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Vicarious traumatisation of counsellors andeffects on their workplacesLeo Sexton aa Victorian Foundation for Survivors of Torture , PO Box 96, Parkville,Melbourne, 3052, AustraliaPublished online: 16 Oct 2007.

To cite this article: Leo Sexton (1999) Vicarious traumatisation of counsellors and effects on theirworkplaces, British Journal of Guidance & Counselling, 27:3, 393-403

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British Journal of Guidance 6.I Counselling, Vol. 27, No. 3, 1999 393

Vicarious traumatisation of counsellors and effects on their workplaces

LEO SEXTON Victorian Foundation for Survivors of Torture, PO Box 96, Parkville, Melbourne 3052, Australia

ABSTRACT The literature on therapists’ reactions to clients’ traumatic material is Critically reviewed. The various attempts within this relatively new literature to conceptualise this phenomenon include countertransference, compassion fat ipe and vicarious traumatisation. The limited research evidence is evaluated and found to support anecdotal accounts by trauma therapists. Empathic engagement with trauma survivors is necessa y for effective psychotherapeutic interuention. However, empathic engagement also makes therapists vulnerable to the detrimental effects of vicarious trauma, with consequent negative effects on individual counsellor effectiveness and organisational dynamics in the workplace.

Identifying the effects of working with traumatised clients

While psychological reactions to trauma have been recognised for hundreds of years, under various names such as ‘shell shock‘, ‘combat neurosis’, and ‘combat fatigue’ (Shalev et al., 1996), it is only as recently as 1980 that post-traumatic stress disorder (PTSD) was formally recognised as an anxiety disorder (Matsakis, 1994). Since then, research into PTSD has grown at an exponential rate (Wilson & Lindy, 1994). A recent development has been the emerging literature focusing on the reactions of therapists and other helpers to working with survivors of trauma (Danieli, 1988; McCann & Pearlman, 1990): as Figley (1995) noted, ‘there is a cost to caring’ (p. 1). Increasingly, therapists are being called upon to assist survivors of violent crime, natural disasters, childhood abuse, torture, and acts of genocide, as well as refugees and war-trauma victims. Professionals who listen to reports of trauma, horror, human cruelty and extreme loss can be overwhelmed. They may begin to experience feelings of fear, pain and suffering similar to those of their clients, and to experience similar trauma symptoms, such as intrusive thoughts, nightmares and avoidance, as well as changes in their relationships with the wider community, their colleagues, and their families. They may themselves come to need help and assist- ance to cope with hearing others’ trauma experiences (Figley, 1995; Pearlman & Saakvitne, 1995a; Wilson & Lindy, 1994).

0306-9885/99/030393-11 0 1999 Careers Research and Advisory Centre

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There have been several attempts to identify the deleterious effects that helpers in the trauma field may experience. Terms such as empathic stress, countertransfer- ence, secondary traumatic stress, compassion fatigue, burnout and vicarious trauma- tisation have been proposed (Figley, 1995; McCann & Pearlman, 1990; Wilson & Lindy, 1994). While there is considerable overlap among these theoretical con- structs, there are also differences which have yet to be integrated. This may be because the field of psychotraumatology is still young and as yet there has been only limited research to examine these constructs (Figley, 1995).

An essential component of successful trauma therapy is the creation of a safe therapeutic environment and a trusting relationship between client and therapist. The therapist’s capacity for sustaining an empathic connection with the client is critical to achieving these goals, as well as being critical to the recovery process as a whole (Wilson & Lindy, 1994). While empathy is necessary in any form of psychotherapy, it is both more important and more difficult to maintain over the course of trauma therapy. This is due to the intense nature of emotional reactions which may be elicited in the therapist, leading to strong countertransference reac- tions that can rupture the empathic stance of the therapist (ibid.).

The concepts of transference and countertransference have their roots in psychodynamic therapy and traditionally refer to the reciprocal impact that the client and therapist have on each other (&id.):

‘In the transference the client misunderstands the present in terms of the past; and then instead of remembering the past, he strives, without recog- nising the nature of his actions, to relive the past in the present. He transfers the past attitude to the present’ (Chessick, 1986, p. 14).

