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Vicarious Traumatisation Amongst |
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Vicarious Traumatisation Amongst |
Abstract
In the past decade the field of traumatology has expanded to incorporate vicarious traumatisation (VT); the impact on the therapist of exposure to traumatic client material. This study was designed to investigate the VT effects experienced by therapists who work with sexual abuse/assault survivors. Twelve psychologists and professional counsellors participated in semi-structured interviews which explored their responses to hearing traumatic material, perceived effects of VT, alterations in their cognitive schemata and their coping strategies. Findings indicated that therapists experience a variety of severe negative effects which may have a pervasive impact on their functioning in both personal and professional domains. However, positive sequelae were also noted, and thus it is suggested that our conceptualisation of VT may be limited. The need to educate therapists about the potential impact of VT and possible coping and preventive strategies is highlighted.
Vicarious traumatisation refers to the cumulative transformative effect upon the trauma therapist of working with survivors of traumatic life events. .... It is a process through which the therapist's inner experience is negatively transformed through empathic engagement with clients' trauma material.
Previous conceptualisations of the impact of trauma work on
professionals have included burnout (Farber & Hiefetz, 1982), and
countertransference (Danieli, 1980). However these phenomena may
occur as a result of working with any difficult client
population. In contrast, McCann & Pearlman (1990) construe VT as
specific to professionals working with trauma survivors. The
potential effects of working with trauma survivors are considered
distinct from those of working with other difficult client
populations because the therapist is exposed to emotionally
disturbing images of horror and cruelty that are characteristic
of severe trauma.
The notion of VT is based on a constructivist personality theory,
and emphasises the role of meaning and adaptation, rather than
focusing primarily on a set of symptoms. An underlying
assumption of VT is that it causes profound disruptions in the
therapist's frame of reference, including their basic sense of
identity, world view, and spirituality. Pearlman & Saakvitne
(1995a, p. 280) summarise the impact of VT as follows:
Multiple aspects of the therapist and their life are affected, including their affect tolerance, fundamental psychological needs, deeply held beliefs about self and others, interpersonal relationships, internal imagery, and experience of their body and physical presence in the world.
Whilst there are many rewards in working as a trauma therapist,
Pearlman & Saakvitne (1995a) assert that VT refers specifically
to the negative aspects experienced by the therapist. The
concept is not intended to assign blame to clients for the
therapists' reactions, rather VT is considered a natural and
inevitable response to spending significant amounts of time
working with, or studying, trauma survivors. VT is a process
which takes place over time, and across clients and therapeutic
relationships.
Many of the effects experienced by the therapist parallel those
of the trauma survivor, but at subclinical levels (Pearlman &
Saakvitne, 1995a). The therapist may experience general changes,
such as having no time or energy for self or others, and
increased feelings of cynicism, sadness, and seriousness. They
may experience other strong emotions such as anger, grief, or
despair. The therapist may also develop an increased sensitivity
to violence, for example, when watching the news on television or
in the cinema (Pearlman, 1993).
Pearlman & Saakvitne (1995a) state that the therapists' self-protective beliefs about safety, control, predictability, and
attachment are challenged through working with trauma survivors.
Consequently the therapist may become anxious, and avoidant of
situations they now perceive as potentially dangerous, such as
being home alone, driving at night, and walking through car parks
(Resick & Schnicke, 1993). These and other effects, which can be
disruptive and painful for the therapist, may occur as a short-term reaction to working with traumatised clients, or may persist
for months or years after the completion of such work (McCann &
Pearlman, 1990).
Pearlman & Saakvitne (1995a) identify two major factors that
contribute to VT: aspects of the work, and aspects intrinsic to
the individual therapist. Aspects of the work include the nature
of the clientele, specific facts of the traumatic event,
organisational contextual factors and social/cultural issues.
Therapist characteristics include personality, personal history,
current personal circumstances and level of professional
development. VT evolves from a complex interaction between these
multiple influences and thus its effects are unique to each
therapist.
McCann & Pearlman (1990) suggest that VT intrudes on four major
areas of the therapist's functioning: cognitive schemata,
psychological needs, the memory system, and frame of reference.
They assert that schemata are cognitive manifestations of
psychological needs such as trust, safety, power, esteem,
intimacy, independence and frame of reference, all of which are
fundamental to trauma adaptation. These needs are sensitive to
disruption by VT, which can therefore cause subtle and/or acute
effects, depending upon the degree of discrepancy between the
client's traumatic memories and the therapist's existing schemas.
