Vicarious traumatization

Vicarious traumatization (VT) is a transformation in the self of a trauma worker or helper that results from empathic engagement with traumatized clients and their reports of traumatic experiences. Its hallmark is disrupted spirituality, or a disruption in the trauma workers' perceived meaning and hope. McCann and Pearlman(1990a) coined this term specifically with reference to the experience of psychotherapists working with trauma survivor clients. Others, including Saakvitne, Gamble, Pearlman, and Lev (2000) have expanded its application to a wide range of persons who assist trauma survivors, including clergy (Day, Vermilyea, Wilkerson, & Giller, 2006), front line social service workers (Pryce, Shackelford, & Pryce, 2007), justice system professionals (Levin & Greisberg, 2003; Peters, 2007), health care providers (Madrid & Schacher, 2006; Shah, 2010a), humanitarian workers (Shah, 2007; Pearlman & McKay, 2009), journalists, and first responders (Shah, 2010a).

Contributing factors

Vicarious trauma, conceptually based in constructivist self-development theory (McCann & Pearlman, 1990b; Pearlman & Saakvitne, 1995; Saakvitne, et al., 2000), arises from an interaction between individuals and their situations. This means that the individual helper's personal history (including prior traumatic experiences), coping strategies, and support network, among other things, all interact with his or her situation (including work setting, the nature of the work s/he does, the specific clientele served, etc.), to give rise to individual expressions of vicarious trauma. This in turn implies the individual nature of responses or adaptations to VT as well as individual ways of coping with and transforming it.

Anything that interferes with the helper's ability to fulfill his/her responsibility to assist traumatized clients can contribute to vicarious trauma. Many social service workers report that they experience the demands of their agencies as the greatest impediment to their effectiveness and work satisfaction (Pryce et al., 2007).

Signs and symptoms

The signs and symptoms of vicarious trauma parallel those of direct trauma, although they tend to be less intense. Workers who have personal trauma histories may be more vulnerable to VT, although the research findings on this point are mixed (see Bride, 2004,for a review of this literature). Common signs and symptoms include, but are not limited to, social withdrawal; mood swings; aggression; greater sensitivity to violence; somatic symptoms; sleep difficulties; intrusive imagery; cynicism; sexual difficulties; difficulty managing boundaries with clients; and core beliefs and resulting difficulty in relationships reflecting problems with security, trust, esteem, intimacy, and control (Arvay & Uhlemann, 1996; Bober, Regehr,& Zhou, 2006; Brady, Guy, Poelstra, & Brokaw, 1999; Cunningham, 1999; Ghahramanlou & Brodbeck, 2000; Pearlman, 2003; Schauben & Frazier, 1995).

Related concepts

While the term "vicarious trauma" has been used interchangeably with "compassion fatigue" [link] and "secondary traumatic stress disorder," "burnout," and "countertransference," [link] and "work-related stress," there are important differences. These include the following:

1. Unlike compassion fatigue, VT is a theory-based construct. This means that observable symptoms can serve as the starting for a process of discovering contributing factors and related signs, symptoms, and adaptations. VT also specifies psychological domains that can be affected, rather than specific symptoms that may arise. This specificity may more accurately guide preventive measures and interventions, and allow for the accurate development of interventions for multiple domains (such as changes in the balance between psychotherapy and other work-related tasks and changes in self-care practices).
2. Countertransference is the psychotherapist's response to a particular client. VT refers to responses across clients, across time.
3. Unlike burnout, countertransference, and work-related stress, VT is specific to trauma workers. This means that the helper will experience trauma-specific difficulties, such as intrusive imagery, that are not part of burnout or countertransference (Pearlman & Saakvitne, 1995). The burnout and vicarious traumatization constructs overlap (specifically in the area of emotional exhaustion [Gamble, Pearlman, Lucca, & Allen, 1994]). A worker may experience both VT and burnout, and each has its own remedies. VT and countertransference may also co-occur, intensifying each other (Pearlman & Saakvitne, 1995).
4. Unlike vicarious trauma, countertransference can be a very useful tool for psychotherapists, providing them with important information about their clients.
5. Work-related stress is a generic term without a theoretical basis, specific signs and symptoms or contributing factors, or remedies. Burnout and vicarious trauma can co-exist. Countertransference responses may potentiate vicarious trauma (Pearlman & Saakvitne, 1995).
6. Vicarious post-traumatic growth. Arnold, Tedeschi, Calhoun, and Cann, 2005) reported this phenomenon after interviews with 21 psychotherapists who were asked about the effects their work had on them. Unlike VTF, VPG is not a theory-based construct, but based on self-reported signs.
7. Body-centred countertransference

