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PREVENTING VICARIOUS TRAUMATIZATION OF MENTALHEALTH THERAPISTS:
IDENTIFYING PROTECTIVE PRACTICES
RICHARD L. HARRISON AND MARVIN J. WESTWOODUniversity of British
Columbia
This qualitative study identified protectivepractices that
mitigate risks of vicarioustraumatization (VT) among mental
healththerapists. The sample included six peer-nominated master
therapists, who re-sponded to the question, How do youmanage to
sustain your personal andprofessional well-being, given the
chal-lenges of your work with seriously trau-matized clients? Data
analysis wasbased upon Lieblich, Tuval-Mashiach,and Zilbers (1998)
typology of narrativeanalysis. Findings included nine majorthemes
salient across clinicians narra-tives of protective practices:
counteringisolation (in professional, personal andspiritual
realms); developing mindful self-awareness; consciously expanding
per-spective to embrace complexity; activeoptimism; holistic
self-care; maintainingclear boundaries; exquisite empathy;
pro-fessional satisfaction; and creating mean-ing. Findings confirm
and extend previ-ous recommendations for amelioratingVT and
underscore the ethical responsi-
bility shared by employers, educators,professional bodies, and
individual prac-titioners to address this serious problem.The novel
finding that empathic engage-ment with traumatized clients appeared
tobe protective challenges previous concep-tualizations of VT and
points to excitingnew directions for research, theory, train-ing,
and practice.
Keywords: vicarious trauma, preven-tion, compassion fatigue,
countertrans-ference, empathy
The risks of working directly with traumatizedindividuals on a
regular basis are well docu-mented (Arvay, 2001; Buchanan,
Anderson,Uhlemann, & Horwitz, 2006; Figley, 2002; Pearl-man
& Mac Ian, 1995). McCann and Pearlman(1990) first identified
the problem of vicarioustraumatization (VT), which they defined as
thecumulative transformative effects upon therapistsresulting from
empathic engagement with trau-matized clients. As part of their
work, these cli-nicians must listen to graphically detailed
de-scriptions of horrific events and bear witness tothe
psychological (and sometimes physical) af-termath of acts of
intense cruelty and/or violence.The cumulative experience of this
kind of em-pathic engagement can have deleterious effectsupon
clinicians, who may experience physical,emotional, and cognitive
symptoms similar tothose of their traumatized clients (Pearlman
&Saakvitne, 1995a, 1995b; Sexton, 1999). How-ever, there is
consensus in the field that there isnot enough empirical literature
on the definitivefactors that contribute to VT, nor the
practicesthat may prevent or ameliorate its harmful effects(Arvay,
2001; Figley, 2004; Pearlman, 2004).
Although research and theory have begun toemerge about VT
vulnerability and treatment(Figley, 1995, 2002; Saskvitne &
Pearlman,
Richard L. Harrison and Marvin J. Westwood, Departmentof
Educational and Counseling Psychology, and Special Ed-ucation,
University of British Columbia.
This article was based on the doctoral dissertation research
bythe principal author, which was generously funded by the
SocialSciences and Humanities Research Council of Canada and
theMichael Smith Foundation for Health Research in partnershipwith
WorkSafe BC (Workers Compensation Board of BritishColumbia). The
primary author wishes to thank his dissertationcommittee (Drs.
Marvin Westwood, Marla Buchanan, and Wil-liam Borgen) for their
insight, rigor, and warmhearted support.
Correspondence regarding this article should be addressed
toRichard L. Harrison, Vancouver Couple and Family Institute,Suite
270, 828 W. 8th Ave, Vancouver, BC, Canada, V5Z 1E2.E-mail:
[email protected]
Psychotherapy Theory, Research, Practice, Training 2009 American
Psychological Association2009, Vol. 46, No. 2, 203219
0033-3204/09/$12.00 DOI: 10.1037/a0016081
203
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1996), it is equally important to understand whatprotects and
sustains clinicians in their work withtraumatized populations. When
individualstrained in the helping professions abandon thefield,
because of a perceived burden of caring andan insufficient ability
to balance work with otheraspects of life, this constitutes an
enormous lossof resources and potential. When clinicians con-tinue
working, despite suffering from the damag-ing effects of VT, this
constitutes a tremendousdisservice to both clients and therapist,
and thehealth of our community is undermined. It isimperative to
address these concerns on ethicalgrounds, as clinicians and
researchers alike muststrive to provide appropriate, effective care
fortraumatized clients as well as those who workwith them.
To date, very little is known about the successand satisfaction
of clinicians who are able tomanage in the workplace despite the
potentiallynoxious demands of their work with traumatizedclients.
This study explored individual and orga-nizational practices that
contribute to the profes-sional satisfaction and well-being of
experiencedclinicians who work with traumatized clients andto the
sustainability of their efforts in the work-place. The purpose of
the investigation was togain and share knowledge about these
protectivepractices, and ultimately contribute to the preven-tion
of VT.
Review of the Literature
Over the past 15 years, researchers and theoristshave given
increasing attention to the construct ofVT, defined by Pearlman and
Saakvitne (1995b) asthe negative transformation in the inner
experienceof the therapist that comes about as a result ofempathic
engagement with clients trauma mate-rial (p. 31). McCann and
Pearlman (1990) firstidentified and conceptualized VT as an
interactive,cumulative, and inevitable process, distinct
fromburnout or countertransference (CT). They positedthat all
therapists working with survivors of traumaexperience pervasive and
enduring alterations incognitive schema that impact the trauma
workersfeelings, relationships, and life. Whether thesechanges are
destructive to the therapist and tothe therapeutic process,
depends, according tothese authors, largely on the extent to
whichclinicians are able to engage in their own pro-cess of
integration and transformation of cli-ents horrific traumatic
material.
Figley (1995, 1999, 2002) identified a relatedconstruct,
Secondary Traumatic Stress (STS),which he described in terms of the
cost of caringfor others in emotional pain (Figley, 1995, pp.
9)that has led clinicians to abandon their work withtraumatized
persons. According to Figley, bothdirect and indirect exposure to
traumatic eventscan be traumatizing and lead to a similar set
ofPTSD-like symptoms. He proposed the existenceof secondary
traumatic stress disorder (STSD), asyndrome of symptoms that
parallel those ofPTSD, among those who care for victims oftrauma.
In the case of STSD, the primary expo-sure to traumatic events by
one person becomesthe traumatizing event for the second
person.Figley considers STS to be a natural, treatable,and
preventable consequence of empathic en-gagement with suffering
people. He recognizedthe importance of warning clinicians in
trainingof the risks associated with caring for the trau-matized.
He also recognized the potential forclinicians suffering from STS
to find a renewedsense of hope, joy, and purpose. Figley also
pop-ularized the term Compassion Fatigue, previouslyemployed by
Joinson (1992) to describe burnoutamong nurses. The terms STS and
CompassionFatigue are used interchangeably.
Arvay (2001) provided an overview of re-search findings on STS,
most of which involvedthe use of surveys and standardized
instruments.She suggested that VT and STS are the samephenomenon.
The number of traumatized clientsin a therapists caseload appeared
to be a factorrelated to development of STS. Working exclu-sively
with traumatized clients was found to bepositively correlated with
development of STSsymptoms, as were years of experience in thefield
and level of education. Younger clinicians,and those with less than
a masters degree werefound to be more vulnerable. The research
wasinconclusive (or contradictory) with regard towhether therapist
personal history of trauma iscorrelated with the risk of STS. There
was aconsensus that VT/STS is distinct from burnout.
