This paper will briefly examine what it is like to be a counsellor working with traumatized clients. Many factors can impact a therapist’s level of compassion fatigue and compassion satisfaction including workplace quality, personal trauma history and number of years in service. I want to overview the currently available research on indirect trauma to help other new counsellors prevent secondary trauma and compassion fatigue early on in their careers. Hopefully this brief research paper will point those of you to research further into the risk and prevention strategies touched upon herein. I will look at the research findings on what facilitates burnout vs what is helpful and make recommendations based on the available findings. I personally am stepping into training as a certified Somatic Trauma Therapist and am keenly interested in understanding the preventative measures available.
More and more therapists are prone to ‘indirect trauma’ which is trauma coming from interventions with clients who are sharing their own traumatic experiences. (Ling, 2013). On CAMH Ontario’s website they define trauma as “the lasting emotional response that often results from living through a distressing event. Experiencing a traumatic event can harm a person’s sense of safety, sense of self, and ability to regulate emotions and navigate relationships. Long after the traumatic event occurs, people with trauma can often feel shame, helplessness, powerlessness and intense fear” (CAMH, 2019). The DSM-IV-TR (American Psychiatric Association, 2000) definition of a traumatic event is “ (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and (2) the person's response involved intense fear, helplessness, or horror “(pp. 467–468).
Another term used to refer to indirect trauma in practitioners/counsellors is ‘vicarious trauma’ (VT) (Hardiman, 2013). There has become more and more interest in understanding the impact of VT/Indirect trauma on counsellors and psychotherapists working with distressed clients since the late 1970’s. (Hardiman, 2013) In the research paper entitled “Spiritual well-being, burnout and trauma in counsellors and psychotherapists” by Piers Hardiman (2013), he describes three main problems that affect counsellors, which are burnout, vicarious trauma (VT) & secondary traumatic stress (STS). Emotional stress is considered to be the main component of these three disorders (Brady, 1999).
Research seems to point to evidence suggesting that those at the highest risk to VT are counsellors who work with victims of sexual abuse & rape (Brady, 1999). In a fascinating research called ‘Vicarious traumatization, spirituality, and the treatment of sexual abuse survivors: A national survey of women psychotherapists’, Brady (1999) found that women psychotherapists experienced damaged spiritual well-being and significantly higher rates of trauma symptoms. She even poses an important question “Should training programs be concerned about exposing trainees to clinical work with such patients” (p 1). I was quite alarmed at the research results and surprised that I have never been warned in my training programs and taught how to manage the VT that is likely to impact me. I am a woman and I am training to specialize in treating PTSD & trauma’s using somatic experiencing very soon and I believe that this Institute (Somatic Experiencing Institute) particularly emphasizes and requires our own trauma therapy. All articles I have referenced have come to the same conclusion; that VT develops and intensifies overtime if not addressed and treated. I have noticed in my group therapy work that after more than a full day of listening to patient stories I end up feeling unwell, fatigued and short on attention. With practice I have learned to step back emotionally in an ebb and flow way to allow for emotional resilience and availability. If I don’t self-monitor and take rest breaks, I distinctly lose my ability for client compassion.
Variables in Practitioner VT
Cross referenced from Brady’s (1999) research on trauma in women psychotherapists is the fact that exposure to violent details of suffering and abuse is a major contributor to VT (Pearlman & Saakvitne, 1995). Furthermore, page 387 of ‘Vicarious traumatization, spirituality, and the treatment of sexual abuse survivors: A national survey of women psychotherapists’ it describes how ‘difficult relational experiences’ between the practitioner and patient create VT as well, “such as self-destructive actions, disassociation, and hostile acting out (Brady, 1999). Female psychotherapists have been found to have more feelings of guilt and inadequacy (p, 387) for not having the same level of trauma as their patients. I personally have heard from many peers, male and female who have difficulty relating to therapeutic patients’ trauma and have witnessed how this can be very distressing for them. There have been many myths about how therapists with trauma should not work with traumatised patients as they are more likely to develop VT. (Brady, 1999) The proof however points in an altogether other direction as you will read later.
Some facts that I found important to note for future clinicians is the ‘The Maslach Burnout Inventory’ (Maslach & Jackson, 1981) which found that three subscales emerge from conclusive psychometric analyses of practitioners who work with trauma patients ; emotional exhaustion, depersonalisation, and personal accomplishment (P, 1). This is important to address and manage as the repercussion to the patient is a therapist who becomes cynical, develops a negative attitude and opinion toward the client and can create dehumanisation and a false perception that the patient is deserving of their suffering (Maslach & Jackson, 1981). Clinicians who work for agencies versus private practice were found to have higher rates of burnout (Hardiman, 2013). Burnout from VT leads to deterioration in the level of care offered by staff in institutions, increase in substance use, marital and family struggles, insomnia, physical exhaustion, job turnover, absenteeism and more (Maslach, 1981. P, 2). It is clear that some preventative measures must be addressed to keep practitioners in mental and behavioral health positions resilient.
