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Part 1 of this series (presented in the Winter 2008 issue of mental health AIDS) tackled the terminology used to describe how clinicians are thought to be affected by their work with trauma survivors. The earlier tool box also summarized literature on recognizing and alleviating the dangers facing clinicians practicing trauma-related psychotherapy. This concluding segment expands on the current state of qualitative and quantitative research in this area and offers emerging evidence for the positive consequences of this work for clinicians.
Practicing What We Preach?
Bober and Regehr (2006) administered traumatic stress and coping measures to 259 therapists working with victims of interpersonal violence in southern Ontario and found that therapists
who spent more time per week counseling individuals who were victims of trauma reported higher levels of traumatic stress symptoms ... and, in particular, higher levels of intrusion symptoms. ... [It bears noting that] hours per week counseling trauma victims was not associated with maladaptive cognitive schemas[, the hallmark of vicarious traumatization (VT)] ... . However, years of experience was associated with more disruptive beliefs regarding intimacy with others. This suggests that degree of exposure has an impact on intrusion and avoidance symptoms but that altered beliefs do not appear to occur in the short run. ... Personal histories of childhood or adult trauma were not associated with ... [traumatic stress] scores except in individuals who sought treatment, suggesting that those who were distressed and unresolved about personal histories were likely to appropriately seek assistance. (p. 7)
Of great interest were findings related to coping strategies. "Although participants generally believed in the usefulness of recommended coping strategies including leisure activities, self-care activities and supervision, these beliefs did not translate into time devoted to engaging in the activities. Most importantly, there was no association between time devoted to coping strategies and traumatic stress scores" (p. 1).
Bober and Regehr conclude that "it does not appear that engaging in any coping strategy recommended for reducing distress among trauma therapists has an impact on immediate traumatic symptoms" (p. 8). The investigators go on to highlight an intriguing inconsistency in this area of clinical practice:
As mental health professionals dedicated to the fair and compassionate treatment of victims in society, we have been strong in vocalizing concerns that those who are abused and battered not be blamed for their victimization and their subsequent traumatic response. Yet when addressing the distress of colleagues, we have focused on the use of individual coping strategies, implying that those who feel traumatized may not be balancing life and work adequately and may not be making effective use of leisure, self-care, or supervision. ... In light of the findings of this study that the primary predicator of trauma scores is hours per week spent working with traumatized people, the solution seems more structural than individual. That is, organizations must determine ways of distributing workload in order to limit the traumatic exposure of any one worker. This may not only serve to reduce the impact of immediate symptoms but may also address the potential longitudinal effects of disrupted beliefs regarding intimacy. ... [I]t is perhaps time that vicarious and secondary trauma intervention efforts with therapists shift from education to advocacy for improved and safer working conditions. (p. 8; see sidebar)
Cloudy, Chance of Showers
Research studies on VT and secondary traumatic stress (STS) have been reviewed and synthesized by a number of investigators in recent years (e.g., Baird & Kracen, 2006; Canfield, 2005; Dunkley & Whelan, 2006; Sabin-Farrell & Turpin, 2003). The most comprehensive synthesis to date was conducted by Sabin-Farrell and Turpin (2003), who reviewed journal articles, peer-reviewed e-journals, and book chapters in their attempt "to disentangle VT and its proposed PTSD [posttraumatic stress disorder] symptoms from alternative explanations involving normal distress to trauma and occupational stress arising within the workplace" (p. 452).
