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Vicarious Trauma and Compassion Fatigue: Organisational and Personal Rights and Responsibilities

“The expectation that we can be immersed in suffering and loss daily but not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet” Rachel Naomi Ramen

Mental and allied health professionals, lawyers, the judiciary, and corrective services staff intersect the lives of others at critical and often traumatic junctures. These professions are frequently indirectly exposed to the traumatic experiences of others through discussion, viewing distressing images, reading police, psychological and medical reports and victim impact statements. They often work with victims of trauma and perpetrators of crimes. Additionally, perpetrators of crime are commonly victims themselves, often childhood trauma and abuse. Professionals may find themselves grappling with seemingly intractable ethical dilemmas, individual vs community and justice vs mercy.

The impact of indirect exposure to trauma is called vicarious trauma (VT) and sometimes called secondary traumatic stress (STS), although there are differences. STS is experienced by professionals who witness the trauma of others but don’t have an ongoing empathic relationship. STS is an acute response. VT is the impact of indirect exposure to another’s trauma in an ongoing empathic relationship. VT is a cumulative impact.

VT is experienced as a profound alteration in a person’s emotional, physical, psychological, and spiritual (meaning and purpose) domains. PTSD-like symptoms may develop in addition to negative changes in sense of Self and identity, innate beliefs, cognitive schemas, and attitudes towards the world and others. Unaddressed, VT can lead to a decrease in a sense of life meaning, or purpose. Compassion fatigue is characterised by emotional and physical exhaustion leading to a diminished ability to empathise or feel compassion for others. It is often described as the negative cost of caring or an occupational hazard.

The impacts of VT can be experienced in all areas of a person’s life; professionally an inability to set boundaries and make ethical decisions, difficulty prioritising workload, with poor outcomes for clients and conflict with colleagues; interpersonal conflicts with partner, family and friends, difficulties with sexual functioning, impaired parenting and divorce; mental and physical health can suffer including emotional numbing, depression, anxiety, substance abuse, sleep disorders and other symptoms of severe stress. VT may at times be a contributing factor in workplace bullying, harassment, unchecked countertransference, and sexual boundary violations in psychotherapy (Steinberg, Alpert, Courtois, 2021) .

Research indicates that trauma therapists with a personal history of trauma are at greater risk of developing VT than therapists who do not have a personal history of trauma (Pearlman, L. A., & MacIan, P. S., 1995). In addition to greater risk of VT they are at further risk of reactivation of past trauma. Many years ago, I worked with a woman who was an experienced ER nurse. One day she arrived at her session and told me she needed to talk about an experience at work. A traffic accident had resulted in the death of two young children, a girl around 8 years and her brother around 10 years old. She was tasked with preparing the body of the little girl for the parents to say goodbye. It was a highly distressing story. My client described the child’s injuries, one of which was a broken jaw. As she was talking, I began to feel my heart race, I could taste the metallic flavour of blood in my mouth. In my mind’s eye I saw images of the undercarriage of a car accompanied with sensations of heat and the smell of petrol. I was re-experiencing an accident I had as an 8 year old, when I was knocked off my bike by a car. One of the injuries I sustained was a broken jaw. As a trauma therapist I was aware of the potential for reactivation of past trauma. This knowledge didn’t prevent it from happening but I was able to ground and soothe myself so I could remain present with my client. It was however a relief when the session ended, and I was able to reflect on the experience. I hadn’t thought about the accident for decades. If it ever came up in conversation, I had never experienced the visceral sensations that arose in the session with my client.

A recent study into VT in corrective services employees in Australia found higher traumatic caseload increases the risk of developing VT, VT increased with each year of employment within the job, non-custodial staff, who are more regularly required to examine narratives of offenders’ crimes would exhibit higher rates of VT than custodial staff, and staff whose role requires them to deal either therapeutically or systematically to reduce offenders’ risk of recidivism are almost three times more likely to experience symptoms of VT than custodial officers who operate from a more punitive perspective (Campbell, J. 2019).

Current life stressors, such as health issues of oneself or a loved one, relationship or financial stressors, common life events that many people experience, can impact resilience, and make a professional more vulnerable to experiencing VT.