Alterations to schemata based on trauma adaptation needs are
reflected in the perspectives that therapists may develop.
Dutton (1992) notes that therapists may develop some of the
following perspectives: there is never a safe place in the world
(safety); the therapist is helpless to take care of the self or
to help others (power); one's personal freedom is limited
(independence); or working with victims sets one apart from
others (intimacy).
McCann & Pearlman (1990) also argue that these and other
cognitive shifts that result from exposure to traumatic client
material may create emotional distress in therapists, including
anger, guilt, fear, grief, shame, irritability, and inability to
contain intense emotions. In addition, Dutton (1992) asserts
that the cognitive shifts may interfere with effective
functioning in the therapeutic role.
In addition to disturbances in cognitive schemata, McCann &
Pearlman (1990) assert that therapists who listen to accounts of
victimisation may internalise their clients' memories, and may
consequently have their own memory systems altered. Disruptions
in their imagery system of memory (Paivio, 1986) are most
frequent and thus the therapist experiences flashbacks, dreams,
or intrusive thoughts; symptoms constituting one of the primary
diagnostic criteria of PTSD (APA, 1994). As with cognitive
shifts, disruptions in the imagery system of memory are
frequently associated with powerful affective states (Paivio,
1986). Therapists have reported various uncomfortable emotions
resulting from their work with trauma survivors, including
sadness, anxiety, or anger (McCann & Pearlman, 1990).
McCann & Pearlman (1990) also assert that VT impacts on the
therapist's frame of reference which incorporates their world
view, identity, and spirituality. Given that individuals view,
experience, and interpret their world through this frame of
reference, any disruption to it is inherently disorienting and
stressful (Pearlman & Saakvitne, 1995a).
Although the phenomenon of VT has received a great deal of
theoretical and clinical attention, there is a paucity of
empirical research investigating the impact of exposure to
traumatic clinical material on professionals working with trauma
survivors. A review of the traumatology literature revealed only
three published empirical studies investigating the effects on
professionals of providing services to survivors of sexual abuse
and sexual assault. Martin, McKean, & Veltkamp (1986) studied
the impact of working with survivors of sexual assault on police
officers and found that PTSD symptoms were significantly more
prevalent amongst police officers dealing with rape survivors
than those who did not. Oliveri & Waterman (1993) conducted a
retrospective survey of 21 therapists who, five years previously,
had been involved in treating sexually abused children in pre-school centres. Therapists reported experiencing PTSD symptoms
and distress as a result of treating the children. Follette,
Polunsny, & Milbeck (1994) examined the impact of providing
services to sexual abuse survivors, and found this to be
significant for both mental health professionals and police
officers.
These studies provide some evidence of the effects of exposure to
trauma material on professionals. However, two were limited by
the use of small sample sizes, and all failed to acknowledge the
need to distinguish between the impact of VT, and the chronic
effects of unresolved personal life issues. Thus there is
limited investigation, either empirical, epidemiological, or
phenomenological, to guide our understanding and intervention in
VT. Consequently, in-depth study of VT in specific therapist
populations, working with specific client populations is
warranted. Thus the present study was designed to explore the
experience of female therapists who work with sexual
abuse/assault survivors. Specifically, we wished to determine
the extent to which therapists reported effects of VT, the impact
of these effects, and the coping strategies used to deal them.
Materials
A semi-structured interview schedule was developed based on
earlier work (Figley, 1995; Follette et al., 1994; McCann &
Pearlman, 1990; Pearlman & Saakvitine, 1995a). The interview
began with general questions about the therapists' experience of
hearing traumatic material, and then became more specific,
focussing on cognitive schemata and coping strategies.
Procedure
Interviews lasted approximately one hour and were tape recorded.
After transcription, thematic content analysis was conducted
independently by two raters and salient issues were identified.
A high inter-rater reliability was achieved.
Several therapists reported self-protective responses in which
they actively sought not to imagine the client's experience. "I
protect myself in some ways. I sometimes find myself
automatically able not to let it get to me". Others reported
being able to focus on therapeutic responses, "to concentrate on
what my role is and what my job is" without the apparent need for
self-protection.