Within the countertransference literature there is some debate over the definition of countertransference, particularly how inclusive the definition should be. Pearlman & Saakvime (1 995a) defined countertransference as ‘( 1) the affective, ideational, physical responses a therapist has to a client, his clinical material, transference and re-enactments, and (2) the therapist’s conscious and unconscious defences against affects, intrapsychic conflicts and associations aroused in the former’ (p. 23). They also argued that countertransference is a feature of every psychotherapeutic relation- ship and that unrecognised and unanalysed countertransference reactions inevitably obstruct accurate empathy and the therapeutic process. The affective, ideational and physical responses of countertransference in trauma counselling can include sadness, rage, fear, grief, shame, anxiety, horror, self-doubt, confusion, intrusive images, nightmares, somatic reactions, sleep disturbance, agitation, and drowsiness (Danieli, 1988; Pearlman & Saakvitne, 1995a; Wilson & Lindy, 1994).

Wilson & Lindy (1994) identified two types of defensive countertransference reaction by trauma therapists: avoidance reactions and over-identification reactions. Avoidance countertransference reactions are characterised by denial, minimisation, distortion, counter phobic reactions, detachment and disengagement from an em- pathic stance. In contrast, over-identification involves idealisation, enmeshment, and excessive advocacy for the client, as well as guilt due to the therapist’s perceived

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failure to provide adequate assistance. These defensive therapist reactions can compromise a client’s recovery.

Trauma-specific transferences are those in which the client unconsciously relates to the therapist in ways that involve unresolved aspects of the trauma event. In these transferences, the client casts the therapist into one or more of the roles associated with the original trauma. The therapist may feel as though he or she has entered the role and is responding to the client’s transference with a countertransfer- ence reaction. The role enactments can be either positive, such as the role of rescuer, or negative, as in the role of perpetrator (Wilson & Lindy, 1994).

Pearlman & Saakvitne (1 995a) suggest that countertransference reactions can be useful tools for the therapist to gain greater understanding of the client during the course of therapy. Trauma survivors are often unaware of their affective experience. The therapist, by attending to the countertransference reaction in his or her self, can become aware of the client’s unconscious feelings. The therapist may experience the client’s rage, fear, grief, shame, and self-doubt. When this happens, it is important that the therapist understand, acknowledge and process these feelings in h iderse l f . Countertransference reactions are not always easily identified because aspects of these reactions are, at first, unconscious. It is therefore necessary to provide opportunities for self-analysis and supervision to work through countertransference reactions. Through reflecting on countertransference reactions in this way, the therapist can gain valuable information about the client, the therapist and their relationship.

Figley (1 995) proposed a concept of secondary traumatic stress, more recently called the phenomena of compassion fatigue. He defined secondary traumatic stress as ‘the natural consequent behaviours and emotions resulting from knowing about a traumatising event experienced by a significant other and the stress resulting from helping or wanting to help a traumatised or suffering person’ (p. 7). He argues that the secondary traumatic stress concept includes, but is not limited to, counter- transference reactions.

In contrast to burn-out, which is ‘a syndrome of emotional exhaustion, deper- sonalisation, and reduced personal accomplishment that can occur among individu- als who do people work of some kind’ (Maslach, 1976, p. 3), secondary traumatic stress can involve a rapid onset of PTSD-like symptoms, as well as feelings of helplessness, confusion and isolation from supporters. The symptoms are discon- nected from the counsellor’s real life circumstances, but there is a faster recovery than in burn-out. Secondary traumatic stress sufferers can experience the full range of intrusive, avoidance and arousal symptoms that are typical of PTSD sufferers.

Vicarious traumatisation as conceptualised originally by McCann & Pearlman (1990) appears to be the most comprehensive account presented so far. ‘Vicarious traumatisation is the cumulative transformation in the inner experience of the therapist that comes about as a result of empathic engagement with the client’s traumatic material’ (Pearlman & Saakvitne, 1995a, p. 31). Whereas counter- transference occurs in all psychotherapies and is a temporary response to a particular client, vicarious traumatisation is the result of an accumulation of experiences across many therapy situations. The effects of vicarious traumatisation ripple beyond the

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particular therapy to other client-therapist relationships as well as to the therapist’s personal and professional life.

