by Alan Kavanagh
We cannot live only for ourselves. A thousand fibers connect us with our fellow men; and among those fibers, as sympathetic threads, our actions run as causes; and they come back to us as effects
(Melville, as cited by Geller, 2016: 295)
Yalom (2002: 257) describes therapists as the ‘cradlers of secrets’, but what do we do when the secrets are so horror-inspiring that they scar? Counsellors are expected to cultivate a countenance of compassion for their clients. However, at times, the very act of helping can be harmful. As I embark on my professional journey towards accreditation, I personally appreciate the struggle to juggle the demands of becoming a psychotherapist. I find myself asking, why we are drawn into this vocation; perhaps, it is our altruistic mind-sets? Arguably, we could spend our whole lives helping people to avoid looking at our own pain, but at what cost? In my view, awareness and acceptance of self and the client is key to helping both beings. Anecdotally, we hear that our clients are our best teachers; if so, in the interest of integrity, it is vital to look at our own woundedness. Trauma impacts 80% of the general population in the Netherlands (De Vries & Olff, 2009). If these figures are even somewhat generalisable, it is paramount to consider the indirect impact on those who support the traumatised (Manning-Jones et al., 2016).
This article will address burnout, secondary traumatic stress and compassion fatigue, as they are indeterminately intertwined with vicarious traumatisation (VT; Van Heugten, 2011).
The traumatisation of therapists?
Is vicarious traumatisation a disorder, occupational hazard or condition, or both? Is it a temporary state that is resolved, or one that is more permanent?
(Hammerslough, 2015: 38)
Vicarious trauma is defined as the fixed state of “transformation in the inner experience of the therapist that comes about because of empathic engagement with clients’ trauma material” (Pearlman & Saakvitne, 1995a: 31). Alternatively, Wagaman et al. (2015: 201), while acknowledging that shared emotions may contribute to this issue, explored “[empathy] as a protective factor.” In fact, they contend that higher levels of empathy are associated with lower levels of secondary traumatisation.
Fundamentally, there are risks to being compassionately involved with clients. In particular, when working with survivors of abuse, repeated exposure to traumatic and graphic accounts can result in therapist traumatisation (Nen et al., 2011). Moreover, Jenkins and Baird (2002) highlight that vicarious traumatisation symptoms mirror those of post-traumatic stress disorder (PTSD). Nevertheless, van Heugten (2011: 25) reflects, “It is not helpful to think of vicarious trauma only at the most serious end of the spectrum because doing this precludes early intervention.” He further states the only differentiating factor between vicarious trauma and burnout is that those affected by the former retain empathy. However, Trippany et al. (2004) counterargues that there are distinct differences between the two, with vicarious trauma resulting from exposure to trauma and burnout as a result of general stress associated with clinical work.
Possible causes of vicarious trauma?
Vicarious traumatisation stems from the intimate, intense working relationship with vulnerable clients, which in turn can leave the therapist in a susceptible, revealing state of being (Pearlman & Saakvitne, 1995a). Chouliara et al. (2009: 47) intimate that VT is a “normal reaction” to frequent interaction with traumatic material; yet, the updated DSM-5 has “made explicit that repeated exposure to the aversive details of a traumatic event during the course of one’s professional duties qualifies as a Criterion A stressor” for PTSD (Hensel et al., 2015: 83). Arguably, this implies it is anything but normal. Therapists are undoubtedly going to encounter graphic, upsetting narratives, so why then do only some practitioners experience this problem? Hence, it is imperative to delve deeper into the possible risk factors associated with vicarious traumatisation.
A personal history of childhood trauma has been indicated in the development of vicarious trauma (Nelson-Gardell & Harris, 2003). As documented by Brewin et al. (2000), a history of childhood abuse is a significant predictor of severe anxiety when dealing with traumatic events. In opposition, Williams et al. (2012) inform us that not all research finds a correlation between childhood trauma and vicarious trauma. Research with social workers found that the Traumatic Stress Institute Belief Scale scores were not “associated with social workers’ personal trauma” histories (Adams et al., 2001: 363). Conversely, Michalopoulos and Aparicio (2011) imply that a personal trauma history may be pertinent, as increasing social support only offered protection to workers who did not have a trauma history. It is plausible that therapists who have suffered childhood trauma may not have fully examined past pain and will be predisposed to experiencing, more acutely, the negative side-effects which occur from listening to clients recount similar experiences (Lerias & Byrne 2003). Marie Adams (2014: 12) quotes Guy (1987:15) who asserts, “Therapists’ own pain may serve to motivate entry into the mental health field in the hopes of relieving similar pain in others.”