VT Versus Countertransference and BurnoutUnlike CT, which is
typically construed as a
short-term response that occurs and is containedwithin the
context of a therapy session, VT in-volves long term alteration in
therapists owncognitive schemas, or beliefs, expectations,
andassumptions about self and others (McCann &
Harrison and Westwood
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Pearlman, 1990, p. 132). Moreover, VT stands inclear
contradistinction to the classical definitionof CT, as described by
Hayes (2004), becausetraumatic events in the clients life account
forclinician VT. Whereas the clinician is the locus oforigin for
classical CT, which is elicited by theclients material but based
upon preexisting per-sonal characteristics of the therapist (e.g.,
uncon-scious, childhood based, inner conflict). ClassicalCT is
understood to be an intrusion of a clini-cians own unresolved
material, including previ-ous trauma experiences, retaliatory or
aggressivefantasies, and so forth. Hayes differentiated be-tween
the classical and subsequent, expanded,definitions of CT. There
appears to be some over-lap between the construct of VT and an
ex-panded, totalistic definition of CT, in which alltherapist
reactions to a client, whether consciousor unconscious,
conflict-based or reality-based, inresponse to transference or some
other material,were considered CT (Hayes, 2004, p. 6).
None-theless, VT extends beyond the latter, inasmuchas it is
cumulative across clients, manifests out-side the therapy hour, and
permeates the clini-cians life and worldview. Gelso and Hayes
of-fered a third, integrative conception (Hayes,2004, p. 7) of CT,
in which CT reactions mayinclude conscious responses to phenomena
otherthan transference, provided the source of thesereside within
the therapist. In contrast to thisintegrative conceptualization of
CT, VT origi-nates in external traumatizing events. More-over,
while unmanaged CT risks injuring thetherapeutic process and client
treatment out-comes (Hayes, 2004), VT risks damaging thetherapist.
Consequently, VT extends beyondand differs from even the most
encompassingdefinitions of CT. Walker (2004) underscoresthis
difference, stating:
[R]esearchers . . . agree that working with traumatized clients
haspotentially considerable and often long lasting negative
effectson therapists (see also Kirk, 1998; Walker, 1992). These
aredifferent from countertransference responses in that they have
anongoing and extensive effect that impacts powerfully on
manyaspects of the therapists self and world. (pp. 179)
According to Pearlman and Saakvitne (1995a;1995b), VT increases
therapist susceptibility tosome CT responses, which may be less
recogniz-able and hence more problematic in therapy.
Not-withstanding differences between VT and CT,knowledge about CT
management is presumablygermane to VT prevention (see below).
McCann and Pearlman (1990) suggested thatthere is some overlap
between conceptualizationsof VT and burnout, inasmuch as symptoms
ofburnout may be the final common pathway ofcontinual exposure to
traumatic material that can-not be assimilated or worked through
(p. 134).In burnout, the nature of the external event is thesource
of distress (as contrasted with the internalfocus of CT). Burnout
is related to the worksituation (e.g., a high stress work
environmentwith low rewards, in which minimum workergoals are
unachievable, or in which worker lackscontrol over unfair
conditions) (Maslach, 1982;Maslach, Schaufeli, & Leiter, 2001)
but not to theinterpersonal interactions specific to VT (Pearl-man
& Saakvitne, 1995a, 1995b). Burnout lacksthe specificity of
therapist exposure to the emo-tionally disturbing images of
suffering and horrorcharacteristic of serious traumas (McCann
&Pearlman, 1990).
Managing CT
According to Hayes (2004), research and the-ory suggest that
therapist self-insight, self-integration, conceptual ability,
empathy, and anx-iety management facilitate management of CT.Hayes,
Gelso, Van Wagoner, and Diemer (1991)conducted a survey study
designed to provide aninitial empirical basis for understanding the
man-agement of CT from the perspective of experts inthe field.
Their findings suggested that CT stemsfrom a therapists inability
to disengage fromidentification with a client, rather than from
em-pathy itself, which involves a process of partial ortrial
identification balanced with relative disen-gagement (standing back
and observing). Theirfindings suggested that therapist
self-integrationand self-insight, including cohesion of
self,selfunderstanding, and differentiation of selffrom others,
played the most important role inmanaging CT. Similarly, Van
Wagoner, Gelso,Hayes, and Diemer (1991) identified five quali-ties
theorized to be important in the managementof countertransference
feelings (p. 412). Basedon survey data completed by 93
experiencedcounseling professionals, they found that reput-edly
excellent therapists, when contrasted withtherapists in general,
were viewed by colleaguesas: (a) having greater insight into the
nature andbasis of their feelings; (b) possessing increasedcapacity
for empathy; (c) better able to differen-tiate between client needs
and their own; (d) less
Preventing Vicarious Trauma
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anxious both in session with clients and in gen-eral; and (e)
more adept at case conceptualiza-tion, all of which were theorized
to contribute tobetter management of CT or
overidentification.However, the authors stated much caution mustbe
exercised in generalizing from perceptions toactual behaviors of
excellent therapists (p. 420).
Coster and Schwebel (1997) researched psy-chologist
well-functioning (which they originallycalled unimpairment),
defined as the enduringquality in ones professional functioning
overtime and in the face of professional and personalstressors (p.
10). Content analysis of interviewswith six practicing
psychologists with 10 yearspostdoctoral experience yielded 10
themes as im-portant contributors to well-functioning: Peersupport,
stable personal relationships, supervi-sion, a balanced life,
affiliation with a graduatedepartment or educational institution,
personalpsychotherapy, continuing education, family oforigin as
source of personal values, awareness ofcost of impairment, and
coping mechanisms(such as vacations, relaxation, rest, exercise,
spir-ituality, and time spent with friends).
Self-awareness/monitoring for early signs of potentialimpairment
and personal values rated as the toptwo reasons for psychologists
well-functioningon a questionnaire in a second study. Coster
andSchwebel (1997) emphasized the importance ofnormalizing
vulnerability to impairment: Accept-ing signs of impending
impairment (as normal) iscrucial to prevention of more serious
problems.The authors advocated a strong role for profes-sional
organizations in the promotion of profes-sional well-being and
called for further investi-gation to correct an existing imbalance
inprofessional education, wherein prevention ofimpairment does not
receive ample emphasis.
Ladany, Friedlander, and Nelson (2005) ad-dressed the important
role supervision plays inCT management. Similarly, Walker (2004)
as-serted that supervision acts as an important pro-tective factor
for both CT and VT by ensuringearly recognition and response, and
thereby act-ing as a protection against burn out and conse-quent
damage to the therapist and to their client(p. 179). Bernard and
Goodyear (2004) proposethat supervision serves a restorative
purpose, be-yond its formative and normative functions; theycite
Hawkins and Shohet (1989), who state it isthe responsibility of the
supervisor to providesupervisees the opportunity to express and
meetneeds that will help them avoid burnout (p. 12).
Moreover, the supervisory relationship is widelyconsidered to be
a crucial element of productivesupervision (Bernard & Goodyear,
2004; Bradley& Ladany, 2001; Holloway, 1995; Nelson,
Gray,Friedlander, Ladany, & Walker, 2001).
Transforming VTMcCann and Pearlman (1990) drew upon their
own work experience to posit strategies for thetransformation of
VT. According to these au-thors, clinicians must acknowledge,
express andwork through painful experiences in a
supportiveenvironment otherwise, therapist numbnessand emotional
distance risk interfering with on-going empathic engagement with
clients. Theysuggested that weekly case conferences and othergroups
for clinicians who work with traumatizedclients can counter
professional isolation and pro-vide emotional support by helping to
normalizeand elucidate therapist reactions to client
trauma.Furthermore, they recommended that cliniciansreceive regular
supervision, balance caseloadswith victim and nonvictim clients,
balance clini-cal work with other professional
responsibilities,such as teaching and research, and maintain
bal-ance between personal and professional life.They identified
other coping strategies, including:advocacy, enjoyment, realistic
expectations ofself in the work, a realistic worldview (that
in-cludes the darker sides of humanity), acknowl-edging and
affirming the ways in which traumawork had enriched lives (of
others and their own),maintaining a sense of hope and optimism, and
abelief in the ability of humans to endure andtransform pain.