The vicarious traumatisation construct as described by Pearlman 81 Saakvitne (zbid.) includes: (a) the therapist experiencing the signs and symptoms of his or her clients, such as anxiety, depression and PTSD symptoms; (b) disruption of the therapist’s self-protective beliefs about safety, control, predictability and attachment; (c) the therapist sometimes being a helpless witness to a client’s repetitive self- destructive or suicidal behaviour; (d) and vicarious traumatisation also manifesting itself in cynicism, despair and loss of hope by the therapist.

Based on their research, personal experience and extensive consultation with therapists in the field, Pearlman & Saakvitne (ibzd.) contend that vicarious traumati- sation is an occupational hazard that will affect all trauma therapists, at least to some extent, at some point in their career. They also argue that the effects of vicarious traumatisation can be modified and ameliorated if they are made conscious and addressed proactively. They believe that trauma therapists need to identify vicarious traumatisation in themselves, and to accept it as a normal response, before they are free to develop strategies and seek support to counteract its effects. They see this as an ethical imperative in order to protect both clients and therapists.

Empirical research into working with the traumatised

To date most of the literature on the effects upon therapists of working in the trauma field has been based on the anecdotal experiences of therapists. As yet there has been very little systematic research in the field. Two of the most notable studies to date have been Danieli’s (1988) study of the countertransference reactions of therapists working with survivors of the Nazi Holocaust and their children, and Pearlman & Mac Ian’s (1995) survey of vicarious traumatisation among 188 self-identified trauma therapists.

Danieli (1988) conducted in-depth interviews with 61 trauma therapists to examine the nature of their emotional responses, and other problems they experi- enced in connection with their work. Content analysis of the interviews resulted in 49 countertransference themes emerging. The most frequently reported themes included: therapist defences (numbing, avoidance, denial, distancing); bystander guilt; rage; shame; horror; grief; privileged voyeurism; and casting the client as victim or alternatively as hero. Until similar research is replicated for therapists who work with other traumatised populations, it remains unclear as to how specific these countertransference themes are to working with Holocaust survivors, and how generalisable they are to working with other traumatised populations.

Pearlman & Mac Ian (1 995) used a questionnaire to survey trauma therapists’ exposure to clients’ traumatic material and to measure therapists’ psychological well-being. Their study found that those therapists who had a personal experience of trauma in their lives reported greater vicarious traumatisation than did those without a personal trauma history. Therapists with a personal trauma history were also more adversely affected by greater length of time doing the work and by the percentage of trauma survivors in their overall caseload. Of the sample, 60%

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reported a history of personal trauma. Pearlman & Saakvitne (1995a) suggest that therapists with a history of trauma may be attracted to working with trauma survivors. While their own experiences may give them greater sensitivity and insight into the affects, needs and defences of trauma clients, it may also make them more vulnerable to vicarious traumatisation. Novice therapists in the study experienced the most severe difficulties. This finding supports claims by Neumann & Gamble (1995) that therapists new to the trauma field are particularly vulnerable to vicarious traumatisation, particularly if adequate education about vicarious traumatisation or adequate organisational support and supervision are not provided.

Experienced therapists without a trauma history reported greater disconnection from their own inner experience. This may be a therapist’s way of not feeling as intensely the pain of their clients. Furthermore, they reported lower concern for others, probably due to constant exposure to the effects of human cruelty (Pearlman & Mac Ian, 1995). Clearly, these effects are likely to have an undesirable impact on a therapist’s relationships with clients, with others, and his or her own inner life. These results strongly support the argument that even experienced trauma therapists need to actively seek professional consultation and support in order to transform the dehumanising effects of trauma work.

Impact of vicarious traumatisation on organisations

When therapists are suffering, there is likely to be a consequent detrimental effect on the organisations within which they work. The quality and effectiveness of the organisation’s work can be compromised. Therapists who do not adequately deal with vicarious traumatisation are likely to experience more disruption of their empathic abilities, resulting in therapeutic impasses and more frequent incomplete therapies. Therapists are also likely to have greater trouble maintaining a therapeutic stance, and to engage in more boundary violations (Neumann & Gamble, 1995; Pearlman & Saakvitne, 1995a). Resignation due to vicarious traumatisation can result in high staff turn-over. Loss of experienced and skilled staff can necessitate additional costs of employing and training new staff. When replacing staff with inexperienced trauma therapists, the organisation must contend with the fact that these novices are likely in turn to suffer more from vicarious traumatisation and to require more support and supervision compared with their more experienced col- leagues (Neumann & Gamble, 1995; Pearlman & Mac Ian, 1995). Furthermore, there is likely to be loss of energy, commitment and optimism among staff generally, with a consequent depressing effect on organisational climate and culture.