In their comparison of quantitative and qualitative studies, Sabin-Farrell and Turpin conclude that
the evidence to support the concepts of VT and secondary trauma is meager and inconsistent, relying on small and variable correlations between symptomatic distress and trauma exposure. The relationship between exposure and altered cognitions and beliefs is even less robust. These quantitative findings starkly contrast with the certainty and conviction of those who write about the effects of working with trauma. Nevertheless, the findings from qualitative studies provide more support for the definition and suggested effects of VT than [do] the quantitative studies. There are clearly a number of important difficulties surrounding the research methods, instruments, and selection of participants within the studies of VT, which may be largely responsible for the inconsistency in the results. (p. 467)
Sabin-Farrell and Turpin further discern from research studies that
a number of factors may contribute to PTSD and other symptoms in staff who work with traumatized clients. These may be both personal and work related, and perhaps interact with each other. This is suggested by the weak correlations and the fact that multiple regression models only predict small percentages of the variance. It is also difficult to distinguish how much of the reported symptoms of distress could be attributed to the stressful nature of the job as opposed to being specifically related to working with traumatized clients. (p. 468)
Additionally, "the evidence suggests that some workers experience disrupted beliefs and cognitions associated with their work, but this may interact with their own history of trauma and other personal and work-related factors. Although the disruption in cognitions is a central part of the definition and theory of VT ..., the evidence for this is unclear, and where evidence for a disruption in beliefs has been found, it is possible that this may relate to or interact with factors other than the trauma work itself" (p. 469). Because "[t]he research related to beliefs ... is inconsistent and inconclusive[,] ... evidence for lasting changes is neither supported nor unsupported" (p. 472).
To summarize, Sabin-Farrell and Turpin conclude that
[t]he evidence for VT in trauma workers is inconsistent and ambiguous. There may be some workers for whom the work is traumatizing and causes PTSD symptoms, more general symptomatic distress, and disruptions in beliefs and schemas. There appears to be more consistent evidence for symptomatic responses, particularly intrusive symptoms, than for cognitive effects. It is also unclear what the associated factors are, and how they interact with each other. Personal history of trauma may be a key factor in interacting with trauma work, but the effect of this is still uncertain. It is also possible that some workers are already utilizing good coping strategies which inhibit the impact of this work and this is likely to influence the results of research in this area. There were also positive effects of trauma work, which were identified by some of the qualitative studies, and it is possible that these factors may also balance the negative impacts of the work. Further research needs to be carried out to investigate these factors and their interactions in more detail, and to assess further whether work with trauma clients affects workers specifically over and above what could be considered to be effects of the stressful nature of mental health work. (pp. 472-473)
Additionally, "the methodological rigor within this area would be considerably improved by attending to the construct validity of VT and its measurement, issues of sampling, and the use of prospective designs. ... [Also, t]o date, the extent of this risk for staff working within the general health care system is not yet known. Previous research has been carried out with staff working solely with trauma, and the effects of working with trauma as part of a more varied caseload have not yet been studied" (p. 475).
Accentuate the Positive
As Sabin-Farrell and Turpin point out, although research has focused largely on risks to clinicians conducting trauma-related psychotherapy, emerging evidence for the positive consequences of this work has also been noted.
In an exploratory study, Arnold, Calhoun, Tedeschi, and Cann (2005) interviewed 21 clinicians with diverse caseloads (i.e., not working exclusively with trauma survivors) to explore the impact of trauma-related work. The findings
confirm the existence of many negative sequelae; all ... 21 clinicians ... said that they had experienced some sort of negative response to trauma-related work, including intrusive thoughts and images of clients' trauma; emotional responses such as sadness, anger, fear, and countertransferential avoidance; physical exhaustion or pain; and concerns about their effectiveness as therapists. ... In addition to describing negative consequences, however, all of the clinicians in this sample reported that their work with trauma survivors had led to the experience of positive outcomes. A clear majority of these clinicians (16 of the 21 therapists, or 76% of the sample) spontaneously mentioned some sort of positive consequence in their responses to the interviewer's neutral, open-ended lead question about how they had been affected by their work with trauma survivors. ... Many therapists reported that their work with trauma survivors had changed their lives in profound and positive ways, a finding that suggests that the potential benefits of trauma work – vicarious posttraumatic growth, if you will – may be significantly more powerful and far-reaching than the existing literature's scant focus on potential benefits would suggest. (pp. 255-256)
Arnold and colleagues observe that "[t]hese perceptions of growth following therapists' vicarious brushes with clients' trauma are remarkably similar in content to those described by individuals who have experienced trauma directly; in fact, all three major categories of posttraumatic growth outcomes1 – positive changes in self-perception, interpersonal relationships, and philosophy of life ... – were reported by the clinicians who were interviewed for this study" (p. 257). Moreover, "certain kinds of vicarious posttraumatic growth – for example, the spiritually broadening effects of accompanying clients on spiritual paths radically different from one's own – would seem to be uniquely linked to the therapeutic role" (p. 260).