Many negative effects outside the therapeutic session were
reported. These effects occurred in various domains of
functioning including physiological, emotional, professional and
interpersonal. Physiological effects included diminished energy
levels, somatic complaints and sleep disturbances. Emotional
responses included comments such as "I get more angry than I
normally would". Seven of the twelve participants reported that
they experienced overwhelming imagery, dreams and intrusive
thoughts. Eight respondents reported increased vigilance
regarding their own safety and the safety of others.
Sometimes I don't feel safe, even in my own environment
I'm more vigilant, and have more safety concerns, and sometimes when I see people with their children I wonder whether they are abusing them.
Some developed mistrust in their ability to do the work
effectively, and others reported a negative impact on their
relationships and interpersonal functioning, both within the
family and beyond. Six therapists reported an increased wariness
of men and a decrease of trust with their partner. Seven
reported changes in their wider social circle:
Some of my friends feel really uncomfortable about me doing this work and just can't cope, so I've actually lost some good friends
At times it affects my ability to feel close to people, my ability to trust people
In response to the more specific question regarding changes in cognitive schemata, all therapists reported changes. The most frequently cited change was "loss of faith in human beings".
I'm reminded of something about human beings that is really quite unpleasant, and sometimes I feel sad about that.
I always thought of the world as intrinsically good, but now I know differently.
Related to this is an increased sense of vulnerability:
At times I feel more vulnerable and I think that is just me being aware that it can happen to anyone at anytime and there's no reason or logic.
Several therapists reported a change in their sense of identity:
Often I'm not sure of myself, particularly with the world, and what I'm doing, and where it's going, and what it all means anyway. A lot of the time I'm struggling with how I feel about myself and who I am.
However, not all responses were negative. Positive self-identity
statements included: "I see myself as being much more adjustable
and flexible", and "I've become really clear about what I want to
do with my life, and my own identity".
In addition, some reported a greater appreciation of their
clients:
I've learnt how strong and resilient people are, and how much inner resources and strengths people have
while others reported a clarification of their values and
attitudes, and a greater depth of compassion. These changes
appear to derive from the increased questioning of life that the
therapists reported:
I spend a lot more time by myself, things like going for walks, and trying to make sense of life, - spending more time thinking about what the whole point of everything is.
Interviewees were asked about the coping strategies that they use
to deal with the effects of their work. They were all very aware
of the need to be proactive in this regard and reported taking
good care of their physical and psychological needs. That is,
they reported efforts to maintain healthy eating, sleeping and
exercise habits, and recognised the need for self-care and to
pursue activities outside their professional duties. They also
reported awareness of the importance of boundaries in both their
personal and professional lives, the need for debriefing, and
ongoing professional development and supervision.
The therapists also reported negative coping strategies such as
drinking too much coffee and alcohol, risk-taking behaviours such
as speeding, and withdrawing from family and friends. All had
experienced episodes of feeling an overwhelming sense of
helplessness, and most reported that these episodes precipitated
negative self-talk and crises of confidence.
When asked what kind of preventative strategies they use,
interviewees re-iterated some strategies for positive coping, and
also reported using a number of additional strategies, both
personal and professional. For example, the majority stressed
the need to create balance between their work and personal lives,
and to endeavour to keep these spheres separate. All
participants stressed the need for personal awareness of their
own vulnerabilities and stress reactions:
When I first started working in this area I made a commitment to being aware of my own responses and what I react to.
Such self awareness enables the therapist to monitor their responses during sessions, seek supervision, and manage their client load accordingly.
The participants also stressed the need for education and
training in both management of sexual abuse/assault clients and
the effects of VT. They argued that the former is vital to their
feelings of competence and helps to mitigate against crises of
confidence mentioned earlier. Knowledge of the potential effects
of VT was considered essential in that it provided validation of
the therapist's experience and encouragement to take preventative
measures.
It is curious that some therapists were aware of using self-protective strategies with clients while others reported that
they were able to continue in the therapeutic role without
interruption. The latter may suggest a lack of self awareness on
the part of the therapist, a desire to be perceived as competent,
or may indicate desensitisation to the traumatic material.
Again, although all the participants reported experiencing the
negative effects of VT, not all stated that these had a negative
impact on their professional lives. The above factors could be
operating again, or alternatively, those denying adverse effects
could be using effective coping and preventative strategies.
Clarification of these possibilities would be useful in
predicting therapist vulnerability to VT and its subsequent
treatment. A longitudinal study could provide much-needed
insight into these issues.