Similar recommendations forameliorating VT have been proffered
bySaakvitne and Pearlman (1996), Pearlman andSaakvitne (1995a,
1995b), and Yassen (1995).
Method
A purposeful sampling procedure was used torecruit peer and
organizationally nominated ther-apists who met the following
inclusion criteria:(a) trained at the masters or doctoral level;
(b),minimum of 10 years professional experiencewith traumatized
clients; and (c) self-identified ashaving managed well in this
work. Potential par-ticipants were recruited through flyers
distributedthrough professional networks and asked to com-plete the
Professional Quality of Life: Compas-sion Fatigue and Satisfaction
Subscales, R-III
Harrison and Westwood
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(Pro-QOL) (Stamm, 2003), a short quantitativemeasure used for
screening purposes only. Thosewho scored below average on the Burn
Out andCompassion Fatigue subscales of the Pro-QOL(i.e.,
self-reports suggested they suffered lessburnout and VT than the
average practitioner)were invited to participate in the study.
Clinicianswho participated in the study had between 10 and30 years
of experience working primarily withtraumatized clients in
organizational (e.g., hospi-tal, community mental health,
residential pro-gram for alcohol and drug abuse) and/or
indepen-dent practice settings. Their clientele includedsurvivors
of sexual and/or physical abuse perpe-trated during childhood
and/or adulthood; pedi-atric and adult palliative care patients and
theirfamilies; survivors of torture and natural disas-ters;
refugees from countries at war; firefighters;bank tellers involved
in robberies; and peoplewith a history of abuse dealing with
poverty,racism, substance abuse, and suicidal ideation.Participants
ranged in age from 49 to 59 years oldand included female and male
therapists of di-verse sexual orientations (heterosexual,
lesbian,and gay) who came from a range of religiousbackgrounds,
including Judaism, Catholicism,Christianity, and Native American
spirituality.The sample size (n 6) allowed for in-depthexploration
of the research questions.
Harrison collected narrative data through inter-views, which
took place in three phases. In aninitial, structured interview,
each clinician pro-vided information about their age, work
setting,caseload, years of experience, and social sup-ports. The
second phase involved open-ended,individual interviews (lasting
approximately 2 hr)in which clinicians were asked, How do youmanage
to sustain your personal and professionalwell-being, given the
challenges of your workwith seriously traumatized clients? and
Howcould protective practices best be engaged inorder to mitigate
the risks of VT and sustain theefforts of others who work with
traumatized cli-ents? With one exception, interviews were
con-ducted in the clinicians workplace. Researchconversations were
recorded on audiotape, tran-scribed, and submitted to a multistage
process ofanalysis. Transcriva software was used to storeand
partially analyze the data.
Data analysis was based upon Lieblich, Tuval-Mashiach, and
Zilbers (1998) typology of nar-rative analysis, with a primary
focus on thematiccontent analysis within and across
participants
narratives. Through multiple readings of eachindividual
transcript, Harrison selected passagesrelevant to the research
questions and coded theseaccording to emergent and convergent
themes,through a process of constant comparison. Heconcomitantly
drew concept maps and wrote re-flexive memos in a research journal.
To confirmthe validity of identified themes, we submittedthe coded
interview transcripts to a peer-reviewprocess.
To further ascertain descriptive and interpre-tive validity
(Maxwell, 1992), Harrison subse-quently wrote and sent a detailed
letter to eachclinician, organized by the coded themes that
hademerged in their respective research interview.This allowed us
to share and receive feedback onour data analyses, and to verify
that any interpre-tation on our part, which we regard as
inevitableand inherent to the process of descriptive quali-tative
research (Alverson & Skoldberg, 2000;Sandelowski, 2000) was
held to a minimum anddid not stray from clinicians descriptions of
theirlived experiences. Harrison then arranged a thirdinterview as
a follow-up/member check, to incor-porate any requested revisions.
After incorporat-ing minimal clarifications and corrections
offeredby the research participants we conducted a cat-egorical
content analysis across clinician narra-tives. Through multiple
readings of the six letters,we subsumed the various codes into nine
majorconvergent themes, presented below. As a furthervalidity
check, the authors subsequently sent thismanuscript to all six
research participants whoread it and endorsed the accuracy of the
cross-narrative themes identified below. Please refer toAppendix
for illustrative examples of our multi-stage process of data
analysis.
Results
The research findings describe how these ex-emplary clinicians
engage in protective practicesthat mitigate the risks of VT. We
have articulatedthese in terms of nine major themes:
counteringisolation (in professional, personal and
spiritualrealms); developing mindful self-awareness; con-sciously
expanding perspective to embrace com-plexity; active optimism;
holistic self-care; main-taining clear boundaries and honoring
limits;exquisite empathy; professional satisfaction; andcreating
meaning. These themes are integrallyinterrelated and constellate in
myriad ways. In-deed, we have come to view the researched phe-
Preventing Vicarious Trauma
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nomenon as a fractal, whose intricacy is such thatthe overall
pattern occurs in each part. Below, wedescribe the nine salient
themes that emergedwithin and across clinicians narratives of
prac-tices that protect and sustain them in their workwith
traumatized clients, thereby mitigating therisks of VT.
Countering Isolation in Professional, Personaland Spiritual
Domains of Life
The first major theme has multiple subsets:Research participants
counter isolation by draw-ing upon continuity in relationships in
profes-sional, personal, and spiritual realms, all of whichrisk
being adversely affected by their work. Do-ing so helps them
restore balance.
Supervision as relational healing. All clini-cians spoke of the
important role supervisionplays in mitigating risks of VT.
Regardlesswhether it takes place within an informal peergroup, an
organizational setting, or as paid con-sultation, they described
how supervision helpsdecrease their isolation, and some said
supervi-sion helps diminish feelings of shame about VTsymptoms.
Most attend at least one peer super-vision group. This practice
enhances their self-awareness and ability to self-monitor, and
re-inforces their commitment to implement self-carepractices, as
needed. Moreover, peer supervisiongroups provide a forum in which
these cliniciansbenefit from learning about each others strate-gies
to address VT symptoms. This form of sup-port within the
professional realm also helps ther-apists maintain healthy
relationships and balancein their personal lives by helping them
recognizewhen overloaded with my work or carrying toomuch. In turn
their personal relationships furthersustain them in their
professional efforts.
Training, professional development, and orga-nizational support.
Clinicians also underscoredthe importance of good training, ongoing
profes-sional development, mentorship, and organiza-tional support.
These practices anchor themwithin a professional community, which
de-creases isolation, anxiety, and despair that canarise when
clinicians feel solely responsible forredress of daunting and
highly distressing prob-lems. All participants asserted that
organizationsthat employ therapists have a responsibility tovalue
and foster clinician self-awareness by ded-icating time and space
for self-reflection at workand creating forums in which therapists
can dis-
cuss VT in an open and nonjudgmental environ-ment. Similarly,
they recommend employers re-main aware of how the work is
affectingclinicians and institute policy to hold caseloads
toreasonable levels. Additionally, some said non-authoritative,
inclusive administrative styles thatconvey appreciation for
clinicians expertise canenhance a sense of belonging, and
professionalsatisfaction. One clinician spoke of the need forearly,
explicit training in self-awareness and self-care strategies.I
really want people to get training (in self-care) before theygo out
and start working. I really want them to learn how totake care of
themselves first, instead of having to learn on thejob! Because
sometimes the damage is already done andpeople have to leave early
in their career because nobodytaught them how to take care of
themselves! Id really like forthat to be promoted as a part of
professional practice. Just asyou have to be really good at your
communication with yourclients, you have to be really good at
self-care or all is lost.And people are too important to lose.