In the trauma therapy field research and training around VT have been available for over two decades. Supervision is a safe and confidential forum where psychologists, social workers and counsellors can explore the interaction of transference, countertransference, and VT. This offers the opportunity to identify and address potential difficulties before therapy reaches an impasse and client and therapist potentially harmed. Supervision is not a failsafe solution. Anecdotally, clinicians working within organisations confide that supervision may not occur on a regular basis, that case load levels mean there is not the opportunity to discuss all their clients, that supervision can be taken up with organisational issues rather than clinical discussion or their supervisor may not have the experience to assist with some cases. Clinicians in private practice often work in isolation, which is a VT risk factor. They may not have time or resources to seek regular supervision, which at times has resulted in seeking assistance after a crisis has developed. Budget limitations for professional development training in organisations and private practice is usually prioritised for knowledge and skill development over selfcare. These are not criticisms or judgments but observations about the realities and challenges of the field.

A 2019 survey of 200 lawyers across Australia and New Zealand found 85% reported experiencing anxiety and 60% had experienced depression (Meritas, 2019). Law is a competitive and high-pressured profession. These elements play a significant factor in the high rates of reported depression and anxiety, including concern disclosure of work-related stressors may have a detrimental impact on career prospects. The impact of VT must be considered alongside workplace culture. The legal profession is tackling long standing issues of gender pay inequality, discrimination, bullying, sexual harassment, and assault. The intense nature of legal work may see similar transference and countertransference dynamics as in psychotherapy. Lawyers, probation and parole officers are at similar risk as therapists regarding boundary crossings in their professional relationship with clients.

Law firms in Australia are increasingly recognising impacts on mental health and wellbeing. A growing number of firms provide regular VT training and trauma informed practices, such as how to respond to highly emotionally dysregulated clients and expressions of suicidality.

In mental health, legal and other professions where employees are exposed to direct and indirect trauma, such as paramedics, SES, firefighters, police and military, there are many considerations around supporting mental health and wellbeing. Trauma-informed services (TIS) recognise the high prevalence of trauma in society and therefore, the possibility of trauma experiences in the lives of clients and employees. A TIS is an environment where staff and the individuals they serve feel physically and psychologically safe. This is achieved through developing trauma informed policy, procedures, and protocols at every level of the organisation, including a VT policy.

The following discussion explores mutual obligations of employers and employees through a three-tier approach to creating a psychologically safe work environment that recognises and addresses the inherent risks to mental health of employees exposed to traumatic material and working with highly distressed clients: organisational – interpersonal – personal (Kezelman, C. A., Stavropoulos, P. 2020)

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Organisational Responsibilities

In April 2022, the High Court found in favour of a lawyer working for the Office of Public Prosecutions (OPP), who developed PTSD because of her role in prosecuting serious sex offences. The court found her employer was responsible for her psychiatric injuries or was negligent. A vicarious trauma policy was in place but was not implemented (Kesley-Sugg, A., S. Carrick, D. 2022). The lawyer told her employer that the work was causing her psychological distress, but the OPP denied this was the case. The OPP failed in their duty of care for their employee in this instance.

Implementation of vicarious trauma policy should commence during the recruitment process. Employers should inquire about applicants’ knowledge of VT and explain the inherent risks of the role. Employers should inquire about applicants’ previous exposure to VT risk, training, and implementation of self-care practices. An outline of the organisations VT policy should be provided.

Mandatory VT training should be conducted within four to six months of commencement. Additional trauma informed practice training to increase awareness, knowledge, and skills to work with traumatized clients should also be provided in the same timeframe.

Training designed to meet the unique needs of specific teams, departments and clients should be part of an ongoing professional development program. Risk and need for support measures change over time. Annual reviews of employees needs should be conducted. Individual consultation or supervision should be provided in circumstances where a case or client is particularly challenging or where there has been a crisis impacting an individual employee or team.

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Interpersonal Responsibilities

TIS proactively address tension and conflict within teams. A psychologically safe team environment promotes mutual support and encouragement, where people are encouraged to express ideas and viewpoints without fear. The team is encouraged to discuss the impact of their work formally and informally but not share traumatic details that will distress colleagues. If a team member needs support to discuss the impact of a case, referral to a professional should be provided. Engagement in non-work-related activity is encouraged, such as lunches or other activities where work discussion is not on the menu or team involvement in a charitable event or fundraiser. Junior staff frequently express concern that if they raise issues that are causing them distress that they will be judged as not up to the job. It is incumbent on team leaders, managers and supervisors to lead by example, modelling self-care, openness to discuss aspects of the work they have found challenging, practices that have helped them and support team accountability e.g. taking meal breaks, not working late on a regular basis and regularly checking in to inquire if someone needs assistance.

