What are mental health professionals’ experiences of vicarious trauma when working with trauma clients?

Increasingly over the past few decades, there has been a wealth of research focused on examining the effects that trauma work has on those who are working with traumatized individuals (e.g. Baird & Kracen 2006; Chouliara, Hutchison & Karatzias, 2009; Cohen & Collens, 2013; Crumpei & Dafinoiu, 2012a, 2012b; Finklestein, Stein, Greene, Bronstein, & Solomon, 2015; Hutchison & Karatzias, 2009; Ivicic & Motta, 2017; Pack, 2013; Voss, Holohan, Didion & Vance, 2011; Wang, Strosky & Fletes, 2014).  Vicarious Trauma (VT) is extensively recognised as a concept in the field of psychotherapy, with a general acceptance that working with traumatized individuals can lead to negative impacts on the psychological health and well-being of mental health professionals (MHP); (Cohen & Collens, 2013).  However, the empirical research on this topic has been wrought with challenges (Devilly, Wright, & Varker, 2009) and continues to remain “fragmented, inconsistent, and does not represent a coherent body of work” (Chouliara, Hutchison & Karatzias, 2009; p.48).  Therefore, this report aims to shed light on the following topic: what is the MHP’s experience of vicarious trauma when counselling trauma clients?

VT defined

Research suggests that a unique characteristic of providing psychotherapy to clients is indirect traumatisation and distress to the practitioner themselves (for example, Chouliara, Hutchison, & Karatzias, 2009; Cohen & Collens, 2013; Ivicic & Motta, 2017; Phipps & Mitchell, 2003; Sprang, Clark, & Whitt-Woosley, 2007). This occurrence is termed as vicarious traumatisation (Baird & Kracen, 2006), which has been widely embraced in mental health research and is the centre of the current report.  A complete definition, as proposed by Pearlman and Saakvitne (1995), is offered in the following:

“The inner transformation that occurs in the inner experience of the therapist (or other professional) that comes about as a result of empathic engagement with clients’ trauma material.” (p. 31).

Researchers continue to investigate the experience of VT as a separate occurrence from other related terms such as PTSD, secondary traumatic stress (STS), counter transference and burnout (e.g. Baird & Kracen, 2006; Tosone, Nuttman-Shwartz & Stephens, 2012). It is postulated that VT differs from burnout as it arises from an interpersonal interaction rather than a work-related context (Maslach, Schaufeli, & Leiter, 2001). It has also been proposed that VT varies from counter transference as the latter is regarded as a controlled, short-term response (Harrison, 2009). Further, it is thought that VT is more complex than STS as it focuses on the theory of what is taking place within the context of trauma counselling (Tosone, Nuttman-Shwartz & Stephens, 2012).  However, other contradictory research has found that VT, burnout and secondary traumatic stress (STS) all converge and in essence relate to the same concept (e.g. Devilly, Wright & Varker, 2009).

Vicarious Traumatisation has been documented in a wide range of groups, in both clinical and non-clinical settings.  Such cohorts within the mental health field include clinicians providing mental health interventions to victims of trauma (e.g. Bride, 2007; Pack, 2013), in particular in working with sexual trauma survivors (Mouldern, & Firestone, 2007) and military veterans (Bride, & Figley, 2009; Voss, Holohan, Didion, & Vance, 2011).  VT has also been found in non-mental health settings including healthcare, emergency and community services (Cocker & Joss, 2016); with research highlighting those amongst the affected as fire fighters (Brown, Mulhern, & Joseph, 2002; Jahnke, Poston, Haddock, & Murphy, 2016), ambulance workers (Cocker & Joss, 2016), those working with victims of catastrophes (such as earthquakes, hurricanes, and war (Wee & Myers, 2002), humanitarian aid workers and peacekeepers (Eriksson, Vande Kamp, Gorsuch, Hoke, & Foy, 2001), attorneys (Levin & Greisberg, 2003) and child protection workers (Bride, Jones &  MacMaster, 2007; Nelson-Gardell & Harris, 2003). Whilst VT is widely experienced across varied settings and contexts, this report will explore VT in mental health professionals exclusively.

Theory on the process of VT

The constructivist self-development theory [CSDT]; (McCann & Pearlman, 1990; cited in Huan-Tang, 2017), is the most well-known theoretical framework used to describe VT. According to the theory, when an individual experiences VT, schemas are altered in an adverse way.  More precisely, VT is triggered by the clinicians’ own reactions to the imagery and vivid detail of their clients’ traumatic experiences, whereby altering their thought patterns and outlooks, views, and beliefs (Harrison, & Westwood; 2009; Tosone, Nuttman-Shwartz & Stephens, 2012).

As the affected practitioner’s thoughts and cognitions begin to merge more closely with those of the traumatized client (Jenkins & Baird, 2002), the person’s existing schemas become discredited, fragmented, or broken (McCann & Pearlman, 1990).  When this takes place, the schemas need to be altered to integrate the newly acquired information into the pre-existing belief system through a process known as accommodation. The resulting effect is a disturbance and increased awareness to information that confirms the new adversely altered schema (McCann & Pearlman, 1990).