People shouldnt go towork and be hurt to the point that they have
to go ondisability. So I think that, just like we do
communicationclasses, we should do self-awareness classes.
Diversity of professional roles. All partici-pants were involved
in a variety of professionalresponsibilities (i.e., some
combination of directpractice, teaching, supervising, and/or
adminis-tration). Several explicitly stated that they foundthis to
be protective and sustaining of their pro-fessional efforts,
because this diversity expandedtheir professional role and put them
into contactwith a larger community, thus allowing them tofeel a
sense of interconnection and renewed hope.
Personal community. All participants valuethe role played by
their personal community offamily and/or friends in helping them to
maintainbalance and separate work from the rest of theirlife. Most
described belonging to a rich networkof mutually caring
relationships, upon which theycan rely when in personal need. Some
contrastedthe reciprocity in these nonprofessional relation-ships
to the asymmetry of their professional roleand explained that the
former helps them to main-tain clear, consistent boundaries with
clients fromwhom they expect nothing in return (and whomthey
actively discourage from taking on a care-giving role in the
therapy relationship). Becausethese clinicians are nourished and
sustained byrelationships in the personal realm, they find
theirprofessional caregiving role less depleting. Somehave
developed strategies to connect physicallywith loved ones and seek
solace when distraught,in a way that neither betrays client
confidentiality
Harrison and Westwood
208
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nor burdens relational partners with potentiallyharmful details.
This kind of physical contactwith trusted close others acknowledges
and helpsclinicians contain the challenging knowledge
andexperiences that they acquire as a consequence oftheir work. In
addition, they look to their rela-tionships outside the
professional domain for op-portunities to experience levity and
joy, to coun-terbalance or expand the restricted and
skewedperspective on life that they otherwise risk de-veloping
based upon the frequent and repeatedstories of suffering and
cruelty to which they areexposed at work. Moreover, the
participants relyon personal community to help them gain aware-ness
at those times when professional concernsare intruding upon
personal life.
Spiritual connection. Participants further de-scribed
experiencing a sense of connection to aspiritual realm or a sense
of larger meaning thattranscends individual boundaries and
reason.This sense of interconnectedness with the myste-rious
transcendent (e.g., this other realm . . . themystery stuff), which
is tacitly known and can-not be clearly articulated through words
or oth-erwise apprehended, is sustaining of therapistsprofessional
efforts and personal well-being be-cause it helps counter isolation
and despair.These clinicians are comforted by the belief thatthey
are part of something larger, meaningful andgood, that they are not
alone in their efforts, andthat these are not futile. This felt
sense of spiritualinterconnection reinforces their positive
disposi-tion and renews their conviction that: (a) peopleare
resilient and can heal; (b) growth can occur inthe wake of trauma;
(c) life is about more thansuffering; (d) their professional
efforts are mean-ingful; and (e) they are not solely responsible
intheir efforts to heal trauma. In these ways, spiri-tual
connection inspires these clinicians and helpsthem to keep going
despite the difficult chal-lenges of their work. Most described
time spentin nature as an important aspect of this sense
ofspiritual connection. Below a research participantdescribed how
her personal, highly cognitive ver-sion of interconnection with
humanity, nature,and the web of life helps her persevere:When I go
walking by the ocean, which I do very frequently,I always think
about and pay attention to how the oceanpersists, and thats how
humanity persists, people persist, youknow, that kind of idea.
Persevering and persisting and main-taining, right? It is important
for all of us who do this work,I think, to have a sense of being
connected, to being part of theweb of life somehow, however we
define that in whateverkind of way that is. Because trauma is so
isolating, and we get
isolated. So however you create meaning helps to break thatdown.
I think you have to do it in the big web of life, I willcall itsome
people call it spiritual, and I think you have todo it in terms of
being with some other folks who are nothelpers. So from the big to
the small. It just reminds me thatI am part of this web of life, I
am one of the threads and myjob is to do my part good enough.
Developing Mindful Awareness: IntegratedPractice of
Spirituality
The practice of mindfulness (present focusedattending to minute,
ongoing shifts in mind,body, and the surrounding world), integrated
intodaily life from initial waking to final momentsbefore sleep,
helps most of these therapists todevelop enhanced patience,
presence and com-passion. Mindulness, as described by
partici-pants, involves curiosity and holistic awarenessof ones
experience in relation to both externaland internal environment.
Breathing consciouslyand redirecting attention to their embodied
expe-rience of the here-and-now helps these therapiststo stay
calmly focused and grounded, which al-lows them to be less reactive
and engage withgreater equanimity. This contributes to
increasedability to embrace complexity and tolerate ambi-guity, as
well as enhanced capacity to hold mul-tiple perspectives, engage in
both/and thinking,and remain hopeful in the face of suffering.
Mindfulness enhanced clinicians ability to en-gage in many of
the other protective practicesidentified below. Profound awareness
and accep-tance of what is helps them accept limits (in-cluding
those of personal vulnerability, range ofpersonal influence,
responsibility for change, andlimits of the known and knowable) and
maintainclarity about self in relation to others, both interms of
interconnections and boundaries. Mind-ful awareness also helps
participants recognize ifand when their interpersonal boundaries
are atrisk of becoming overly permeable, as well asother times when
they need to take action torestore balance in their lives (e.g.,
employ imag-ery or ritual, engage in self-care practices,
seekconsultation, and reach out to personal commu-nity). In
addition, moment-by-moment embodiedawareness of self and
surroundings helps thera-pists develop the kind of interpersonal
presenceand clarity crucial to the practice of exquisiteempathy
(described below). Moreover, we pro-pose that because it is
impossible to be trulypresent in two places at once, the practice
ofmindful self-awareness helps these clinicians
Preventing Vicarious Trauma
209
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keep personal and professional realms separate.Their ability to
fully engage in the present mo-ment, while in the personal realm,
protects themagainst intrusions from the professional realm.
Most clinicians related mindful awareness totheir practice of
integrated spirituality and senseof purpose. Through mindfulness
practice theyseek to make connections between mind, body,and
spirit, to maximize and enrich every mo-ment and interaction with
heightened attentionand loving acceptance. They described how
thisin turn facilitates professional satisfaction andrelated sense
of making a meaningful contribu-tion to life through work. While
some currentlyor previously engaged in a structured
meditationpractice to develop mindfulness, others had neverdone
so.
Consciously Expanding Perspective ToEmbrace Complexity
Participants consciously challenge negativecognitions to expand
their perspective whencaught up in despair. They purposefully
remindthemselves of other ways of viewing life by cuingthemselves
through self-talk, use of imagery ormetaphor, time in nature, or
interactions withpeople in other lines of work, to encompass
widerhorizons of possibility and counterbalance theirskewed
perspective on the world. Because theseclinicians are able to
embrace cognitive complex-ity, tolerate ambiguity, and
simultaneously holdmultiple perspectives (including those of
clientand self), they can accept the inevitability of painand
suffering as well as lifes potential forbeauty, joy and growth.
Therefore, even the cu-mulative knowledge of clients horrific
experi-ences of trauma does not eclipse their positiveworldview or
sense of hope and purpose (morebelow). Moreover, they are able to
see a giftside of loss, which is to say that devastatingexperiences
can also be generative, and that theseare not mutually exclusive.
They recognize thatpositive growth does not diminish or efface
ago-nizing pain; rather, pain and positive transforma-tion coexist.