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Personal Responsibilities

Research shows that 55 – 70% of adults experience at least one traumatic event during their lifetime and 14 – 43% experience at least one traumatic event during childhood. Statistics are higher in First Nation peoples and LGBTQIA+ communities. A survey of 558 mental health and law enforcement professionals indicated that 29.8% of therapists and 19.6% of officers reported experiencing some form of childhood trauma (Follette, Polusny, Milbeck, 1994). Responses to trauma include post-traumatic stress disorder (PTSD), personality disorders, anxiety, substance abuse, eating disorders, dissociative disorders, self-harming behaviours, suicidal ideation, depression, and sometimes, criminal behaviour. I encourage thinking of these trauma responses as trauma adaptations or accommodations rather than disorders.

An organisation has an obligation to provide a psychologically safe work environment but can it be held accountable for reactivation of past trauma because of the nature of the work? Does a prospective employee have a duty to disclose past trauma, a current or past psychiatric diagnosis? Does an employer have the right to ask? If an employee has a history of trauma or psychiatric diagnosis does this mean an organisation cannot be held liable for future psychiatric injury? Is it possible to assess what degree of an employees psychological distress is due to work related issues and how much is reactivation of past trauma? Is this relevant to employer and employee rights and responsibilities? These are not questions I attempt to answer but foresee they may become the subject of future legal proceedings between an employee and employer.

The impacts of trauma can mean that some people may not recognise signs or symptoms of stress. They might not be able to acknowledge their need for help, reach out for, or accept support. Everyone around them, colleagues, family, and friends may see the person is struggling but be ignored, dismissed or pushed away if they express concern. In these extreme situations managers and human resources may need to step in to address concerns.

I do not suggest that people with a history of trauma are unable to be fully functional or capable of fulfilling their professional responsibilities. To the contrary, people with such a history often bring a level of insight, compassion, empathy and humanity born from such experiences that enhance their professional skills and competencies. The personal obligation of the three-tier approach advocates responsibility to support ourselves to the best of our ability at any given point in time with the understanding that our capacity and resilience is not static. It may rise and fall due to internal and external influences.

The activities and behaviours above the waterline on the self-care iceberg are what generally first springs to mind when we think about self-care. They are important activities in our self-care repertoire. Yet, it is the activities below the waterline that are fundamental to maintaining our lives above the waterline. When activities above the waterline do not alleviate stress, bring the same pleasure, relaxation and balance to our lives that they have in the past, it is a call to action, to dig deeper and explore the interaction of our professional and personal life and how they are impacting each other. Exploration can take many forms, journaling, mindfulness practice, yoga, meditation, a retreat, seeking a mentor, entering or returning to therapy. Self-awareness and personal development are key personal obligations to support and develop resilience and assist in protecting ourselves from VT, a very human response to bearing witness to the suffering of others.

VT is not inevitable. Exposure to the trauma of others can lead to vicarious post-traumatic growth (Arnold, Calhoun, Tedeschi & Cann, 2005) or vicarious resilience (Hernandez, Gangsey, Engstorm, 2007). Vicarious resilience (VR) describes the growth that helping professionals (and other professionals) experience through witnessing the experiences and triumphs of victims under adverse circumstances . VR is a positive transformation in one’s worldview and spirituality in response to helping others live through trauma. It leads to a deeper understanding of the world, suffering and humanity’s capacity to overcome adversity, renewed or enriched spirituality, greater value and appreciation of relationships, compassion, understanding of various cultures, fulfilment, sense of purpose, meaning and pleasure. Vicarious transformation is the process of integrating a larger understanding of the human condition and humanity as a result of facing the truth and impact of traumatic events …. a positive transformation in the self of the therapist or other trauma worker that comes about through empathic engagement with the traumatised people we attempt to assist, their courage and their struggles, their losses and their sorrow and active engagement with the changes in ourselves that come about in response to that work, our VT”, ( Saakvitne, Pearlman, 1996). Vicarious transformation is a process, not an endpoint or outcome.  

In the words of the late Leonard Cohen, “there is a crack in everything, that’s how the light gets in”.