Nishith et al (2000) assert that women have a higher lifetime rate of developing PTSD than men, as women’s incidents of trauma tend to be of a greater extreme, i.e., rape, physical abuse. Kessler et al. (1995), in a large PTSD study, found prevalence rates overall to be 7.8%, with 5% for men compared to 10% for women. So, how does this relate to the causes of VT? Kassam-Adams (1999) argues that women are more likely to experience vicarious traumatisation. Likewise, Byrne et al. (2006:173) found a substantial gender difference in those indirectly exposed to bushfires, “with more females (73.9%) being allocated to the vicarious traumatization group than males (26.1%)”.
Nonetheless, if Nishith et al. are correct, and women are more likely to experience greater trauma, then perhaps the variable at play here is not gender, but rather a personal history of trauma. Way et al. (2004: 57), in their analysis, found negligible gender differences, “indicating that the clinician groups do not differ in their sexual abuse history, even when controlling for gender.” Equally, Schauben and Frazier (1995: 49), in their research, maintain, “Symptomatology was not related to counselors’ own history of victimization”. This appears to contradict Kassam- Adams’ (1999) finding that being female is a predictor for vicarious trauma.
Work environment and practices
Hensel et al. (2015), in their meta-analysis, found that trauma-patient caseload had the strongest effect size in terms of risk. Correspondingly, Creamer and Liddle (2005) indicate that a more intensive caseload was associated with higher levels of vicarious trauma. That said, Devilly et al. (2009: 382) found “no significant difference in VT or STS [secondary traumatic stress] for those with high exposure to trauma patients compared to those with low exposure to trauma patients”. In contrast, Trippany et al. (2004: 34) discovered, “counsellors who work primarily with trauma survivors experience a greater measure of VT…” which implies that workloads should be balanced between trauma and non-trauma cases.
Additionally, Salston and Figley (2003: 168) report that “work-related burnout is not limited to persons working with the traumatized” as conflictive values of the individual along with organisational demands and an overload of responsibilities, are factors in burnout. Moreover, Craig and Sprang (2010) identified that thorough trauma training was associated with lower rates of burnout. Finally, while unquestionably self-care is a chief responsibility of counsellors, “it is not sufficient for employers…to instruct therapists to take care of themselves off the job; active preventative measures should be a regular part of the work environment” (Munroe, 1999: 216). However, what about the many therapists that are self-employed in private practice? Saaktine et al. (1996: 75-76) propose that “if we, the helpers, don’t stay connected to a larger, more complex world, we can get lost with them in a persecutory morass”.
Signs and symptoms of vicarious trauma
A rigorous review into signs and symptoms reveal that there is a change in therapists’ self and worldview (Figley, 2002). Affected practitioners may become socially reclusive, sceptical, and emotionally labile or experience a numbing of feelings. For instance, Izzo and Miller (2010) maintain it is characterised by a lack of connection and a difficulty feeling happiness. Furthermore, Etherington (2000: 380) describes a personal account of “vivid dreams, intrusive thoughts and images…” as well as feelings of loneliness and distancing herself from close relationships.
Lerias and Byrne (2003: 131-132) describe “persistent avoidance”, “increased arousal”, “re- experiencing the event”, and impairment of functioning as common symptoms of vicarious trauma. Meyer and Ponton (2006) highlight the overwhelming effect this can have on the sufferer, noting that those impacted can experience profound loss and emptiness.
Prevalence of vicarious trauma
As Pearlman and Saakvitne (1995b: 159) reflect, “it is impossible to provide a statistical estimate of the extent of vicarious traumatization among psychotherapists…all trauma therapists are at risk”. Essentially, research into prevalence appears limited, however Dunkley & Whelan (2006b) found prevalence rates of 45.9% in Australian counsellors. Interestingly, when reviewing the research, it emerges that this 45.9% merely refers to certain scores on the sub-scales used, as opposed to overarching rates of vicarious trauma. In fact, the Dunkley and Whelan (2006b: 463) study demonstrated a “low to average range for mean vicarious traumatisation scores.”
Related research into compassion fatigue and burnout indicate ranges of between 7.3% and 40%, although this refers to ICU staff, not therapists (Van Mol et al., 2015). While not directly referencing vicarious trauma, Meldrum et al. (2002: 99) found that 18% of mental health workers presented with symptoms “equivalent to those experienced by people who meet criteria for a diagnosis of PTSD.”