This awareness is sustaining of cli-nicians because it allows for
the possibility thatclients, too, can achieve an expanded
perspectivethat embraces lifes pain and beauty in the wakeof
devastating trauma. The research participantshave been inspired by
their experiences of wit-nessing and accompanying clients who have
doneso. They described their lives as having been
enriched, deepened, and empowered by theirvicarious experiences
of client posttraumaticgrowth (Calhoun & Tedeschi, 1998, 1999;
Tede-schi & Calhoun, 1995), as well as personal expe-riences of
trauma and subsequent growth.
Furthermore, conscious shifts in perspectivehelp these
clinicians counter isolation and toler-ate ambiguity. They remind
themselves that theyare not in it alone, that others are doing
similarwork to redress abuse, and that change is incre-mental and
happens slowly over time. A clinicianwho worked in a residential
treatment programdescribed how such shifts in cognitive
perspec-tive are protective:You have to keep reminding yourself
that behind the cloudsthere is sun. Im standing in a dark place
too, but I knowbeyond it there is something more. And the thing is
it dependson your perspective. I mean, there is beauty even in
theSUFFERING of these youth as they come in there. Theirresiliency.
If you have any idea of the human suffering, thehuman misery that
some people have experienced, and yetthere they are. Like, what a
heroic story. Its a great tale ofheroism. Its remarkable. You can
either see the darkness ofit or a very heroic story. Its both.
Ultimately, this expanded perspective encom-passes openness to
the unknown, and a belief ortacit sense that meaning and purpose
transcendthe limits of individual identity, language,
andquantifiable knowledge. Participants accept theirinability to
articulate or apprehend this mysteri-ous, transcendent unknown.
They do not feel aneed to name or otherwise define it
(althoughseveral associate it with light). Many equated thiselusive
realm with their sense of spirituality,which they primarily
practice outside the contextof organized religion (most of the
clinicians wereraised in a religious tradition, which they
subse-quently left or moved beyond). Remaining opento the idea that
some aspect of life transcendspersonal boundaries and interconnects
all peoplemakes trauma work less distressing for these cli-nicians,
because it counters isolation on a largerscale (as described
above), and helps them to feelthat life is meaningful, even when
difficult. Manyequated their calling to trauma work with
someineffable or elusive purpose. Moreover, sometook solace in
mystery, itself, and found it com-forting to accept that some
things are beyond theken of human understanding.
Active Optimism
The belief that people can heal is central to apositive
disposition, which envelops and under-
Harrison and Westwood
210
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lies the phenomenon of clinicians who managewell in their work
with clients who have experi-enced serious traumatic events.
Research partic-ipants shared an overarching positive
orientation,conveyed in terms of an ability to maintain faithand
trust in: (a) self as good enough; (b) thetherapeutic change
process; and (c) the world asa place of beauty and potential
(despite and inaddition to pain and suffering). These three
at-tributes parallel the core assumptions that Janoff-Bulman (1992)
identified as being shattered byexperiences of trauma. The
clinicians in our studyviewed the world as ultimately benevolent,
thetherapeutic enterprise as meaningful, and self asgood and
capable in their professional endeavors.There is a circular quality
to this positive orien-tation, inasmuch as the ability to sustain
hope andmaintain faith that things get better informs manyof the
protective practices these exemplary clini-cians engage in, which
in turn serve to renewtheir enduring hope and trust. Several
explicitlyequated optimism with awareness. One cliniciandrew upon a
Buddhist parable to describe this:
I dont see the people I work with as TRAUMA!! (boomingvoice) You
know, I see them as people (softer) who in someway are very stuck
in some holes and they believe that it isdark and fearful and they
cannot get out of the hole. And forme, you know, life has holes.
Big holes, little holes, but thereis no life with no holes. And if
I can almost like tell people,have a peek in the road, you know,
get off the hole. But theawareness is not just where you ARE if you
are in a hole. Theawareness is there are holes and I accept it. And
I also feelvery . . . faithful [trusting] that I can get out of the
hole. Thatlife is not a hole. And thats how I protect myself. I
accept myholes and I dont feel I get dragged in peoples holes. I
feelvery sad, very sorry, but I feel very . . . empowered, I feel
veryhonored that I am asked to assist people. And that for me
issomething that I grab like you know, a real light switch.
These clinicians put their optimism into action,through
proactive problem solving. They ap-proach problems as solvable.
When the scope ofa problem is too large, they look at what
smallpart they can address, which may take the form ofadvocacy or
self-talk to let go of anger and dwellin acceptance. This active
approach to problemsolving also informs how they respond to
theunique challenges of their work with traumatizedclients. For
instance, they use their heightenedself-awareness to recognize how
work is affect-ing them, then determine what to do about this.Most
have consciously developed a plan or per-sonalized set of
strategies to counter VT andrecommend that other therapists do so,
as well.Their practice of active optimism involves creat-
ing time and space for self-care practices to re-store balance
in their lives. They have purpose-fully developed strategies to
separate work andpersonal life, as well as effective
communicationskills to deal with problems in either of theserealms.
Sometimes active problem solving in-volves using imagery or ritual
to maintain clarityaround boundaries or provide closure (more
be-low). In addition, participants consciously seekout
opportunities for laughter or to take in beauty,and some have
deliberately joined book clubspopulated by members in different
lines of work,to be reminded of other perspectives on
life.Moreover, most participants create and enact op-timism by
purposefully planning pleasurable ac-tivities, including travel or
time in nature. Oneclinician described this as follows:One of my
strategies is to always have something to lookforward to. I always
plan for something good to come next.And thats been a comfort. I
mean, as soon as I finish onething, there is the seed for something
more. I never gowithout, even if the seed is a teeny tiny little
kernel, even if Idont have the money even if I dont have the time
yet, theseed is started and so its a beginning place.
Holistic Self-CareThese clinicians take a holistic approach
to
self-care, which they consider crucial to theirability to
maintain personal and professionalwell-being. They attend to
physical (e.g., healthydiet, ample sleep, regular exercise, holding
andbeing held), mental (e.g., training, continuing ed-ucation,
mindful awareness), emotional (e.g., per-sonal therapy, trusting
relationships, laughter andjoy, emotional expression, release or
redirectionof anger), spiritual (e.g., meditation, time spent
innature, creating meaning and purpose), and aes-thetic
(purposefully bringing beauty in) aspectsof self-care. Some think
of self-care in terms ofpracticing what they teach, or walking my
talk.They practice self-care within both the personaland
professional realm, and their ability to sepa-rate these two realms
of life is itself a form ofself-care. Self-care provides balance,
and at timesclosure. Moreover, it is renewing and conse-quently
allows them to be more present whenengaging in both personal and
professional rela-tionships. They recommend all clinicians whowork
with trauma engage in self-care practices,including some form of
personal therapy. Manyhave found group-based therapy to be
particu-larly helpful. Moreover, these clinicians recog-nize that
there is an ethical component to self-
Preventing Vicarious Trauma
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care. If they do not take care of themselves, theyare at risk of
harming others. Consequently, theystrongly believe that taking care
of caregiversneeds to become a higher priority in health careand
related fields. They think that there is a needto incorporate
self-awareness and self-care intoprofessional training, at an early
stage. Below, aclinician talked about the importance of
dailyself-care in her life:
I get up every morning at five oclock, and I have a friend,
andwe walk for about an hour and 10 minutes, Monday to Friday.We
dont miss, doesnt matter if its raining. Sometimes wewalk in
silence, sometimes we talk, but if I miss that, my dayis totally
different. That gets me grounded, that gets meconnected. I see the
seasons change, I am aware of things, Ihave a friend that I really
love and care about with me everymorning, and its something I
justits REALLYIMPORTANT TO ME. So walking becomes really, it is
awalking meditation {laughs} to some extent.