Given that vicarious traumatisation is an inevitable occupational hazard for therapists working with the severely traumatised (Pearlman & Saakvitne, 1995a), it clearly raises important occupational health and safety issues in the field. It may be that one day organisations will be subject to compensation claims or litigation by employees claiming psychological injury at work by vicarious traumatisation, partic- ularly in circumstances where an organisation has not initiated preventive structures and strategies to reduce the likelihood of vicarious traumatisation and to ameliorate its effects.

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Moylan (1 994) suggests that there are powerful unconscious processes that operate in human service organisations. If these processes remain unconscious, the whole organisation can become caught up in a similar ‘state of mind’ to the client group it serves. The more distressed the client group, the stronger the unconscious countertransference effects are on staff, and the more likely it is that the issues of the clients will be played out within the organisation. Similarly, Bustos (1990), writing about the experiences of rehabilitation organisations for refugee survivors of torture and trauma, argued that the ‘pathological reactions of the patient, transmitted through the individual therapist, are projected onto the organisation’ (p. 145), creating an organisational climate of anxiety and threat. Clients’ conflicts interact with staff and organisational tensions, resulting in a distortion of interpersonal relations. The internalisation of the relationship between tormentor and tortured leads to the perception of the world in dichotomous terms, as good and evil, us and them. This type of thinking encouraged by regression leads to paralysing depression or splitting and paranoid ways of interpreting reality, which in turn lead to organisa- tional psychopathology.

Organisational strategies for managing vicarious traumatisation

Given the apparently serious effects of secondary or vicarious exposure to traumatic material for trauma therapists, their clients, and the organisations that employ them, it is important that prevention and management of this phenomenon is taken seriously by all concerned.

Traditional counselling and psychotherapy training does not generally equip therapists to deal with massive trauma and its long-term effects (Danieli, 1994) and as yet there are few graduate programmes in Great Britain, USA or Australia providing courses on survivor issues (Pearlman & Saakvitne, 1995b). Yassen (1995) suggests that, in the past, training schools for psychotherapists have perpetuated societal denial of the prevalence and impact of violence and trauma in people’s lives. Clearly, an important aspect of preparing trauma therapists is adequate training. The International Society for Traumatic Stress Studies has begun to address this lack of training by developing a model curriculum. A key component of this curriculum is training in the identification and working through of intense counter- transference experiences (Danieli, 1994).

The overwhelming weight of opinion in the literature is that countertransfer- ence and vicarious traumatisation are normal responses to empathic engagement with traumatised clients (Danieli, 1994; Pearlman & Saakvitne, 1995a). The impli- cation is that the therapist should not need to feel ashamed of such reactions, nor should others blame or attribute the reactions to some personality difficulty: their cause is the nature of the work itself. It is important for organisations to foster an environment in which work-related stress is accepted as real and legitimate; where the problem is owned as an organisational one and not just as an individual one; where the focus is to seek solutions rather than attribute blame; and where support and tolerance are clearly expressed to the suffering therapist (Catherall, 1995).

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Organisations can ensure that adequate resources are made available to help therapists to process disturbing clinical material (Figley, 1995). This can be done in a variety of ways, including clinical supervision or consultation, case conferences, peer process groups, personal psychotherapy, trauma therapy training, professional development and regular organisational team meetings (Neumann & Gamble, 1995). Sometimes it is useful to engage external consultants in order to provide objectivity in dealing with vicarious traumatisation issues where the organisational dynamics may be part of the problem (Pearlman & Saakvitne, 1995a).

Supportive structures for the processing of traumatic material in and of them- selves do not guarantee that staff will use them effectively. McCann & Pearlman (1990) describe allocating specific time within their case conferences to the sharing of feelings related to the work. They also noted the ambivalence the staff feel in discussing their trauma-related reactions: on one hand, a need to verbalise the trauma; on the other, a wish to protect their colleagues from the trauma they carry. Staff may also feel ashamed or professionally exposed and hence avoid sharing their pain and vulnerabilities with their colleagues. This can be addressed by fostering an explicitly supportive, accepting and non-judging work culture (Neumann & Gamble, 1995).