Although they recognize that "it would be inappropriate to extrapolate the experience of the clinicians interviewed in this study beyond this sample," (p. 259), Arnold and colleagues suggest that "[a]dopting a more inclusive, less pathologizing conceptualization ... of trauma work – as an endeavor that holds the promise of life-affirming benefits as well as sadness and pain – might help clinicians to view themselves, their clients, and the work in new and empowering ways" (p. 260).
Similarly, Hernández, Gangsei, and Engstrom (2007) propose a new concept – vicarious resilience (VR) – on the basis of interviews with 12 psychotherapists working with victims and families of victims of political violence in Bogotá, Columbia. This concept "draws on a synthesis of several different areas of clinical theory, research, and practice. The first relates to the vicarious impact of trauma survivors' stories and experiences on the professionals who work with them. This phenomenon has been analyzed primarily through the concepts of ... [VT, STS,] and compassion fatigue ... . The second relates to resilience, exploring the way in which trauma survivors access adaptive processes and coping mechanisms to survive and even thrive in the face of adversity ..." (p. 229).
The themes emerging from this qualitative study indicate ... that therapists who work in extremely traumatic social contexts learn about coping with adversity from their clients, that their work does have a positive effect on the therapists, and that this effect can be strengthened by bringing conscious attention to it. ... VR ... is characterized by a unique and positive effect that transforms therapists in response to client trauma survivors' own resiliency. In other words, it refers to the transformations in the therapists' inner experience resulting from empathic engagement with the client's trauma material. VR may be a unique consequence of trauma work. ... [Hernández and colleagues] argue that this process is a common and natural phenomenon illuminating further the complex potential of therapeutic work both to fatigue and to heal. (p. 237)
As Hernández and colleagues see it,
a complex array of elements contribut[es] ... to the empowerment of therapists through interaction with clients' stories of resilience. These elements are witnessing and reflecting on human beings' immense capacity to heal; reassessing the significance of the therapists' own problems; incorporating spirituality as a valuable dimension in treatment; developing hope and commitment; articulating personal and professional positions regarding political violence; articulating frameworks for healing; developing tolerance to frustration; developing time, setting, and intervention boundaries that fit therapeutic interventions in context; using community interventions; and developing the use of self in therapy. Awareness of the phenomenon and component elements of VR and introducing the concept into the professional vocabulary can guide therapists in strengthening themselves and their work. (p. 238)
---- Compiled by Abraham Feingold, Psy.D.
References
Arnold, D., Calhoun, L.G., Tedeschi, R., & Cann, A. (2005). Vicarious posttraumatic growth in psychotherapy. Journal of Humanistic Psychology, 45(2), 239-263.
Baird, K., & Kracen, A.C. (2006). Vicarious traumatization and secondary traumatic stress: A research synthesis. Counselling Psychology Quarterly, 19(2), 181-188.
Bober, T., & Regehr, C. (2006). Strategies for reducing secondary or vicarious trauma: Do they work? Brief Treatment & Crisis Intervention, 6(1), 1-9.
Canfield, J. (2005). Secondary traumatization, burnout, and vicarious traumatization: A review of the literature as it relates to therapists who treat trauma. Smith College Studies in Social Work, 75(2), 81-101.
Dunkley, J., & Whelan, T.A. (2006). Vicarious traumatisation: Current status and future directions. British Journal of Guidance & Counselling, 34(1), 107-116.