Mechanism

The posited mechanism for vicarious traumatization is empathy [link](Pearlman & Saakvitne, 1995; Rothschild, 2006; Wilson & Thomas, 2004). Different forms of empathy may result in different effects on helpers. Batson and colleagues have conducted research that might inform trauma helpers about ways to manage empathic connection constructively (Batson, Fultz, & Schoenrade, 1987; Lamm, Batson, & Decety, 2007). If helpers identify with their trauma survivor clients and immerse themselves in thinking about what it would be like if these events happened to them, they are likely to experience personal distress, feeling upset, worried, distressed. On the other hand, if helpers instead imagine what the client experienced, they may be more likely to feel compassion and moved to help.

Measurement

Over the years, people have measured VT in a wide variety of ways. Vicarious trauma is a multifaceted construct requiring a multifaceted assessment. More specifically, the aspects of VT that would need to be measured for a complete assessment include self capacities, ego resources, frame of reference (identity, world view, and spirituality), psychological needs, and trauma symptoms (see McCann & Pearlman, 1990b, Pearlman, 2001, and Saakvitne et al., 2000 for discussions of these realms of the self). Measures of some of these elements of VT exist, including the following: Psychological needs: Trauma and Attachment Belief Scale (Pearlman, 2003). This scale is available through Western Psychological Services, Inc. at www.wpspublish.com. Self capacities: Inner Experience Questionnaire (Pearlman, 1995). Available from Laurie Anne Pearlman at lpearlmanphd@comcast.net Inventory of Altered Self-Capacities (IASC, Briere, 2002). Available from Psychological Corporation. Trauma symptoms:

• PTSD Checklist (PCL, Weathers et al., 1993)
• Impact of Events Scale (IES, Horowitz, 1979)
• Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1996)
• Children's revised Impact of Events Scale - Arabic Version CR-IES13 (Veronese & Pepe, 2013)
• Trauma Symptom Inventory (Briere, 1996)
• Detailed Assessment of Posttraumatic Stress (DAPS, Briere, 2001)

World view: World Assumptions Scale (Janoff-Bulman, 1989)

Addressing

Vicarious traumatization is not the responsibility of clients or systems, although institutions that provide trauma-related services bear a responsibility to create policies and work settings that facilitate staff (and therefore client) well-being (Shah, 2008; Shah, 2010b). Each trauma worker is responsible for self-care (Saakvitne, Pearlman, and the Staff of the Traumatic Stress Institute, 1996), working reflectively (Pearlman & Caringi, 2009), and engaging in regular, frequent, trauma-informed professional confidential consultation (Pearlman & Saakvitne, 1995).

There are many ways of addressing vicarious traumatization. All involve awareness, balance, and connection (Saakvitne et al., 1996). One set of approaches can be grouped together as coping strategies. These include, for example, self-care, rest, escape, and play. A second set of approaches can be grouped as transforming strategies. Transforming strategies aim to help workers create community and find meaning through the work. Within each category, strategies may be applied in one's personal life (Saakvitne et al., 2000; Saakvitne et al., 1996) and professional life(Pearlman & Caringi, 2009). Organizations that provide trauma services can also play a role in mitigating vicarious trauma (Rosenbloom, Pratt, & Pearlman, 1995; Stamm, 1999).