Maintaining Clear Boundaries andHonoring Limits
These clinicians maintain clear and consistentboundaries in
multiple realms of interaction.They accept, honor and maximize
limits, includ-ing those of their professional role in
relationshipto clients. All participants acknowledge their
ownlimits, including personal vulnerability to VT,and they believe
that it is imperative for others inthis work to do so, as well. In
addition, theymaintain clarity about the limits of their sphere
ofinfluence. They avoid dual relationships, and rec-ognize that as
therapists, they are not responsiblefor making change in clients
lives.
Furthermore, participants hold realistic expec-tations of self,
other, and the world, and do notconfuse the ideal with the actual
or the likely.They recognize that change unfolds slowly, insmall
increments, and that larger scale change isa community rather than
an individual responsi-bility. However, some do engage in
advocacy.One said, I do advocacy work, but only when Ifeel
passionate about it. Im really also very ableto say NO. I give at
the office, so to speak. Sherecognizes that taking on too much
volunteerwork can interfere with the balance in life thatshe
requires to sustain her professional efforts asa clinician.
Moreover, these exemplary clinicianshave developed a range of
strategies to helpmaintain boundaries (both psychological
andphysical) between work and personal life. Theseinclude use of
supervision, peer consultation, per-sonal therapy, physical
self-care and/or mindful
attending to unresolved material in order to pro-cess it and to
achieve closure; personal ritualsbefore and after work; meditation
practice; takingtime off work to travel; and consciously
settingtemporal and spatial limits between professionaland personal
realms (e.g., keeping work-relatedbooks at the office, limiting
time spent debriefingwith partners, not working on ones
birthday),among others.
Perhaps most importantly, they maintain clearboundaries with
regard to the distinction betweenempathy and sympathy. While
remaining highlyattuned to clients, they do not engage in
emo-tional fusion or otherwise confuse clients feel-ings or
experiences with their own. Instead, theymaintain firm
interpersonal boundaries that aresufficiently permeable to allow
them to experi-ence intimate connection within the context of
apresent-oriented professional relationship withthe person here and
now, without losing per-sonal perspective. Moreover, participants
are at-tentive to those times when clients stories reso-nate more
powerfully with the therapistspersonal history, in which case they
may seeksupervision or personal therapy to help maintainclarity and
manage what gets stirred up for them.In these ways, exemplary
clinicians differentiatebetween their own worldview and those of
trau-matized clients with whom they empathize. Thisclarity around
boundaries is helpful to clients andprotective of therapists. One
clinician explainedthat although he feels connected and is
oftendeeply touched by clients stories of prior trau-matic events,
he remains clear that:Its still their story. Its not my story. [It]
doesnt get paintedon my wall, you know. It passes through. I dont
lose myselfin it. I dont have to. I can care [but] Im not in [the
traumastory]. I didnt have that thing happen to me. Certain
storiesyou, know are ones that are harder for me for
whateverreason, and of course, Im in peer support groups, I
haveplaces to go to talk about stuff with people, I swim, I hike
alot, I live with someone, and I have those places to be
withpeople, unload distress in an appropriate way [when]
certainthemes become cloudier for me around [whether] its
theirstory or is it my story.
Moreover, these exemplary clinicians employvisualizations,
metaphor, and personal ritual as aself-management strategy to
simultaneously stayfully present in sessions and maintain
consistentboundaries when client material risks encroach-ing upon
their personal life or perspective. Thisallows them to remain
empathically engaged,highly present and connected, yet protected
anddistinct in their role as attuned, caring witness to
Harrison and Westwood
212
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client stories of traumatic experience. Below, aclinician
described one such strategy:I try to think of myself as a screen
door, where the wind blowsthrough and doesnt attach to the screen.
Its an image that I findparticularly helpful. I see their story as
the wind and Im thescreen. They will have stories that could, if
forceful like a galewind, be dangerous and something to be
contended with, but ifmy door is solid and my screen allows for air
to move throughit, then even a gale force wind can pass through my
screen door.
Exquisite Empathy
Most of the clinicians described how intimateempathic engagement
with clients sustains themin their work. This finding surprised us,
becausewe went into the research thinking that empathicengagement
was a risk factor rather than a pro-tective practice. However, when
clinicians main-tain clarity about interpersonal boundaries,
whenthey are able to get very close without fusing orconfusing the
clients story, experiences, and per-spective with their own, this
exquisite kind ofempathic attunement is nourishing for therapistand
client alike, in part because the therapistsrecognize it is
beneficial to the clients. Thus theability to establish a deep,
intimate, therapeuticalliance based upon presence, heartfelt
concern,and love is an important aspect of well-being
andprofessional satisfaction for many of these clini-cians. One
research participant elaborated on this:I actually can find
sustenance and nourishment in the work itself,by being as present
and connected with the client as possible. Imove in as opposed to
move away, and I feel that is a way thatI protect myself against
secondary traumatization. The connec-tion is the part that helps
and that is an antidote to the horror ofwhat I might be hearing.
Its about working with the heart froma place of warmth and care and
even love.
Professional SatisfactionAll participants take satisfaction in
being ef-
fective in their work, making a meaningful con-tribution through
their professional efforts, andbeing highly skilled at what they
do. In theseways, they find the work deeply rewarding. Theyare
honored by their professional role, which hasexpanded and enriched
their life in nonmone-tary (as well as fiscal) ways. They consider
it tobe an extraordinary privilege to assist people whohave
experienced trauma, and this sustains themin their professional
efforts. Clinicians suggestedthat organizational cultures and
managerial stylesthat value therapist expertise and afford
practitio-ners greater professional autonomy further con-tribute to
professional satisfaction. One said:
I mean I have been very, very privileged. I have
experiencedthings . . . the depth of things or the beauty of things
or thewisdom of things in this healing process that other
peoplehave never ever had. Most people, I think, dont ever get
asense to touch that kind of depth or that kind of stuff, so
Iwouldnt quit my job.
Creating Meaning
Finally, these therapists recognize the impor-tance of their
ability to create or perceive mean-ing, regardless whether through
belief in an ulti-mate universal goodness, an elusive
transcendentgreater purpose, their commitment to family,work,
and/or community building, or a sense ofinterconnection with the
efforts of others in con-tinuity over time. This last finding
relates back tothe notion of countering isolation in the
spiritualdomain of life. Furthermore, it parallels the workof
Briere and Jordan (2004) and van der Kolk andMcFarlane (1996), who
found that the process ofmaking meaning beyond concrete events
helps tocontextualize and reduce the threat of trauma.Below, a
clinician explained how creating mean-ing sustains her professional
efforts:Even though Ive known people who have gone throughdifficult
things, [and I] have had difficult experiences in myown life, I
have a belief that there is some meaning or purposein that, even if
Im not aware of it. That makes it moretolerable. That makes it more
endurable.. When I just acceptthat the universe wanted me to have
these experiences, andthat they were meant to be helpful,
supportive, then it allmakes sense. And so then that is the
ultimate goodnesscoming through. The ultimate goodness, which is,
you know,we are meant to be here. We are meant to have
experiencesthat challenge us and cause us pain, but ultimately it
is aboutthe goodness. Because then, it feels like, people [clients]
will notbe left only with pain and suffering, that they too will
have theopportunity to process and work through this to a point
wherethey make those connections to the goodness. They can lookback
and say, That was really terrible and awful, and . . . Thatsnot all
thats there.