The impact of VT on mental health workers

Whilst not all affected practitioners will experience the same set of symptoms, the psychological impact of VT can have harmful consequences for MHP’s professional and personal life, both in the short term and long term (Bell & Robinson, 2013; Tosone et al., 2012).  Specifically, VT is known to result in the development and onset of problematic symptoms akin to those of their client (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995) such as significant emotional, behavioural, physical and cognitive difficulties. These difficulties include depressive thoughts, anxiety, somatic difficulties, feeling emotionally numb, intrusive thoughts and images, intimacy issues, and an increased sense of distrust (Pearlman & Saakvitne, 1995).

The potential long-term adverse consequences of VT relate to altered belief systems and changes to the way in which the MHP experiences themselves, others, and their surrounding world (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995).  As the individual’s world view becomes impeded, they adopt a negative world view in which others are seen from a cynical and suspicious outlook (Iliffe & Steed, 2000; Ortlepp & Friedman, 2002; Regehr & Cadell, 1999). Other longer term responses can consist of physical and emotional exhaustion, feelings of hopelessness (Iliffe & Steed, 2000), and persistent high levels of distress (Chouliara, Hutchison & Karatzias, 2009; Cohen & Collens, 2013; Pack, 2017).  Even further, some researchers have claimed the effects of VT can be permanent (Mouldern & Firestone, 2007).

These short and long term effects have been highlighted considerably in the research.  For example, in a systematic review by Chouliara, Hutchison and Karatzias (2009), VT was found to be experienced at high levels with negative effects for mental health workers in the sexual violence/child sexual abuse field.  Again, in a sample of 88 mental health employees, Ivicic and Motta (2017) found comparatively high levels of secondary trauma amongst participants (23-27%). Further, Cohen & Collens’ (2013) meta-synthesis of 20 published articles found that the impact of trauma work lead to high levels of distress and shifts in an individual’s schemas and day-to-day routines. However, interestingly, it was noted that such negative effects can be navigated through the development of coping strategies, and trauma work can also result in both positive and negative cognitive shifts (Cohen & Collens, 2013).

Factors that influence VT in mental health workers

Numerous predisposing and mediating factors are believed to shape an individual’s experience of VT, which pertain to both individual and organisational/structural considerations (Chouliara, Hutchison, & Karatzias, 2009).  Systematic reviews conducted by both Beck (2011) and Sabin-Farrell and Turpin (2003) found the following influencing individual factors: personal stress, negative coping strategies, gender (with women reporting higher levels of symptoms than men), and personal trauma history. Similarly, a relationship between personal histories of trauma and abuse with VT has been documented in a range of other studies in the area (e.g. Jenkins & Baird, 2002; Pearlman & MacIan, 1995; Wall, 2001).  However, the link between personal trauma history and VT remains somewhat unclear as there have been inconsistencies documented across the literature (e.g. Dunkley & Whelan, 2006).

A range of organisational factors have been identified as holding a role in VT symptom level in MHP’s.  Notably, the number/percentage of trauma cases within a MHP’s caseload (Beck, 2011; Marmar et al., 1999; Ortlepp & Friedman, 2002; Sabin-Farrell & Turpin, 2003) and overall degree of exposure to clients’ trauma (Beck, 2011; Sabin-Farrell & Turpin, 2003) are frequently emphasised within the literature.  For example, Bober & Regehr (2006) recount that, in a study of 259 MHP’s, those workers who spent more hours per week counselling trauma clients reported greater levels of traumatic stress symptoms (and in particular, increased levels of intrusion symptoms).  However, such findings have also been challenged by juxtaposing research in which other studies found no influencing relationship between the extent of exposure to client’s trauma and VT (Sabin-Farrell & Turpin, 2003).

Additionally, other structural considerations have been linked to VT such as the supports, training and systems in place to safeguard MHP’s within the workplace. For example, opportunities to access supervision (Baird & Kracen, 2006) and accessibility of social support in the workplace have been found to mitigate the effects of VT (Ortlepp & Friedman, 2002).  Perceived adequate training has additionally been linked to aiding workers against VT, as it decreases MHP’s sense of hopelessness related to trauma work (Ortlepp & Friedman, 2002).

Conclusion

Whilst VT is broadly accepted as a phenomenon of significance across a range of mental health and non-clinical fields, the empirical research on this topic remains plagued by inconsistencies and divided findings (Chouliara, Hutchison & Karatzias, 2009; Devilly, Wright & Varker, 2009; Ivicic, & Motta, 2017).  In particular, consensus is lacking throughout the literature on the individual and organisational factors which mould VT in MHP’s (e.g. Dunkley and Whelan, 2006; Ivicic, & Motta, 2017).  Given that these contributing factors remain somewhat unknown, current interventions are restricted in their ability to use the literature to inform interventions designed to alleviate the negative effects of VT experienced by MHP’s.  Clearly, further research is required to determine the factors that contribute to the development of VT in MHP’s, in order to tailor prevention and intervention approaches to safeguard the psychological and physical well-being of MHP’s working in the trauma field.

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