Teamwork is also highly desirable, offering mutual support, sharing and reflection (Comaz-Diaz & Padilla, 1990). Munroe et al. (1995) propose a team treatment model. They argue that a key factor in preventing secondary traumatic stress is strengthening social networks. The team functions as a social network for the therapist and provides opportunities to work through secondary traumatic stress by validation of feelings and supportive relationships. The team can absorb individ- uals’ trauma by diffusing it among the members and demonstrating understanding of individual experiences. The team model also has advantages in dealing with disagreements within the staff. Team meetings can provide an opportunity to identify, work through and resolve destructive divisions within the staff that have been amplified by clients’ traumatic transferences. Teamwork can provide a sense of shared responsibility within the team for clinical work, by sharing the burden. It can also facilitate greater accountability for therapists’ clinical work.

Wherever possible, the organisation should assist therapists to maintain realistic limits and boundaries on their work. Clear and manageable caseloads must be formally set, and excessive commitment to work should be discouraged. Above all, organisations should avoid being bureaucratic, impersonal and disempowering, since this leads to feelings of helplessness which exacerbate the experience of vicarious traumatisation (Catherall, 1995).

Individual strategies for managing vicarious traumatisation

Therapists need to learn to: (a) identify their own reactions and those salient themes that elicit strong countertransference reactions; (b) develop awareness of their own specific somatic signals of distress; (c) understand early warning signs of vicarious traumatisation in themselves; and (d) accurately name and articulate their own trauma-related inner experience and feelings. Therapists should understand their

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personal tolerance for hearing traumatic material, and remain confident that strong aversive emotions will subside, rather than being overwhelming. This realisation can assist therapists in staying empathically engaged rather than resorting to defensive countertransference reactions (Danieli, 1994).

Therapists need to acknowledge that a personal history of trauma, as well as other unworked-through negative experiences, is likely to interact destructively with the client’s trauma. When feeling hurt, the therapists should take time to heal and recover (Danieli, 1994). They should also be aware that other major life stressors will make them more vulnerable to the effects of secondary traumatic stress (Figley, 1995). It is important to maintain a fulfilling personal life and to keep clear boundaries with work in order to counteract the effects of vicarious traumatisation. This requires identifying creative, regenerating and healing activities, such as: art; music; time with family, friends and children; writing; exercise; dancing; hobbies; meditation; and other recreational activities. Developing and maintaining a network of people who can offer support and with whom trauma-related work can be shared also seems to be important (Danieli, 1994; Pearlman & Saakvitne, 1995b).

Several authors in the field also suggest that it is important to attend to one’s spiritual life, because vicarious traumatisation damages a person’s sense of meaning, connection and hope. Efforts need be made to find a way to restore faith in something larger than one’s self. Maintaining realistic optimism, hopefulness and a sense of humour in the face of the traumatic experience of clients is a difficult but essential aspect of being an effective trauma therapist (McCann & Pearlman, 1990; Munroe et al., 1995; Pearlman & Saakvitne, 1995b).

A useful and practical contribution to the management of vicarious trauma has been Saakvitne & Pearlman’s (1 996) self-help workbook Trunsfoming the Pain. Their book is a resource for therapists to identify, manage and transform the effects of vicarious trauma. It provides a good summary of the theory, self-assessment tools and therapeutic exercises for individuals, dyads and groups.

A vital element of a trauma therapist’s self-care and professional accountability is to arrange regular supervision or consultation, regardless of his or her level of experience. The work is too demanding to do without supervision, and this should be understood as an ethical responsibility. If supervision is not available at work, outside arrangements should be made (Pearlman & Saakvitne, 1995a; Yassen, 1995).

Pearlman & Saakvitne (1 995a) suggest four key components of trauma therapy supervision: (a) a solid theoretical grounding in trauma therapy; (b) attention to both conscious and unconscious aspects of the therapeutic relationship; (c) attention to countertransference and parallel processes; and (d) education about, and explo- ration of, manifestations of vicarious traumatisation. Supervision can provide oppor- tunities to acknowledge, express and process horrific stones, graphic imagery and destructive re-enactments that are an inevitable part of the work. Supervision can offer a supportive, confidential and professional relationship within which the therapist can work through these difficult issues (Pearlman & Mac Ian, 1995).