Vicarious transformation

Beyond vicarious traumatization lies vicarious transformation (VTF). This is the process of transforming one's vicarious trauma, leading to spiritual growth. Vicarious transformation is a process of active engagement with the negative changes that come about through trauma work. It can be recognized by a deepened sense of connection with all living beings, a broader sense of moral inclusion, a greater appreciation of the gifts in one's life, and a greater sense of meaning and hope. Like VT, VTF is a process, not an endpoint or outcome. If the clients’ extraordinary pain can be embraced instead of fended off, humanity is expanded. In this receptive mode, caring can be deepened. The clients feel that they are allowed to exert their influence, and this reciprocal process conveys respect. People can learn from trauma survivor clients that people can endure horrible things and carry on. This knowledge is a gift that can be passed along to others.

See also

• Historical trauma

References

• Arvay, M. J., & Uhlemann, M. R. (1996). Counsellor stress in the field of trauma: A preliminary study. Canadian Journal of *Counselling, 30, 193-210.
• Batson, C. D., Fultz, J., & Schoenrade, P. A. (1987). Distress and empathy. Journal of Personality, 55, 19–39.
• Bober, T., Regehr, C., & Zhou, Y. R. (2006). Development of the Coping Strategies Inventory for trauma counsellors. Journal of *Loss & Trauma, 11(1), 71-83.
• Brady, J., Guy, J., Poelstra, P., & Brokaw, B.(1999). Vicarious traumatization, spirituality, and the treatment of sexual abuse survivors. Professional Psychology, 30, 386-393.
• Bride, B. (2004). The impact of providing psychosocial services to traumatized populations. Trauma and Crisis, 7, 29-46.
• Cunningham, M. (1999). The impact of sexual abuse treatment on the sexual abuse clinician. Child and Adolescent Social Work Journal, 16, 277-290.
• Day, J.H., Vermilyea, E., Wilkerson, J., & Giller, E. (2006). Risking connection in faith communities: A training curriculum for faith leaders supporting trauma survivors. Baltimore, MD: Sidran Institute Press.
• Gamble, S.J., Pearlman, L.A., Lucca, A.M., & Allen, G.J. (October 29, 1994). "Vicarious traumatization and burnout in Connecticut psychologists: Empirical findings." Paper presented at the annual meeting of the Connecticut Psychological Association, Waterbury, CT.
• Ghahramanlou, M., & Brodbeck, C. (2000). Predictors of secondary trauma in sexual assault trauma counselors. International Journal of Emergency Mental Health, 2, 229-240.
• Lamm, C., Batson, C. D., & Decety, J. (2007). The neural substrate of human empathy. Journal of Cognitive Neuroscience, 19(1), 42-58.
• Levin, A.P., & Greisberg, S. (2003). Vicarious trauma in attorneys. Pace Law Review, http://digitalcommons.pace.edu/lawrev/520. Accessed November 13, 2009.
• McCann, I. L., & Pearlman, L. A. (1990a). Vicarious traumatization: A framework the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131-149.
• Madrid, P.A., & Schacher, S.A. (2006). A critical concern: Pediatrician self-care after disasters. Pediatrics 117(5), S454-S457.
• McCann, I. L., & Pearlman, L. A. (1990b). Psychological trauma and the adult survivor: Theory, therapy, and transformation. New York: Brunner/Mazel.
• Pearlman, L. A. (2003). Trauma and attachment belief scale manual. Los Angeles: Western Psychological Services.
• Pearlman, L.A. (2001). The treatment of persons with complex PTSD and other trauma-related disruptions of the self. In J.P. *Wilson, M.J. Friedman, & J.D. Lindy (Eds.), Treating psychological trauma & PTSD, pp. 205–236. New York: Guilford Press.
• Pearlman, L.A., & Caringi, J. (2009). Living and working self-reflectively to address vicarious trauma. In C.A. Courtois & J.D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 202–224). New York: Guilford Press.
• Pearlman, L.A., & McKay, L. (2009). Understanding and addressing vicarious trauma. On-line self-study module, Headington Institute, Pasadena, CA. http://www.headington-institute.org/Default.aspx?tabid=2646
• Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: Norton.
• Pryce, J.G., Shackelford, K.K., Price, D.H. (2007). Secondary traumatic stress and the child welfare professional. Chicago: Lyceum Books, Inc.
• Rosenbloom, D.J., Pratt, A.C., & Pearlman, L.A. (1995). Helpers' responses to trauma work: Understanding and intervening in an organization. In B.H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators, pp. 65–79. Lutherville, MD: Sidran Press.
• Rothschild, B. (2006). Help for the helper. New York: Norton.
• Saakvitne, K. W., Gamble, S., Pearlman, L., & Lev, B. (2000). Risking connection: A training curriculum for working with survivors of childhood abuse. Lutherville, MD: Sidran Press.
• Saakvitne, K. W., Pearlman, L. A., & the Staff of the Traumatic Stress Institute (1996). Transforming the pain: A workbook on vicarious traumatization. New York: W.W. Norton.
• Schauben, L.J., & Frazier, P.A. (1995). Vicarious trauma: The effects on female counselors of working with sexual violence survivors. Psychology of Women Quarterly, 19(1), 49-64.
• Shah, S.A. (2010a). Mental Health Emergencies and Post-Traumatic Stress Disorder. In G.B. Kapur & J.P. Smith (Eds). Emergency Public Health: Preparedness and Response(493-516). Boston: Jones and Bartlett Publishers.
• Shah, S.A. (2010b). Three Principles of Effective Staff Care. Monday Developments: The Latest Issues and Trends in International Development and Humanitarian Assistance. Vol 28:12, December 2010, p. 8-10, 30.
• Shah, S.A. (2008). Addressing Stress in National Staff. Monday Developments: The Latest Issues and Trends in International Development and Humanitarian Assistance. Vol 26:9, September 2008, p. 21-22.
• Shah, S.A., Garland, E. & Katz, C. (2007). Secondary Traumatic Stress: Prevalence for Humanitarian Aid Workers in India. Traumatology, 13, 59-70.
• Stamm, B.H. (Ed.) (1999). Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (2nd ed.). Lutherville, MD: Sidran Press.
• Veronese, G. & Pepe, A. (2013) Psychometric proprieties of the Impact of Event Scale (short version) in contexts of military violence. Research on Social Work Practice, 23(6), 710-718.
• Wilson, J. P., & Thomas, R. B. (2004). Empathy in the treatment of trauma and PTSD. New York: Brunner-Routledge.