Sexual abuse survivors may serve as a catalyst for therapists' personal growth. This exposure to disturbing material may produce a momentary spiritual crisis and cognitive dissonance but, evidently, can eventually result in a stronger, healthier sense of spiritual well-being” (P, 392. Brad, 1999)
Spirituality has been found to be beneficial in the careful treatment of trauma (Lee, 2003) and needs further research to understand how it acts as a “protective buffer” (P, 45) and especially for those who already integrate spirituality in their lives. It has been strongly encouraged to not be diminished as a resiliency tool for community or clinical work. A clear definition of how spirituality should be integrated as a resource where it isn’t already integrated, but further studies should be done to evaluate it with caution (P, 45). In Brady’s research paper on VT and Spirituality, he writes “no matter what the psychological condition of the survivor, trauma will influence his or her spiritual development. He asserted that the survivor will become more focused in his or her search for meaning and purpose because trauma necessarily calls into question old perspectives, requiring a re-examination of values and core beliefs. Likewise, therapists who are exposed to trauma vicariously are confronted with spiritual challenges” (P, 387). As therapists work with patients who have recounted such horrific stories, they are forced to reassess and address their own relationship with hope. Brady also insists that VT and spirituality are so intertwined that it is the foundation of spirituality itself that is shattered by vicarious trauma, making VT the most dangerous threat to a therapist. Addressing spirituality in recovery work is essential (Brady, 1999).
Prevention and coping strategies need to be integrated into training programs as well as educating practitioners about the high risk of vicarious trauma especially if they themselves have a history of trauma. Normalizing the idea of seeking therapeutic help for VT needs to be integrated as well so therapists feel it is acceptable and expected to have to seek help for the symptoms that will show up in themselves (Brady, 1999).
In a research by Winblad (2018) called ‘Effect of Somatic Experiencing Resiliency-Based Trauma Treatment Training on Quality of Life and Psychological Health as Potential Markers of Resilience in Treating Professionals’, it was found that counsellors and practitioners attending the 3 year SE training course that I personally begin this year, had significant improvement including “quality of life (well-being), and psychological symptoms (anxiety and somatization” (P, 1). One of the key foundations of the SE model of training is that therapist resiliency is a clear outcome of the program. (Levine, 2010; Payne et al., 2015). A good portion of the training is focused on practitioner resiliency. It is clear in the research mentioned about and in Levine’s research that clinician resiliency directly impacts patient outcomes in the clinical setting. (Levine, 2010). I believe that all counselling training program should integrate resiliency training into their curriculum and hope that this paper’s brief summary of research will inspire future curriculum adaptations.
‘Psychotherapists need to emphasize “rest, relaxation, physical exercise, avocations, vacations" (Brady, 1999. P, 390) in order to avoid exasperation. To maintain a quality in service research indicates that psychotherapists must engage in spiritual and mindfulness practices (Brady, 1999).
Brady urges that agencies and organisations of therapists must encourage and implement “emotionally supportive, physically safe, and consistently respectful work” (P, 390) environments, regular staff meetings that discuss emotions and concerns related to the trauma cases and an openness to regularly reassess systematic issues that pertain to the treatment of trauma (Brady, 1999). On a positive note Stamm (2002) found that positive and negative effects of VT can coexist at the same time. In his paper ‘Measuring compassion satisfaction as well as fatigue: Developmental history of the Compassion Fatigue and Satisfaction Test’, he claims that there are protective mechanisms that appear in relation to VT (Stamm, 2002). Ling’s (2013) research highlighted that practitioners who were able to thrive in trauma work by feeling that they had a beneficial impact on the patient were more resilient to the effects of VT. ‘Navigating the empathic journey’ is described as another resilience tool for practitioners (Ling, 2013). Counsellors that embraced & accept that what they are hearing and seeing is horrific and that allow their empathy to flow were more resilient and able to manage their stress reactions meaningfully (Ling, 2002). The ability to remain a ‘step-back’ emotionally from the traumatic content is a necessary skill to maintain emotional stamina as well as the ability to adjust in an “ebb and flow” type process to what is being heard (Ling, 2002).
