the client (Raquepaw & Miller, 1989).

Secondary trauma refers to the sudden unpleasant reaction mental health workers can experience when working with trauma survivors (Jenkins & Baird, 2002). The symptoms are nearly identical to those of PTSD, with the key difference being that PTSD is acquired through direct exposure to a traumatic event, whereas secondary trauma is acquired through exposure to the person suffering the effects of a trauma (Baird & Kracen, 2006; Jenkins & Baird, 2002). Three domains of secondary trauma have been defined by Figley (1995a):
 * 1) Re-experiencing of the traumatic event originally experienced by the primary survivor.
 * 2) Avoidance of reminders and/or emotional numbing in response to reminders encountered.
 * 3) Persistent arousal.

Vicarious trauma and secondary trauma share several similarities due to the fact that they both occur as a result of engaging with trauma survivors in a therapeutic context; however they are believed to differ in several domains:
 * 1) Focus on symptomatology versus theory - secondary trauma focuses on the rapid onset of PTSD like symptoms; vicarious trauma concentrates on theoretical underpinnings of constructivist self-developmental theory (Jenkins & Baird, 2002).
 * 2) Nature of symptoms - more attention to the tangible symptoms and aetiology of PTSD is given in secondary trauma; vicarious trauma tends to focus on the covert changes in core beliefs (McCann & Pearlman, 1990a, Pearlman & Saakvitne,1995b; Pearlman & Saakvitne, 1995).
 * 3) Relevant populations - secondary trauma can be applied to professionals such as police officers, lawyers and nurses (Figley, 1995b), whereas vicarious trauma can only be applied to mental health professionals (Pearlman & Saakvitne, 1995).
 * 4) Critical amount of exposure to trauma clients - vicarious trauma is believed to result from increased exposure to traumatised clients over time (McCann & Pearlman; 1990a)

It is important to note that burnout, countertransference, secondary trauma, and vicarious trauma are all capable of interacting with each other (Pearlman & Saakvitne, 1995). For example, when a mental health worker is experiencing vicarious trauma, they may be experiencing symptoms nearly identical to those of PTSD. Further, they may also be experiencing conscious or unconscious feelings towards a client as a result of being so empathically engaged, and an accumulation of all these experiences may lead the worker to feel emotionally exhausted or burnt out.

Causes of vicarious trauma
Not every mental health worker who works with traumatised clients will develop vicarious trauma. It is important to look at variables that may affect a clinician's level of vulnerability to experiencing these symptoms.

Empathic engagement
The phenomenon of vicarious trauma is based on the notion that if mental health workers overly engage empathically with their clients, they themselves will begin to experience symptoms of trauma (Pearlman & Mac Ian, 1995). For example, listening to an explicit narrative of a traumatic event may cause the listener (therapist) to empathise strongly with the victim and in turn cause them to experience the same emotions as the client. This experience may result in the therapist developing an internal picture of the event in their own mind, which may become quite intrusive and distressing, a common feature of vicarious trauma (Steed & Downing, 1998).

Caseload
Research has shown that the longer mental health workers spend with traumatised clients and the greater their caseload, the greater at risk they are for developing vicarious trauma (Pearlman & Mac Ian, 1995).

Individual factors
There are a number of individual factors that may effect a mental health worker's likelihood of experiencing vicarious traumatisation:

History of trauma
A history of personally experienced trauma, particularly childhood abuse, has been found to be a significant predictor in clinicians developing vicarious trauma (Lerias & Bryne, 2003).

Mental health
Poor general mental health has been found to result in poor psychological adjustment in being indirectly exposed to trauma (Van der Kolk, McFarlane & Weisaeth, 1996), and mental health symptoms (such as anxiety) are often exacerbated when vicarious trauma is experienced (Lerias & Bryne, 2003).

Social support
Social support is considered a critical variable in predicting how an individual will respond to exposure to trauma (Lerias & Bryne, 2003). One study found that social support was a significant determinant for predicting how psychologists would adjust after being exposed to violent traumatic events when working in an international relief setting (Eriksson, Vande Kemp, Gorsuch, Hoke, & Foy, 2001).