Discussion
This study yielded the novel finding that em-pathic engagement
can be a protective practicefor clinicians who work with
traumatized clients.This finding challenges prior assumptions
aboutthe causality and inevitability of VT. Clinicianswho engaged
in what we have called exquisiteempathy (a discerning, highly
present, sensi-tively attuned, well-boundaried, heartfelt form
ofempathic engagement) described having been in-vigorated rather
than depleted by their intimateprofessional connections with
traumatized cli-ents. Previously, therapist empathy for trauma-
Preventing Vicarious Trauma
213
-
tized clients had consistently been depicted as akey risk factor
for VT. Consequently, the currentstudy challenges prior
conceptualizations of VTand points to exciting new directions for
researchand theory, as well as applications to practice.
Notwithstanding the differences between theconstructs of CT and
VT, prior research andtheory on CT management may help explain
ournovel finding that a discerning form of empathicengagement
characterized by exquisite listen-ing, loving attunement, and
therapist ability todifferentiate self from clients, appeared to
beprotective for some clinicians in their work withtraumatized
clients. Hayes and colleagues (Hayeset al., 1991; Van Waggoner et
al., 1991) previ-ously offered initial evidence in support of
asimilar hypothesis: that enhanced capacity forempathy plays a
principal role in clinicians abil-ity to manage CT. These authors
suggested thatCT stems from a therapists inability to disengagefrom
identification with a client, rather than fromempathy itself, which
involves a process of par-tial or trial identification balanced
with relativedisengagement (standing back and observing).Their
findings also suggested that self-integrationand self-insight,
including cohesion of self,selfunderstanding, and differentiation
of selffrom others, played the most important role inmanaging CT
(Hayes et al., 1991).
Similarly, our current findings suggest thateffective,
protective empathic engagement withtraumatized clients involves
neither overiden-tification with nor avoidance of clients
trau-matic material. Rather, exquisite empathy re-quires a
sophisticated balance on the part of theclinician as s/he
simultaneously maintains clearand consistent boundaries, expanded
perspec-tive, and highly present, intimate, and
heartfeltinterpersonal connection in the therapeutic re-lationship
with clients, without fusing, or los-ing sight of the clinicians
own perspective.Moreover, we believe that, for some
clinicians,efforts to avoid or resist the intensity of
clientstrauma stories may be counterproductive. In-stead, our
findings suggest that some cliniciansmay benefit from accepting
their relationship toclients traumatic material and integrating
thisaspect of their professional life into their iden-tity. This is
in keeping with the literature onPTSD treatment, which guides
therapists tohelp traumatized clients integrate traumatic
ex-periences into their identity and self story,rather than
splitting these off (Herman, 1992).
Implications for PracticeIf VT is indeed a form of trauma, in
which
clients accounts of traumatic experiences be-come the traumatic
stressor for clinicians, it fol-lows that clinicians may benefit
from embracingtheir professional relationship to clients trau-matic
material rather than attempting to distancethemselves from this
aspect of their work. Ex-quisite empathy may be a way of
accomplishingthis, because it affords clinicians opportunity
toethically benefit from healing connections(Mount, Boston, &
Cohen, 2007, p. 372) withclients, without ever sacrificing clients
needs totheir own. In this sense, exquisite empathy mayconstitute a
form of mutual, reciprocal, healingconnection, in which clients and
clinicians alikebenefit from the latters caring,
well-boundaried,ethical attunement to the client.
Additional findings herein appear to be ver-ifying of previous
recommendations for ame-liorating VT and underscore the ethical
respon-sibility shared by employers, educators,professional bodies,
and individual cliniciansto create time and space to address this
seriousproblem (e.g., through: regular supervision,within the
context of a supportive supervisoryrelationship; peer and social
support networks;life-work balance; self-care, including
personaltherapy, as needed; and self-reflection withinand beyond
the workplace). Moreover, many ofour results reinforce Coster and
Schwebels(1997) recommendations for psychologist well-functioning.
However our findings about ex-quisite empathy and mindful
self-awareness arenotable additions to this prior research.
Results related to the important role thatsupervision and
therapist self-care appear toplay in mitigating the risks of VT
could helpinform the decision making processes of com-munity
agencies with regard to how to bestsupport clinical staff, and also
be highly bene-ficial to individuals in independent practice.Based
upon these qualitative research findings,we recommend that greater
time and attentionbe dedicated to therapist self-reflection
andself-care as crucial components of ethical prac-tice. Moreover,
all clinicians who work withtraumatized clients are advised to
access ongo-ing, regular supervision and be part of eitherformal
clinical teams or informal peer net-works, to minimize risk of harm
to self orclients. We consider it a shared responsibility
Harrison and Westwood
214
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on the part of employing organizations, profes-sional bodies,
and independent practitioners toensure that clinicians have access
to and takeadvantage of these supportive resources. Fur-thermore,
we recommend that clinicians ac-knowledge the importance of both
their profes-sional and nonprofessional relationships, andactively
nurture these. Our results suggest it isimportant to the well-being
of therapists, cli-ents, and our communities that no
clinicianshould work with trauma in isolation.
The current research may also raise ques-tions about the value
of organizational policyand structure in some community
agencies,where programs for traumatized clients (e.g.,sexual abuse)
are staffed separately from othertherapy services. This practice
typically doesnot promote balance within caseloads or
amongprofessional tasks. All of the peer-nominatedexemplary
clinicians who participated in thecurrent study had some diversity
in their pro-fessional responsibilities as well in the type
oftraumatized clients that they treated. Further-more, most of
their caseloads offered somebalance between trauma and nontrauma
clients.It is not clear why therapists who worked ex-clusively
providing direct service to clientstraumatized by a similar type of
traumaticstressor did not present for inclusion in thestudy, but
one possible hypothesis may be thatthey are not managing as well as
those whohave greater balance in professional responsi-bility or
diversity of clientele.
Implications for TrainingIn addition, the results from this
study sug-
gest it may be helpful to future clinicians andclients alike to
incorporate mindfulness train-ing in therapist education, along
with curricu-lum that invites (and teaches) trainees how toexpand
perspective to embrace complexity, tol-erate ambiguity, recognize
their own limits,and differentiate between empathic engage-ment and
sympathetic overidentification withclients. Finally, there is an
ethical obligation towarn trainees about the risks of the
workingwith traumatized clients, as well as to teachthem about
protective practices. In this way,training could also serve a
self-screening func-tion that might prevent future VT and
profes-sional attrition. Well-informed trainees who
areuncomfortable with ambiguity and/or who ex-
perience a significant degree of interpersonalisolation could
elect not to pursue this kind ofwork, or alternatively, actively
seek to developmore expansive cognitive and social practices.
Limitations and Implications forFuture Research
Although the qualitative research design andsmall sample size
precludes generalizing fromthe data, the current findings may be
helpful toothers in the fields of psychology, psychiatry,social
work, psychiatric nursing, and relatedhealth care disciplines, at
the levels of educa-tion, training, and practice. It is, however,
im-portant to underscore the potential for individ-ual differences
among clinicians who workwith traumatized clients. Consequently, we
of-fer our results and recommendations tenta-tively, in the absence
of further data from fu-ture studies with larger sample
sizes.Moreover, the validity of our findings could bestrengthened
through future research compar-ing clinicians who are managing well
in theirwork with traumatized clients with those whoare faring less
well. This kind of additionalresearch is warranted to further
explore thecurrent findings and assess their representative-ness,
particularly the novel finding that em-pathic engagement appeared
to be a protectivepractice for some clinicians.
Summary
Although previous research has been con-ducted on VT, there is a
great paucity of re-search investigating protective practices
thatmitigate the risks for clinicians who work withseriously
traumatized clients. Consequently,this study makes an important
contribution tothe existing literature and begins to fill agap that
deserves continued attention. More-over, this study augments the
existing litera-ture, much of which has been based uponquantitative
research, by offering thick, richdescription of the lived
experiences of exem-plary clinicians who are managing well
despitethe risks of this work. While the current find-ings confirm
and extend prior research, theyalso depart from previous literature
in interest-ing ways. Most notably, the finding that exquis-ite
empathy seems to be a protective practicefor some clinicians
challenges previous ways
Preventing Vicarious Trauma
215
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of conceptualizing VT and points to excitingnew applications to
practice and avenues forfurther study.
