PREVENTING VICARIOUS TRAUMATIZATION OF MENTAL … · University of British Columbia This qualitative study identiÞed protective practices that mitigate risks of vicarious traumatization

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 Zilber’s (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 (Worker’s 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, 203–219 0033-3204/09/$12.00 DOI: 10.1037/a0016081

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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 worker’sfeelings, 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 therapist’s 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 master’s 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 Burnout

Unlike CT, which is typically construed as ashort-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 &

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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 client’s life account forclinician VT. Whereas the clinician is the locus oforigin for classical CT, which is elicited by theclient’s 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-cian’s 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-cian’s 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 therapist’s 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 therapist’s 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,self—understanding, 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

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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 one’s professional functioning overtime and in the face of professional and personalstressors” (p. 10). Content analysis of interviewswith six practicing psychologists with 10 years’postdoctoral 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 VT

McCann and Pearlman (1990) drew upon theirown 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


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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 clinician’s 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 Zilber’s (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-


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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 other’s 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! I’d 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 shouldn’t 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


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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 therapists’professional 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 that’s 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 it—some 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 one’s 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


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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 life’s 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 “gift”side 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 life’s 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. I’m 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. It’s a great tale ofheroism. It’s remarkable. You can either see the darkness ofit or a very heroic story. It’s 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-


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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 don’t 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 that’s how I protect myself. I accept myholes and I don’t feel I get dragged in people’s 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 that’s 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 Idon’t have the money even if I don’t have the time yet, theseed is started and so it’s a beginning place.

Holistic Self-Care

These clinicians take a holistic approach toself-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 times“closure.” 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-


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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 o’clock, and I have a friend, andwe walk for about an hour and 10 minutes, Monday to Friday.We don’t miss, doesn’t matter if it’s 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 it’s something I just—it’s 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. I’m 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 one’s 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 therapist’spersonal 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:

It’s still their story. It’s not my story. [It] doesn’t get paintedon my wall, you know. It passes through. I don’t lose myselfin it. I don’t have to. I can care [but] I’m not in [the traumastory]. I didn’t have that thing happen to me. Certain storiesyou, know are ones that are harder for me for whateverreason, and of course, I’m 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] it’s 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


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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 doesn’t attach to the screen. It’s an image that I findparticularly helpful. I see their story as the wind and I’m 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 client’s 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. It’s about working with the heart froma place of warmth and care and even love.

Professional Satisfaction

All 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 has“expanded 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, don’t ever get asense to touch that kind of depth or that kind of stuff, so Iwouldn’t 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 I’ve 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 I’m 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 . . . That’snot all that’s 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-


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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 therapist’s 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,self—understanding, 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 clinician’s own perspective.Moreover, we believe that, for some clinicians,efforts to avoid or resist the intensity of clients’trauma 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 Practice

If VT is indeed a form of trauma, in whichclients’ 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 latter’s 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 Schwebel’s(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


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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 Training

In 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


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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 Excerpt

Joy

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 it’s 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. It’s 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) thatthat’s 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 it’s 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)


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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-ple’s 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 Harrison’s 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:


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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


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PREVENTING VICARIOUS TRAUMATIZATION OF MENTAL … · University of British Columbia This qualitative study identiÞed protective practices that mitigate risks of vicarious traumatization

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