Pearlman & Saakvitne (1 995a) argue against authoritarian and expert-based models of supervision, in favour of a more relational and interactive model. This is

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important if supervision is to offer a safe relationship within which the therapist can be honest and open. Therapists who are themselves survivors of trauma may require more supervision to help disentangle their unresolved issues from those of their clients. They may also benefit from undertaking their own psychotherapy to help resolve aspects of their own trauma.

Other alternatives to one-to-one supervision include peer consultations and group supervision. Peer consultation involves two clinicians taking turns to consult with each other about their work. Group supervision can consist either of a small group of peers sharing responsibility for the group, or of a group meeting with an experienced trauma therapist facilitating the group (Pearlman & Saakvitne, 1995a). The advantage of group supervision is that participants learn from the experiences of a number of colleagues. The disadvantage is there is less time to focus on any one individual’s issues, and that it can be more difficult to establish trust within a group than in a one-to-one supervisory relationship.

Given the importance of supervision for trauma therapists’ self-care and clients’ protection, Pearlman & Mac Ian’s (1995) finding that only 53% of their sample of 1 88 self-identified trauma therapists received any form of trauma-related supervision is of concern. Pearlman & Saakvitne (1995a) identify several deterrents that may influence therapists not to engage in supervision. Some therapists erroneously believe that only inexperienced therapists need supervision. They may feel too embarrassed or professionally vulnerable to admit to a supervisor that they are struggling. Some therapists deny the emotional impact of the work, believing that they can stay cold and objective and still be effective, while others fear a breach of client confidentiality if they were to discuss a case with a consultant. The availability and cost of competent and appropriate supervision are also another barrier. Where appropriate supervision cannot be found within the workplace, the cost of arranging it privately can be prohibitive for those therapists on relatively low incomes in the public sector. Finally, a prior negative experience of supervision can deter a therapist from seeking supervision again. It is important that therapists interview and choose a consultant who can provide a respecthl, safe, yet challenging, experience of supervision.

For the therapist, an important aspect of self-care and nurturance is to remem- ber why one chooses to do trauma work and to appreciate the inherent rewards it offers. To be part of the healing process can be transforming, inspiring and rewarding for the therapist. The work is challenging and demands that therapists plumb new depths in themselves, discovering new skills and a deeper humanity. Clients’ courage and determination can inspire a deepening in personal growth in the therapist. Also, working with clients who have lost so much can instil a profound appreciation for much that is taken for granted in life: beauty, joy, nature and love. Working with various populations of trauma survivors can be an action of great social and political meaning. Witnessing the trauma of those that have been hurt by society, trying to repair the damage, and speaking out about such injustices can provide the therapist with a strong sense of social purpose and meaning in life (Comas-Diaz & Padilla, 1990; Neumann & Gamble, 1995; Pearlman & Saakvitne, 1995a).

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Conclusion

Available research and clinical experience is clear in acknowledging the pervasive and deleterious effects of empathic engagements with survivors of trauma. These effects have been variously called empathic strain, countertransference, secondary traumatic stress, compassion fatigue and vicarious traumatisation. Regardless of label, the experience has serious implications for trauma therapists, trauma therapy and organisations that treat traumatised clients. The symptoms, issues and conflicts experienced by trauma therapists and organisations parallel the traumatic sequelae experienced by survivors. While the impact upon therapists is unavoidable, it can be ameliorated by proactive strategies implemented by trauma treatment agencies and by individual therapists. Strategies suggested in the literature include: development of specialised trauma therapy training programmes; creating an organisational cul- ture that acknowledges and normalises vicarious trauma reactions and offers practi- cal support; and opportunities for therapists to process the impact of their clients’ traumatic material. In addition, it is important that therapists take time to reflect on their experiences and to develop self-awareness of their reactions to the work. It is recommended that therapists maintain a range of supportive professional relation- ships, such as supervisors, colleagues, and team members, with whom they can discuss and process their reactions. It is also important to balance the demands of work with an active and hlfilling personal life. Finally, a crucial element of the trauma therapist’s self-care and ethical responsibility is to arrange regular super- vision or consultation, regardless of level of experience.

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