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Appendix
Illustrative Examples of Data Analysis Process
The following excerpts are offered to illustrateour iterative
data analysis process. We have en-tered corresponding codes to
replicate the processof recording emergent codes.
Transcript ExcerptJoy
One of the things that I do is I have supervision (1), andthat
is really helpful to me, and we have a vicarious[trauma] group (2)
that I go to once a month, and its frompeople in the service and we
have a little bit of a coregroup. There is about seven or eight of
us (3) from differentteams who come together, and it is a place
where for anhour and a half, at least, what we do is that we talk
about,uhm, it started off us trying to really connect (4) with
eachother and not just tell horror stories (5,6), which
werere-traumatizing? {giggle} to starting to trust each other
(7)where we talk about ourselves (6) and some of the thingsthat we
notice might be going on for us, and differentthings that we are
doing to help with some of those symp-toms (8) that might be coming
up. Its almost kind of likegoing on Weight Watchers, too. You have
other people thatyou can talk to (9) so that it keeps it in your
mind (6) thatthats something that is telling you that you need to
dosome shifting here around some things (10,11,12).RH
I just want to stay with that for a second. Does that alsomean
that having other people helps you remember it is
important to YOU?. is it also being sort of being
almostaccountable to more than just yourself?Joy
Yes it is. but on a very personal level again (13), right?And
that is why I say its almost like weight watchers,because when you
tell somebody and you open up and it isno longer a secret (9,14)
and you are no longer ashamed(15) about the fact that, you know,
you are more irritableand you are snapping at somebody (5,6), and
you know thatand you actually put that out as a reality (9,16),
then otherpeople know that and then they are interested (17),
theycare, and they inquire about that (18) {laughs}.RH
So you are building relationships (exactly), and I assume you
are making a gesture with your hands {hands offeringforth from
chest] by put that out there, you mean put thewords out there?
Joy
Yes. So that helps you do. It helps you keep on track aboutthose
things and keep more mindful (19,20,21). The otherthing I do that
is just like the people I work with, is that ittakes away some of
the shame when you say these things(14,15,16).Codes
(1) Supervision; (2) VT group; (3) Peer group;
(4)Connection/build relationships; (5) Attentive to risk of VT;(6)
Self-awareness; (7) Build trusting relationships; (8)
Sharestrategies; (9) Counter isolation; (10) Make a shift;
(Appendix continues)
Preventing Vicarious Trauma
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(11) Belief that something can happen; (12) Active
problemsolving; (13) Personal relationships; (14) Open up;
(15)Counter shame; (16) Express reality; (17) Being witnessed;(18)
Create caring networks; (19) Keep on track; (20) Self-monitoring;
(21) Mindfulness.
Harrison highlighted and coded the originaltranscript in the
margins. Through multiple read-ings, the following codes emerged:
supervision;VT group; peer group; personal
relationships;connection; attentive to risk of VT; self-awareness;
build trusting relationships; sharestrategies; counter isolation;
make a shift; beliefthat change can happen; active problem
solving;being witnessed; open up; counter shame; ex-press reality;
being witnessed; create caringnetworks; keep on track;
self-monitoring; mind-fulness. These codes were then incorporated
intoa larger concept map that explored relationshipsbetween:
self-monitoring/mindfulness, self-awareness re: risks and signs of
VT, belief in theability to shift, intention/decision to shift,
form-ing personal relationships in professional con-texts,
supervision, personal therapy, counteringisolation, decreased
shame, being witnessed bycaring others, shared strategies, active
problemsolving, enhanced personal relationships, and de-creased VT
symptoms. The codes that emergedfrom the transcript excerpt above
were ultimatelysubsumed primarily under the cross-narrativethemes,
countering isolation (in professional, per-sonal and spiritual
realms), developing mindfulself awareness, and active optimism.
Validity Checks
The following is an excerpt from the detailedletter Harrison
sent to Joy to share his interpre-tive analysis of their research
interview conver-sation and check its validity:Dear Joy,
I am writing you this letter to share my emergent
under-standings of our research conversations about how youmanage
to maintain your personal and professional well-being given the
challenges of your work with clients whohave experienced serious
trauma. In talking with you, I gotthe sense that awareness, focus,
and presence within eachunfolding moment, accompanied by a strong
commitmentto personal responsibility, well-developed abilities
tocheck in with yourself and self-regulate as necessary, yourrich
relational life, and your enduring belief in both peo-ples ability
to heal and the inevitability of change, all playan important role
in your ongoing, evolving practice ofpersonal and professional
well-being. You have developedstrategies and opportunities to care
for yourself emotion-ally, physically and spiritually, and you
actively and con-
sistently engage in these with commitment and purpose.This
allows you to experience profound and sustainedinterpersonal
contact and connection (with self and others),while maintaining a
clear sense of personal perspective andboundaries in relationship
to others. I will elaborate onthese and other themes below:
Relational Self-Healing: Supervision, Peer Support,Personal
Therapy
You are involved in several different peer supervision/support
groups, which help mitigate effects of VT. Youhave built trusting
professional relationships where youcan share your concerns about
VT symptoms. Doing sohelps minimize isolation and shame, because
you are ableto give voice to your awareness of how trauma work
isaffecting your life. When you put that out as reality andit is
witnessed by caring others, this reinforces your com-mitment to
taking active responsibility for your well-being(which is informed
by your enduring conviction that peo-ple, including yourself, can
heal). You are able to benefitfrom shared strategies of other group
members, and theyalso help you self-monitor by checking in with you
peri-odically to ask how you are doing. Drawing on this sup-port,
you are better able to recognize and deal with yourtendency to
internally distance yourself from your partnerand others, when you
are feeling too filled up with work.You also use supervision and
personal therapy to helpmanage those times when work begins to
intrude uponpersonal life. All of this helps you maintain
enhancedrelationships in your personal life, which further
sustainyou professionally.
The participant subsequently confirmed thevalidity of Harrisons
initial analysis of theirresearch interview. After conducting a
thematiccontent analysis across participant narratives,Harrison
sent each participant the followingemail, along with a copy of this
manuscript, asa further validity check:
Dear (participant),
I hope this email finds you well.
I have just finished a manuscript based on my
dissertationresearch that I am submitting for publication. I am
hoping youwill be able to read through the attached draft, and let
meknow whether all of the findings apply to you, or whethersome of
the cross narrative themes articulated do not fit foryou. This
would allow me to incorporate any necessary cor-rections.
Thanks again for your participation in the research.
warm Regards,
Richard
All of the participants wrote back to endorse theaccuracy of the
research results, as presented in thisarticle. Below are examples
of their replies:
Harrison and Westwood
218
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Richard,
I have no problem with any of the cross narrative themes. Ithink
it is an excellent paper.
Frank
HI Richard
article is good! Nothing I disagreed with and I was interestedto
read some of the other comments. Good job!regards, Abigail
All looks good to me, Richard. and Congratulations on a jobwell
done.
Ernest
Hi Richard - I am happy to read that you are attempting to
getyour work published. I think it is an important piece of
workthat was well down.
As with your dissertation, the paper is beautifully writtenand
captures your passion. It is interesting to me that thenature of
your research really has to do with connection,spirituality,
life!!! and that you have been able to combinethe intellect and the
emotion and produce a very beautifulpaper.
I am very happy to have been a part of your paper and Ihave no
objection to anything - I think you did a wonderfuljob.Good
Luck,
Joy
Preventing Vicarious Trauma
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