Further reading

• Hernandez, P., Gangsei, D., & Engstrom, D. (2007). Vicarious resilience: A new concept in work with those who survive trauma. Family Process, 46(2), 229-241.
• Kearney, M.K., Weininger, R.B., Vachon, M.L.S., Harrison, R.L., & Mount, B.M. (2009). Self-care of physicians caring for patients at the end of life. Journal of the American Medical Association, 301(11), 1155-1164.
• Meadors, P.,& Lamson, A. (2009). Compassion fatigue and secondary traumatization: Provider self care on intensive care units for children.
• Journal of Pediatric Health Care, (22)1, 24-34.
• Norcross, J.C., & Guy, J.D. (2007). Leaving it at the office: A guide to psychotherapist self-care. New York: Guilford Press.
• Peters, J.K. (2007). Representing children in child protective proceedings 2007: Ethical and practical dimensions(3rd ed.). LexisNexis Matthew Bender.
• Shah, S.A. (2009). “To do no harm,” Spiritual Care and Ethnomedical Competence: Four cases of Psychosocial Trauma Recovery for the 2004 Tsunami and 2005 Earthquake in South Asia. In G.H. Brenner, D.H. Bush, & J. Moses (Eds.) Creating Spiritual and Psychological Resilience Integrating Care In Disaster Relief Work, 157-178. New York: Routledge.
• Wicks, R.J.J. (2007). The resilient clinician. New York: Oxford University Press.