Post Script: Vicarious trauma is a significant work related issue that requires a three-tiered approach to address. However, it is important to recognise that VT is not the only mental health challenge organisations face. Bullying, discrimination, sexual harassment, lack of resources and support to fulfil duties and gender pay and power disparities are the root cause of much mental health and work related stress. These issues will be the focus of future articles.

Upcoming training: Befriending the Tiger: Vicarious Trauma, Resilience And Self-Care On The Frontline

On-Demand: Sexual Boundary Violations in Psychotherapy 

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References and Recommended Reading

Arnold, D., Calhoun, L. G., Tedeschi, R., & Cann, A. (2005). Vicarious Posttraumatic Growth in Psychotherapy. Journal of Humanistic Psychology, 45(2), 239–263. https://doi.org/10.1177/0022167805274729

Campbell, J. (2019) The impact of caseload and tenure on the development of vicarious trauma in Australian corrective services employees, Psychotherapy and Counselling Journal of Australia, Vol 7, No. 2, December 2019 https://pacja.org.au/2019/12/the-impact-of-caseload-and-tenure-on-the-development-of-vicarious-trauma-in-australian-corrective-services-employees-2/

Cieslak, R., Shoji, K., Douglas, A., Melville, E., Luszczynska, A., & Benight, C. C. (2014). A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma. Psychological Services, 11(1), 75-86.  https://dx.doi.org/10.1037/a0033798

Figley, C. (1995) Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder In Those Who Treat The Traumatized, Brunner-Routledge, New York & London

Follette, V.M, Polusny, M.M., Milbeck, K. (1994) Mental Health and Law Enforcement Professionals: Trauma History, Psychological Symptoms, and Impact of Providing Services to Child Sexual Abuse Survivors, Professional Psychology: Research and Practice, Vol. 25, No. 3, 275-282

Hernández, P., Gangsei, D., & Engstrom, D. (2007). Vicarious resilience: A new concept in work with those who survive trauma. Family Process, 46, 229-241.  

Kesley-Sugg, A., S. Carrick, D. (2022) Kozarov v State of Victoria: Special leave granted for High Court appeal https://www.abc.net.au/news/2022-05-25/zagi-kozarov-psychiatric-injury-at-work-law-report/101081728 Posted Wed 25 May 2022 at 5:00amWednesday 25 May 2022 at 5:00am, updated Wed 25 May 2022 at 7:14am

Kezelman, C. A., Stavropoulos, P.  (2020), Trauma and the Law: Applying Trauma Informed Practice to Legal and Judicial Contexts, Blue Knot Foundation

Kezelman, C. A., Stavropoulos, P.  (Updated 2020), Organisational Guidelines for Trauma-Informed Service Delivery, Blue Knot Foundation

Landers & Rodgers (June 2021) https://www.landers.com.au/legal-insights-news/kozarov-state-of-victoria-special-leave-granted-high-court-appeal

McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131-149. https://doi.org/10.1007/BF00975140

Meritas Australia and New Zealand Wellness Survey, 2019, https://www.swaab.com.au/assets/download/Meritas-Wellness-Survey-Report.pdf

Newell, J. M., & MacNeil, G. A. (2010). Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue. Best Practices in Mental Health, 6(2), 57-68. Retrieved https://www.ingentaconnect.com/content/follmer/bpmh/2010/00000006/00000002/art00006

Pearlman, L. A., & MacIan, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional psychology: research and practice, 26(6), 558-565. http://dx.doi.org/10.1037/0735-7028.26.6.558

Ramen, R. N. (1996) Kitchen Table Wisdom: Stories that Heal, Penguin New York

Ross, C. A. & Halpern, N. (2009) Trauma Model Therapy: A Treatment Approach for Trauma, Dissociation and Complex Comorbidity, Manitou Communications Inc.

Saakvitne, Karen W.; Pearlman, Laurie A. (1996). Transforming the Pain: A Workbook on Vicarious Traumatization. W.W. Norton.

Steinberg, A. (L.), Alpert, J. L., & Courtois, C. A. (Eds.). (2021). Sexual boundary violations in psychotherapy: Facing therapist indiscretions, transgressions, and misconduct. American Psychological Association. https://doi.org/10.1037/0000247-000

Van der Kolk, B. (2014) The Body Keeps The Score: Mind, Brain and Body in the Transformation of Trauma, Allen Lane

 

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