Impact of vicarious trauma
Therapists’ wellbeing is key for ethical and safe practice
Research into this area highlights the importance of therapist wellbeing and self-care. When we lack the practice of self-care, can it be perceived as though we do not care? Certainly, as the body of literature predicates, the impact of vicarious traumatisation on our ability to remain empathic can be resounding and long-lasting. Saakvitne (2002) indicates that the footholds of hope and meaning in our professional work can be toppled by cynicism and pessimism, which consequently leaves therapists on shaky ground. Moreover, as Dunkley and Whelan (2006a: 107) describe, “when a counsellor is suffering, the quality of work and the effectiveness of the organisation may be compromised”. Therapists and organisations are duty bound to deal with VT as it is clearly “an inevitable occupational hazard” and, if unattended, can have a deleterious impact on therapists’ empathic capabilities resulting in “therapeutic impasses… frequent incomplete therapies” and “boundary violations” (Sexton, 1999: 397).
Contrariwise, although this paper reflects mainly on the negative outcomes of vicarious trauma, it is imperative to state that positive consequences can occur. Arnold et al. (2005: 243) define this as “psychological growth following vicarious brushes with trauma.” Furthermore, Cosden et al. (2016) highlight that psychotherapists who had a history of trauma and processed their trauma in therapy were more inclined to experience vicarious posttraumatic growth. This suggests that on-going self-development and personal therapy may aid in the prevention of vicarious trauma and the development of resilience.
Izzo and Miller (2010) remind us that helping others can come at a significant cost to the professional. While supervision is an ameliorative measure, those who are traumatised vicariously may also need therapy.
An integrated approach to counselling those with vicarious trauma
All of us who attempt to heal the wounds of others will ourselves be wounded; it is, after all, inherent in the relationship
(Hilfiker, 1985: 207)
Hunter (2012: 180) maintains “The quality of the relationship between the psychotherapist and the client has long been understood as the core of the psychotherapeutic method”. There is a lack of literature relating to clinical practice with psychotherapists who are impacted by vicarious trauma.
While supervision, coping-skills, self-care and psycho-education on traumatology have all been shown to help the therapist affected by vicarious trauma (Sommer, 2008), the levels of impact have been comparable to PTSD (Salston & Figley, 2003), giving rise to a possible need for therapists to enter therapy themselves. It also indicates that further study in how to help such therapists is needed. What we do know is that vicarious trauma is a form of trauma, and approaches drawn from psychotherapeutic approaches to trauma work may be useful when working with psychotherapists who are experiencing vicarious trauma.
With that in mind, the reader will be presented with an integrated approach to therapy, blending Carl Rogers’ Person-Centred Therapy (PCT) and William Glasser’s Choice Theory/ Reality Therapy (CT/RT). Cheston (2000: 256) advocates “that the subject of counselling theory and practice can be organised around three principles: a way of being, a way of understanding and a way intervening”, therefore this integrated approach will be examined using this theoretical framework.
A way of being (WOB)
Pearlman and Saakvitne (1995a: 360) recommend that “a mutually respectful interpersonal climate” is essential when treating vicarious trauma. Both PCT and CT/RT place huge value on the creation and maintenance of the relationship for positive client change. Rogers depicts this interpersonal climate, stating, “there are no conditions on acceptance, no feelings of ‘I like you only if you are thus and so’… no ‘ifs’, ‘buts,’ or ‘not reallys’” (2007: 243). Similarly, in CT/RT a “genuine, caring counselor-client relationship” is vital (Turpin, & Ososkie, 2004: 199). Murphy and Joseph (2013: 2) argue that the “therapeutic relationship [should be] at the heart of trauma-related work”, and Joseph (2004) formulates a solid case for the use of client-centred therapy with trauma. In fact, Rogers coined the phrases “client-centred” and “non-directive” when writing about therapeutic work with veterans returning from war (Purton, 2004).
It is evident that CT/RT and PCT merge well. Wubbolding and Brickell (2017) maintain that Rogers’ principle of unconditional positive regard is interwoven into the application of Reality Therapy. They describe this as remaining calm, non-judgemental and accepting. Prenzlau (2006: 26) posits, “the reality therapist is often seen as confrontational”; however, what this means is that the therapist enables the traumatised client to self-evaluate which puts the control in the hands of the client. Lemma (2010: 415) highlights the importance of this safe and supportive relationship in therapeutic trauma work when she notes “attachments to others are the building blocks of the mind, and hence that the provision of new attachments was healing”. Munroe et al. (2013: 209) echo this, declaring: “Social support has been identified as a source of significant psychological benefit to trauma survivors”. This fits perfectly with the way of being of a reality therapist, who will focus on the here-and-now, encouraging the traumatised client to, “develop or deepen current relationships” for social support (Wubbolding, 2000: 77).