Experience
In a study by Way, VanDeusen, Martin, Applegate, & Jandle (2004), it was found that newer mental health workers who had been providing treatment for survivors of sexual abuse reported higher levels of vicarious trauma than those who had been in the field for longer. Additionally, research has shown that younger clinicians report higher numbers of physical symptoms and intrusive imagery than their older counterparts (Adams, Matto, & Harrington, 2001). This is hypothesised to be due to older mental health professionals having more life experience, thus being better able to deal with the stressors associated with trauma work (Marmar Weiss, Metzler, & Delucchi, 1996).

Coping mechanisms
Everyone copes with exposure to trauma in a different way. Negative coping behaviours are those that are intended to decrease feelings of distress, but actually end up exacerbating the individual’s levels of distress (Steed & Downing, 1998). Examples of negative coping strategies include abusing alcohol, negative self talk, self blame (Steed & Downing, 1998), and engaging in avoidance behaviours (Pearlman & Saakvitne, 1995).

Constructivist self-development theory
The constructivist self-development theory (CSDT) suggests that individual's realities are constructed through the development of cognitive schemas or perceptions, and changes in these schemas or personal realities can occur as a result of working with traumatised clients (McCann & Pearlman, 1992; Pearlman & Saakvitne, 1995a; Saakvitne & Pearlman, 1996). CSDT argues that irrational perceptions are developed to protect the self from emotionally traumatic experiences, and that these changes in the clinician’s schemas can be pervasive (e.g. can affect every area of the clinician’s life), and cumulative (e.g. can be potentially permanent because every client with a trauma history can reinforce these changes in the clinician’s schemas) (McCann & Pearlman, 1990; Trippany et al., 2004).

According to CSDT, there are five components of the self and how the self and an individual’s reality is developed. These components reflect the areas which become distorted when an individual is affected by vicarious trauma (Pearlman & Saakvitne, 1995a):
 * Frame of reference
 * Self-capacities
 * Ego resources
 * Psychological needs
 * Cognitive schemas, memory, and perception.

Frame of reference
A frame of reference is an individual's framework for understanding and viewing themselves and the world around them  (Pearlman & Saakvitne, 1995b). Any disruptions to the clinician’s frame of reference can create a rupture in the therapeutic relationship (Trippany et al., 2004). For example, the therapist may come to believe that it is the client’s fault they were abused, so that their experience does not dispute the therapist’s frame of reference.

Self-capacities
The self-capacity component allows individuals to manage emotions and feelings regarding themselves and others (Pearlman & Saakvitne, 1995a). As a result of vicarious trauma, when a mental health worker’s self-capacity is tarnished, it often results in loss of identity, interpersonal difficulties, difficulties controlling negative emotions,  avoidance of exposure to triggering media, and feelings of being unable to meet the needs of loved ones (Trippany et al., 2004).

Ego resources
Ego resources help individuals meet psychological needs and relate to others interpersonally (Pearlman & Saakvitne, 1995a). These include the ability to conceive consequences, the ability to set boundaries, and the ability to self-protect (Trippany et al., 2004). When vicarious trauma disrupts ego resources, mental health workers may experience issues surrounding perfectionism and overextension at work, as well as experiencing an inability to empathically engage with clients (Trippany et al., 2004).

Psychological needs and cognitive schemas
These components comprise of basic psychological needs an individual has, as well as how individuals process information in relation to these needs in developing schemas regarding themselves and others (Pearlman & Saakvitne, 1995a).

Safety needs
Cumulative work with trauma survivors can disrupt one's sense of security. Therapists experiencing vicarious trauma can experience higher levels of fearfulness and vulnerability, which may cause them to be overly cautious regarding their own or their loved one's safety (e.g., they may take self-defence classes, they may now allow their children to ride the bus to school anymore) (Pearlman, 1995; Trippany et al., 2004).

Trust needs
Trust needs encompass an individual's ability to trust their own perceptions and beliefs, as well as others to meet their emotional, physical and psychological needs (Trippany et al., 2004). Repeated work with traumatised clients can disturb this trust. For example, working with female clients who have predominantly been abused by older males may lead to a clinician regarding this particular class of people as untrustworthy. Further, clinicians constantly exposed to trauma clients may experience disruption in their trust in themselves; a therapist may begin to question their ability to work effectively with traumatised clients (Trippany et al., 2004).

Esteem needs
Esteem needs reflect value for self and value for others (Pearlman, 1995). Experiencing vicarious trauma can lead to clinicians feeling inadequate in themselves, and questioning their clinical abilities in working with clients (Trippany et al., 2004).