Effects in physiological functioning were frequently cited by the
therapists, in particular fatigue, and disturbed sleeping
patterns. The majority of therapists had been exposed to
traumatic imagery they found too overwhelming to integrate, and
also reported experiencing flashbacks, dreams, and intrusive
thoughts. However, contrary to Pearlman & Saakvitne's (1995a)
assertion that VT is a cumulative effect, the majority of
therapists did not perceive the negative effects as increasing
over time. Again, it is possible that some therapists have
become desensitised through repeated exposure, or that effective
coping strategies are curtailing the accumulation of negative
effects.
Over half of the therapists reported that they had become more suspicious and distrusting. Specifically, several therapists mentioned that when they are out in public and see a man with a child, they wonder if the child is being abused. Although Pearlman & McCann (1990) construe such changes as disruptions in cognitive schemas, the therapist may simply be more mindful of child abuse issues; an appropriate response to working in the field of sexual abuse/assault. Pearlman & McCann (1990) do not, however, draw distinctions between increased awareness and disturbances in cognitive schemas. We suggest that the utility of conceptualising alterations in cognitive schemas on a continuum ranging from awareness, to exaggeration and paranoia, be explored.
The finding that many of the therapists experienced positive
changes in their sense of identify, and beliefs about self and
others, suggests that other than detrimental effects arise from
listening to traumatic material. There was evidence of positive
alterations in their sense of meaning/spirituality, and world
view, including re-evaluation of previously held beliefs,
increased self awareness, and the acquisition of new
perspectives. As the concept of VT specifically refers to
negative changes in therapists' frame of reference, it is thus
inadequate as a conceptual framework for understanding the full
range of effects of trauma counselling. Recognition of, and
investigation into, the positive effects of trauma therapy on the
therapist would constitute a more comprehensive and holistic
approach to the phenomenon.
The majority of therapists identified a large repertoire of
strategies for coping with, and preventing, the negative effects
of their work. The range of individualised strategies reported
on both personal and professional levels suggests a high level of
awareness of the need to care for the self. Considering the
deficits in education about VT, this awareness may be more
intuitive than the result of any formal training. Coping and
preventative strategies used by these therapists represented all
the major types of strategies identified in the literature
(Dutton, 1992; Pearlman & Saakvitne, 1995b). Although the
respondents had been able to develop their own strategies, all
agreed on the need for education and training, both for novice
counsellors and those continuing to work in the area.
Results of this study may have been limited by several factors.
First, the small sample size is acknowledged, but is acceptable
given the exploratory nature of the study. Second, the sample
was not homogeneous in that not all the therapists worked with
sexual abuse/assault on a full-time basis, and the location of
practice varied between private rooms and agencies. However, it
may equally be argued that such diversity provides a greater
exposure to different experiences.
Perhaps the most serious limitation was some therapists'
inability to accurately remember their beliefs and level of
functioning before they began working in the field. This is
understandable as nearly half of the therapists had worked with
this client group for more than 7 years. In addition to memory
recall problems, some therapists may have failed to identify
changes that occurred gradually over a long period of time.
Clearly there is a need for a longitudinal study to clarify the
cumulative effects of VT.
Finally, the therapists' inability to distinguish the vicarious
effects of trauma therapy from the effects of unresolved personal
issues, is also of concern. Separating these two sources of
stress can, however, be problematic as each aspect may interact
with the other. Some therapists demonstrated an ability to
separate these effects whilst others did not. Further, it may be
functional for therapists to attribute the effects of personal
problems to the nature of their work. This would effectively
remove the need to deal with their personal issues. The impact
of the therapist's own past traumatic life experiences is also an
important consideration. The interaction between therapists'
history of abuse, their responses to hearing traumatic client
material, and the VT effects they experience, have received some
recent attention (Follette, et al., 1994), and require further
investigation.
As questions in the interview schedule related specifically to
trauma therapy with sexual abuse/assault survivors, these
findings are not generalisable outside of this therapist group to
the wider domain of trauma therapy. Research with therapists
working in other fields of trauma would be enlightening.
This study has contributed to the understanding of VT by
providing experiential evidence of its widespread existence and
impact on therapists' personal and professional lives. The need
for a broader conceptualisation of the phenomenon was
highlighted, as was the need for further research. As the field
of traumatology expands, therapist education and training becomes
a top priority.
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