Hernández, P., Gangsei, D., & Engstrom, D. (2007). Vicarious resilience: A new concept in work with those who survive trauma. Family Process, 46(2), 229-241.
Sabin-Farrell, R., & Turpin, G. (2003). Vicarious traumatization: Implications for the mental health of health workers? Clinical Psychology Review, 23(3), 449-480.
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Kicking More of It Upstairs
Bell, Kulkarni, and Dalton (2003) drew from multiple sources to offer a number of prevention and intervention strategies that merit consideration as an agency's administrative response to the vicarious traumatization of its workers. Four areas – organizational culture, workload, work environment, and education – of the seven identified by Bell and colleagues were discussed in the Winter 2008 issue of mental health AIDS. The three remaining areas – group support, supervision, and resources for self-care – are briefly discussed here:
- Group support – Both the burnout literature and the writings about vicarious trauma emphasize the importance of social support within the organization ... . Staff opportunities to debrief informally and process traumatic material with supervisors and peers are helpful ... . Critical incident stress debriefing ... is a more formalized method for processing specific traumatic events but may be less helpful in managing repetitive or chronic traumatic material ... . Support can also take the form of coworkers' help with paperwork or emergency backup. Time for social interaction between coworkers, such as celebrating birthdays ... as well as organized team-building activities and staff retreats, can increase workers' feeling of group cohesion and mutual support.
Peer support groups may help because peers can often clarify colleagues' insights, listen for and correct cognitive distortions, offer perspective/reframing, and relate to the emotional state of the ... worker ... . Group support can take a variety of forms, such as consultation, treatment teams, case conferences, or clinical seminars, and can be either peer led or professionally led. ...
Regardless of the form group support takes, ... it should be considered an adjunct to, not a substitute for, self-care or clinical supervision. (pp. 467-468)
- Supervision – Effective supervision is an essential component of the prevention and healing of vicarious trauma. Responsible supervision creates a relationship in which the ... worker feels safe in expressing fears, concerns, and inadequacies ... . Organizations with a weekly group supervision format establish a venue in which traumatic material and the subsequent personal effect may be processed and normalized as part of the work of the organization. ...
In addition to providing emotional support, supervisors can also teach staff about vicarious trauma in a way that is supportive, respectful, and sensitive to its effects ... . If at all possible, supervision and evaluation should be separate functions in an organization because a concern about evaluation might make a worker reluctant to bring up issues in his or her work with clients that might be signals of vicarious trauma. ... In situations where ... supervisory and evaluative functions [cannot be separated], agency administrators might consider contracting with an outside consultant for trauma-specific supervision on either an individual or group basis. The cost of such preventive consultation might be well worth the cost savings that would result from decreased employee turnover or ineffectiveness as a result of vicarious trauma. (p. 468)
- Resources for self-care – Agencies can make counseling resources available for all staff that interact with traumatic material ... . If there are many employees encountering the same type of trauma in the agency or within the larger community, agencies may consider the feasibility of forming a peer support group, as discussed earlier. Workers also need health insurance that provides mental health coverage ... .
... [I]n addition to providing resources for therapy, organizations should provide opportunities for structured stress management and physical activities. Organizations with limited resources might consider exchanging training on areas of expertise with other agencies that have experts in stress management. ... [S]ending one staff member to a conference or workshop to learn stress management techniques and then asking that person to present what he or she learned to coworkers is a cost-effective way to circulate this information through an organization. Organizing something as simple as a walking or meditation group during the lunch hour or after work might also contribute to staff wellness at no cost. (p. 468)
Reference
Bell, H., Kulkarni, S., & Dalton, L. (2003). Organizational prevention of vicarious trauma. Families in Society, 84(4), 463-470.
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1 For more information on posttraumatic growth among people living with and affected by HIV/AIDS, go to the Tool Box entitled "From Surviving to Thriving: HIV-Associated Posttraumatic Growth" in the Winter 2007 issue of mental health AIDS.
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Spring 2008 Newsletter / Volume 9, Issue 3
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