Intimacy needs
Intimacy needs are characterised as the need to feel connected to those around us (Pearlman & Saakvitne, 1995a). Experiences of vicarious trauma can cause disturbances in intimacy needs, which can present in ways such as feeling empty when alone, difficulty in spending time alone, and avoidance and withdrawal from loved ones (Trippany et al., 2004).

Consequences of vicarious trauma
The degree to which vicarious traumatisation can impair a clinician’s functioning varies in severity among individuals. These consequences can occur on both a professional and personal level (Trippany et al., 2004).

Professional
A mental health worker’s ability to manage their affective reactions to disclosures of traumatic experiences is imperative in providing effective treatment to trauma survivors (Knight, 1997). Cognitive schemas disruptions (caused by vicarious trauma) may lead to boundary violations or a decline in treatment, for example forgetting appointments, double-booking appointments, unreturned phone calls or emails, or even abuse towards clients (Trippany et al., 2004). Moreover, therapists being unable to manage their affective reactions to disclosure may avoid discussion of traumatic material with clients, or push the client to divulge information (such a name of the perpetrator) before they are ready (Trippany et al., 2004).

Pearlman and Saakvitne (1995) suggested that a significant ethical concern surrounding vicarious trauma is the effect it has on the clinician’s capacity to work with trauma survivors. This loss of ability, perceived or real, can result in loss of energy, optimism and commitment (Sexton, 1999), and in turn may cause clinicians to discontinue their work in the industry (Figley, 1999).

Personal
Hearing repeated reports of horrific sexual abuse can cause therapists to experience a heightened awareness to their own vulnerability (Steele, 1989). This vulnerability, in addition to a sense of helplessness in being unable to change one’s traumatic past, can be shattering to a clinician’s identity (Pearlman & Saakvitne, 1995b). In one study, feelings of being overwhelmed by their work and increased vulnerability in personal relationships were the most common issues that clinicians working with sexual abuse victims reported (Knight, 1997). Other common reactions to their client’s experiences were sadness, anger, horror, and fantasies of “rescuing” their clients from their pain (Knight, 1997). Sexton (1999) reported a range of negative emotions experienced by victims of vicarious traumatisation, including sadness, rage, fear, grief, anxiety, shame, horror, and confusion; which are often accompanied with nightmares, physical complaints, sleeplessness, agitation and drowsiness.

Clinicians who treat survivors are seen to experience increased cynicism, depressed mood, lack of encouragement, disruptions in sexuality, and increased substance use (Rich, 1997). Saakvitne and Pearlman (1996) found that vicarious trauma can have a significant impact on how mental health professionals relate to friends and loved ones. They found that feelings of guilt and intrusive imagery interfered with counsellor’s ability to be intimate.

Posttraumatic Growth
Not all people who are indirectly exposed to trauma react negatively, in fact, some people cope well or even report positive outcomes (Brady, Guy, Poelstra, & Brokaw, 1999; Eidelson, D’Alessio, & Eidelson, 2003; Steed & Downing, 1998). Posttraumatic growth refers to a significant positive change that occurs as a result of exposure to trauma (Tedeschi & Calhoun, 1995; Tedeschi, Calhoun, & Cann, 2007).

The theory behind this phenomenon is that trauma challenges an individual schemas, and as a result triggers cognitive processes which can result in either no change to previous schemas (assimilation), positive changes to previous schemas (positive accommodation), or negative changes to previous schemas (negative accommodation) (Joseph & Linley, 2008; Tedeschi & Calhoun, 1995, 2004; Cohen & Collens, 2013.) Positive accommodation results in posttraumatic growth, which can be seen in positive changes in perceptions to the self and world (e.g., developing the belief that humanity is resilient) (Joseph & Linley, 2008, Cohen & Collens, 2013).

 Unaddressed vicarious traumatisation, manifest in cynicism and despair, results in a loss to society of that hope and the positive actions it fuels. This loss can be experienced by our clients, as we at times join them in their despair; by our friends and families, as we no longer interject optimism, joy, and love into our shared pursuits; and in larger systems in which we were once active as change agents, and which we may now leave, or withdraw from emotionally in a state of disillusionment and resignation (Pearlman & Saakvitne, 1995, p. 33)

Preventing vicarious trauma
Being aware of the risk of vicarious trauma may itself help prevent oneself from experiencing it. However there are many factors that mental health professionals need to take into consideration to decrease their risk of developing vicarious trauma.