Being continuously self-aware was found to be crucial for sustaining empathic engagement and having supervision, peer support & professional development (Ling, 2002). McKim (2014), found that it is imperative for counsellors to have ‘perceived control’ in their work environment such as the number of cases and levels of intensity of the cases that they accept to work on. A surprise conclusion in the research by Mckim (2014) was that therapists with previous experience of trauma had a higher level of purpose and achievement in their work (Mckim, 2014), and “the healing effects of compassion satisfaction can promote and sustain the counsellor in their most difficult times” (P, 67). This, in my opinion, is an important finding to note as there has been a lot of myths and judgments between therapists about the inadequacies of counsellors with a history of trauma and their ability to successfully treat trauma survivors effectively. McKim encourages further study around the healing power of compassion satisfaction in the prevention of VT as it has been proven that counsellors with their own trauma have a more successful therapeutic alliance to trauma victims due to their ability to become fully empathic, whereas therapists with little to no substantial history of trauma are negatively impacted by their own self judgments and difficulty to emphasize and guilt over their clients suffering (Brady, 1999).
If the findings of this study were replicated elsewhere, then it might be more confidently concluded that a counsellors’ trauma history might no longer need be viewed as a hindrance to trauma work. Perhaps this shift in perspective on the relationship between personal trauma history and compassion satisfaction might encourage trauma counsellors to be open about their own history, to seek help and support, and eventually to provide support to others.” (Mckim, 2014. P, 66).
Conclusion; Research Implications & Recommendations.
To conclude this brief overview of current research on the impact of VT on trauma workers, the following points are to be highlighted and discussed in organizations, training schools, and clinics (Ling, 2013) to prevent compassion fatigue and VT and promote compassion satisfaction.
1- attending to both the adverse and rewarding aspects of trauma work in discussions and supervision is key.
2 -having access to appropriate support structures, such as regular supervision, group support around the feelings that come up in relation to client trauma. (Mckim, 2014)
3- A safe work environment & practitioner autonomy, where they have some authority and choice where it pertains to the number and frequency of client cases assigned to them. (Brady, 1999)
4- Incorporating variability and diversity in the work. (Ling, 2013)
5- Regular relaxation, mindfulness/spirituality practice, vacation & exercise, especially for psychotherapists who work independently from an organization. (Brady, 1999)
6 -Integration of resiliency training in all institutions as a foundation of therapeutic skills (Payne, 2015).
I am hoping that this overview provided some new insights for new counsellors on the topic of the impact of trauma, vicarious trauma on the therapist and has provided a baseline of research to develop open discussions and strategies to prevent compassion fatigue, burnout & secondary trauma. I also hope that it encourages institutions and organizations to consider the well-being of their staff and make sure time is set aside daily or weekly to let feelings associated with client cases be discussed and discharged. It is clear that time off and self-care if key to longevity in the therapeutic realm so caring for others also involves the integration of self-care.
My wish is that all training schools will integrate resiliency training into their curriculum as a baseline necessity and that more education will be presented to students to inform them about the risks involved in working with trauma so that they can not only learn the skills needed to prevent VT and compassion fatigue but that they can adopt an openness around the necessity in sharing the emotional impact that the trauma stories of their client are having on them. The desired outcome of this is and social acceptability in the therapeutic realm. If more people understood that it is acceptable and likely to be impacted by clients trauma, then the greater the likelihood that practitioners will speak up about their struggles around their client’s cases and prevent burnout, VT and compassion fatigue.
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Stamm, B. H. (2002). Measuring compassion satisfaction as well as fatigue: Developmental history of the Compassion Fatigue and Satisfaction Test. In C. R. Figley (Ed.), Treating compassion fatigue (pp. 107–119). New York, NY: Brunner/Mazel.
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The final sample that was used for data analyses consisted of 98 trauma counsellors (73 female, 25 male). The sample also was primarily White (N=90), followed by Latino (N=3), Other (N=3), and African American (N=2). Participants were asked to report their profession, which consisted primarily of psychologists (N=49), followed by social workers (N=26), and professional counsellors (N=23). Participants reported an average Compassion Fatigue score of 11.03 (SD=6.13) and an average Compassion Satisfaction score of 40.87 (SD=5.59). Stamm (2005) recommended that a score of 33 or above on the Compassion Satisfaction subscale indicates a significant level of compassion satisfaction. A score of 17 or below on the Compassion Fatigue subscale indicates a significant level of compassion fatigue. Scores for compassion fatigue 62 Int J Adv Counselling (2014) 36:58–69 ranged from 1 to 36, with the mean score of 11.03 being below the cutoff score for compassion fatigue as recommended by Stamm (2005). Scores for compassion satisfaction ranged from 21 to 50, with the mean score of 40.87 being above the cutoff score for compassion satisfaction as recommended by Stamm (2005). Table 1 includes the descriptive statistics for the measures used in this study (P, 63. McKim, 2013).