A way of understanding (WOU)
Joseph (2004: 104) proposes: “In person-centred terminology, PTSD symptoms are simply another way of talking about what Rogers (1959) described as the breakdown and disorganization of the self-structure”. Bearing in mind that we are primarily considering psychotherapists as clients who present with vicarious trauma, from a PCT perspective it is probable that there will be a gap between their real and imagined selves. After all, such clients may see themselves as ‘the healer’ and may struggle to reconcile themselves with the image of being the one that needs to be healed. Their human fragilities are exposed by the vicarious traumatisation, which Joseph (2004: 106) maintains leads them to question “their previous values and assumptions about themselves” and perhaps their competence as a helper.
In Choice theory, the central tenet is that “our motivation and behaviour is an attempt to satisfy one or more of our (five) universal ‘needs’, and that we are responsible for the behaviours we choose” (Brickell & Wubbolding, 2000: 22). Corey (2011: 337) tells us “we do not satisfy our needs directly” but rather we create a quality world (QW) of need-satisfying pictures. CT/RT involves a present-focused stance, recognising “that past traumas cannot be changed, and people can only choose how to respond to the past trauma” (Chu-Lien Chao, 2015: 188). Lee and James (2012) note that when clients are traumatised, and they have a trauma memory, their body and brain reacts as if it is threatened. In CT/RT terms, this signifies that their survival need is frustrated, and they will behave (helpfully or harmfully) to ease this.
Figley (2002) highlights the problems that can be generated when he notes that compassion fatigue can be caused by “psychotherapists’ chronic lack of self-care”. In the case of vicarious trauma, this may be compounded by the fear of loss of earnings or being seen as ‘impaired’. To some degree, this amounts to a further threat to the survival need, which may lead to more deficits in self-care, and prevent the person from engaging in help-seeking behaviour (Bearse et al., 2013).
Glasser (2001) has always refuted the pathologisation of emotional and psychological distress. Prenzlau (2006: 23) asserts that Glasser viewed a range of physical and psychological pains as “the body’s creativity”, which “can be expressed in all four components of our total behavior.” Therefore, using this approach, the behavioural, cognitive, emotional and physiological domains warrant exploration with the client. Reflecting and examining how the vicarious trauma is manifesting in the client’s ‘doing’, ‘thinking’, ‘feeling’ and ‘physical’ components of behaviour would all be grist for the mill in the therapeutic space.
A way of intervening (WOI)
PCT is a ‘non-directive’ approach, where Rogers contended that clients are the experts of their own lives. Thus, in a therapeutic space, they can heal themselves (Thorne & Sanders, 2013). Hanley, Scott and Winter (2016: 100) maintain “underpinning this position is the belief that given the right environment, individuals will grow constructively, as guided by the actualising tendency perceived to be within all humans.” In many ways, in PCT, the Way of Intervening and the Way of Being is the same thing. McLeod (2013: 175) refers to this when he proclaims that PCT “is a relationship therapy.” At heart, the core conditions of empathy, unconditional positive regard and congruence are the methods by which change is facilitated. Brockhouse et al. (2011: 736) claim: “An empathic response to vicarious trauma might be a mechanism through which positive changes occur”.
Giuffra (1981: 25) informs us that burnout in therapists is characterised by a belief that “they are not doing enough. They must do more”. When considering a client who has vicarious trauma, an empathic, genuine, accepting space is paramount, particularly if they are beating themselves up for not being good enough, resilient enough, or perhaps viewing themselves, overall, as not being enough. Part of the power of PCT is that it can be reassuring to the traumatised person to know that:
There are people who are there, who though they cannot genuinely understand what has been experienced, are willing and ready to be beside them as they try to make sense of their shattered world, and often shattered structure of self
(Bryant-Jefferies, 2005: 20)
Without question the person-centred therapist believes in a person’s innate ability to self- actualise and become more fully functioning. Regarding trauma of any kind, including vicarious trauma, with appropriate support Tedeschi and Triplett (2012) remind us that positive change can occur when the client courageously processes their traumatic experiences. Core to CT/RT is the precept that people behave (constructively or destructively) to satisfy their basic needs (Nelson-Jones, 2011). When someone has been traumatised, it is likely that they will have experienced a sense of threat which will frustrate the survival need. When discussing trauma, Wubbolding (2000: 77) maintains: “While the trauma has resulted in a wound, it need not cause a perpetual and painfully excruciating scar.” He further outlines that the role of the therapist is to support the client in maintaining and developing need-fulfilling relationships in their current life. This does not negate the trauma, and in fact, Wubbolding (2016) recommends that clients who repeatedly talk about a traumatic event are seeking relief from their inner torment. He further proposes that treating the client with compassion, listening, and then explaining how the Glasser approach works may help ameliorate their distress.