Caseload
Mental health professionals with a heavy caseload have been shown to have an increased vulnerability to vicarious trauma, as this can lead to reduction in coping resources, tension between family and professional responsibilities, and a depletion in feelings of professional self-efficacy (Finklestein, Stein, Greene, Bronstein, & Solomon, 2015). A study by Trippany, Wilxocon, and Satcher (2003) found that sexual abuse counsellors who reported an average of 14 to 15 clients per week did not show statistically significant experiences of vicarious trauma, indicating that management of caseloads may minimise potential vicarious trauma risk.

Supervision
Supervision between peers serves as a sharing experience of vicarious trauma between mental health workers, which offers social support and normalises the experience (Trippany et al., 2004). This normalisation diminishes the impact of vicarious trauma, resulting in a minimalisation in cognitive distortions, thus helping clinicians maintain objectivity (Trippany et al., 2004). Supervision is helpful in providing the clinician with validation and support, venting their feelings (Oliveri & Waterman, 1993), offers support in dealing with the aftereffects of trauma work (Dyregrov & Mitchell, 1992), decreases feelings of isolation, increases empathy and compassion (Lyon, 1993), decreases issues of countertransference, and reaffirms a clinician’s confidence in their clinical skills (Pearlman & Saakvitne, 1995b).

A study conducted by Finklestein et al. (2015) examined vicarious trauma in mental health professionals working in communities exposed to high levels of trauma from rocket attacks from the Gaza Strip. They found that professional support, including workshops, debriefing sessions, and manager supervision, moderated the relationship between exposure and distress, and, in some cases, lead to working in such an area to be an empowering and rewarding experience (Finklestein et al., 2015).

Organisational responsibility
It has been recommended that organisations implement case consultations for staff, in which clinicians can share difficult cases with fellow colleagues and source advice and support (Catherall, 1999; Fontes, 1995). Trippany et al. (2004) suggested the following professional development resources should be made available for mental health workers by their organisations: Further, Pearlman and Saakvitne (1995b) suggested that the following employee benefits could minimise the impact of vicarious trauma:
 * opportunities for supervision
 * consultation
 * staffing
 * continuing education.
 * insurance for personal counselling
 * paid vacations
 * limiting the amount of trauma survivors for each clinician’s caseload.

Training
Way et al. (2004) suggested that specialised training targeting the potential risks of doing trauma work is important to protect new clinicians in the trauma field. They further suggested that organisations should provide ongoing staff training regarding vicarious trauma and self-care techniques. Research by Finklestein et al. (2015) found education to be a strong predictive variable for vicarious trauma, and consequently stressed the importance of post graduate training, specifically for working with trauma survivors, to prepare social workers. One study found that an overwhelming 96% of mental health workers reported that education regarding sexual abuse was essential to effective coping with difficult trauma survivors (Follette, Polusny, & Milbeck, 1994).

Self-care


Socialising with friends and family, engaging in hobbies, and being physically active help preserve a sense of self and hence are all important in preventing vicarious trauma (Pearlman, 1995; Trippany et al., 2004). Going on holidays and spending leisurely time with loved ones has a restorative nature and therefore is successful in counteracting the effects of vicarious trauma (Pearlman, 1995). Also, as vicarious trauma can cause such a disruption in an individual’s sense of trust and interpersonal relationships, maintaining strong social support networks is imperative (Trippany et al., 2004). Activities such as journaling, meditation, and engaging in personal therapy can be helpful in managing the clinician’s emotions (Trippany et al., 2004).

Conclusion
Working in a profession in which one listens to accounts of abuse, horror, extreme loss, and human cruelty on a regular basis can create pervasive changes in a person (Sexton, 1999). Vicarious trauma changes how a clinician sees themselves and the world around them. Vicarious trauma has the potential to disrupt a clinician’s sense of safety, interpersonal relationships, and professional ability. Due to these severe consequences, organisations and mental health workers themselves need to take precaution in order to minimise the risk of the development of vicarious traumatisation. Agencies need to ensure they limit their clinician’s caseloads, provide regular supervision, and offer and encourage training and education regarding trauma work. Clinicians should implement self-care strategies regularly, such as taking holidays, spending leisurely time with loved ones, and engaging in relaxing activities such as meditation and journaling.