Strengths and limitations of the integrated model
The NICE guidelines (2005) purport that trauma should be treated with trauma-informed CBT, though Spalek (2016) advocates that an integrative approach is important as it incorporates the best of multiple approaches. While PCT offers that safe supportive relationship, and that absolute belief in the client’s ability to transition from trauma to post-traumatic growth, clients may need other interventions.
I believe that integrating the Glasserian and Rogerian approaches presents the best of both worlds to traumatised clients, as it straddles the humanistic and cognitive-behavioural domains. There is a useful directedness to CT/RT that is not present in PCT. Glasser (1998: 334) viewed the presenting problem as “always part of our present lives” whereas Rogers allowed for exploration of the past more than Glasser. Both offer valuable options to those dealing with vicarious trauma.
Wubbolding et al. (2012: 22) argue that an effective therapist will explore what the client wants. This belief blends well with PCT as it allows the client to direct therapy, and to work on what they want to address. Once the client’s wants are established, the therapist should focus on their total behaviour. What is it that they are doing, thinking and feeling, and what is happening in their body? (Fulkerson, 2015). When considering VT, it is evident that clients will experience physiological and emotional distress as well as disturbed thinking (Pearlman & Saakvatine, 1995b). Gently, and without imposing blame on a client who is already experiencing pain, the therapist will help the client to self-evaluate their current behaviour, before supporting them in planning for change. At every step of this CT/RT process, PCT can be integrated. The therapist can reflect, summarise and paraphrase, to demonstrate accurate empathic understanding (Kirschenbaum & Henderson, 1989).
In the therapeutic field, there is an often-heard colloquialism, ‘it cannot be all heart’. Heart is obviously vital, as our ability to empathise makes us effective. However, repeated exposure to clients’ traumas can leave us vulnerable and traumatised. On the other hand, “Congruence and compassion open the way to the therapist’s primary instrument of healing: the personal vulnerability of his own trembling self” (Woskett, 1999: 214). Additionally, trauma-informed education, self-care, organisational and social support, and supervision can all help to prevent and intervene with those experiencing VT. Nevertheless, sometimes, therapy will be warranted.
There is no therapist and no person immune to the inherent tragedies of existence
(Yalom, 2002: 8)
In my own personal therapy, my therapist poignantly reflected that, ‘You always turn up for others…when do you ever turn up for yourself?’ As an empathic person, I have no doubt that the pain and complexities clients will bring will have the power to impact me. Oil does not run in my veins; I am a human being, not a machine. As I am identifying with their vulnerabilities – from that vulnerable place within me – I have no doubt that I will require the outlet that the supervisory relationship will afford me. Furthermore, I know that I will make mistakes, or find myself in the place of ‘not knowing’, or struggle to maintain boundaries when helping others to help themselves. For these reasons, I imagine that the supervision space will be a vital tool in my development. In essence, both personal therapy and supervision are helping relationships that can challenge, support, guide and assist me as I journey onward. With these supports, I hope I can continue to look inward, to process and own what belongs to me, and to move forward with greater acceptance and an ability to be present. Any resistance to engaging honestly and openly in these processes is not only a failure to my clients but also to myself.
In summation, it is worth noting that counsellors are not impervious; we too need to be mindful that:
A wound is raw and vulnerable and when the salty tears of a client fall upon it the pain may be too intense to bear. It is to be hoped that work in personal therapy will lessen the degree of pain, but for many of us, there will remain areas in which our vulnerability will continue to be restimulated by clients
(Page, 1999: 109)
Alan Kavanagh is a BA (Hons) student at IICP College and a student member of IACP. He has completed a certificate in Counselling and Addiction studies (Liberties College) and a Level 7 in Addiction Studies (Maynooth University). Alan is a trainee therapist in the Village Counselling Service, Tallaght and recently accepted a position with Dublin Simon Community. He can be contacted by email on firstname.lastname@example.org
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