This article is illustrated throughout with the personal account of 'David', who experienced secondary trauma and is now a writer and speaker on psychological issues.
It has long been recognised that clinicians working with survivors of trauma can be affected by the nature of their work, and this can be a cumulative effect. More recently, attempts have been made to conceptualise the potential impact of secondary exposure to trauma. Some theorists consider that clinicians may develop secondary traumatic stress which encompasses symptoms of intrusion, avoidance and hyper-arousal, while others argue that therapists may also experience vicarious trauma, which refers to lasting alterations in basic cognitive beliefs. The cumulative effect of such exposure may also lead to symptoms associated with burnout including exhaustion, depersonalisation and reduced sense of personal accomplishment.
Exposure to trauma
Psychologists witness the immediate and long-term consequences of trauma for their clients, and frequently encounter their clients’ experiences of trauma when listening to graphic descriptions of events such as child abuse, violence and sexual assault. When psychologists put themselves in their clients’ shoes through their use of therapeutic empathy, they ‘taste’ the same emotional and physiological ‘pain’ of their clients, via what Daniel Siegel calls the ‘resonance circuits’. Siegel says that we ‘read’ our client’s emotional state through reading our body’s response to their stories and their non-verbal language; in this way, we experience some of what our clients’ experience (Siegel, 2009)
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David began his first position as a psychologist in his early 20s in a country gaol after completing his ‘4+2’ training. He did not have immediate clinical supervision from a senior psychologist. He came across some of NSW’s most hardened criminals, murderers, robbers, rapists and paedophiles. While working in a second gaol, a high-profile murder case occurred, and David was asked to assist one of the accused who was on remand in the prison. The verbal reports David heard of what this man and his co-accused had done were horrific. He felt a visceral sense of disgust as he sat before the inmate while also having sympathy for him, as threats were being on the inmate’s life, and his family, inside and outside the prison.
After a few years of this work David noticed that he was preoccupied in his thinking about the gaol and its inmates, and his emotional wellbeing was being affected. He left to commence his PhD training as a clinical psychologist while also working part-time in community health, and later on, as a university counsellor. Upon completion of his postgraduate training he commenced private practice. This included critical-incident stress debriefing, where he was exposed to victims of industrial and motor vehicle accidents, victims of assault and robbery, brain injury, suicide and natural disasters. His caseload during the later years of his private practice, which he terminated in 2006, included family assessments for the NSW Children’s’ Court Clinic. At the same time, his children were of a similar age to those he was assessing. He found himself running hypothetical scenarios in his mind of his own children experiencing neglect or abuse like those he was assessing, and waking in the night in fright.
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The impact
The theoretical literature argues that in secondary traumatic stress (STS), similar psychological processes are involved as those that occur in posttraumatic stress disorder (PTSD), including symptoms associated with intrusion, avoidance and hyper-arousal, albeit to a lesser extent. Whilst not specific to psychologists, research has identified that therapists may manifest these three clusters of STS symptoms in similar ways to those that have directly experienced traumatic events. Across the published research, reported levels of STS vary from mild to clinically significant. Additionally, positive relationships have been established between levels of exposure and intrusive and avoidant symptoms (e.g., Bride, 2007).
Therapists may also experience vicarious trauma (VT), which refers to lasting alterations to basic cognitive beliefs as a result of secondary exposure to trauma such as “the world is not a safe place” and “life has lost its meaning”. Five psychological needs and their associated schema have been identified as particularly susceptible to the effects of both primary and secondary psychological trauma. These psychological needs are manifested in relation to both the self and others, and relate to safety, trust, esteem, intimacy and control (Pearlman & Saakvitne, 1995). A limited number of studies have explored the development of VT in therapists, and qualitative studies in particular have provided support for the concept of VT.
Secondary exposure to trauma has also been associated with the burnout dimensions of emotional exhaustion, depersonalisation and reduced levels of personal accomplishment (e.g., Craig & Sprang, 2010). Emotional exhaustion is characterised by a lack of energy, and feeling that one’s emotional resources are depleted. Depersonalisation relates to the interpersonal aspect of burnout, and refers to the negative or detached responses to aspects of employment, while reduced personal accomplishment is characterised by negative self-evaluation.
| When David finally accepted that his work was making him unwell, he sought help from a clinical psychologist, and was diagnosed with PTSD and major depression. Some of his cognitions at that time were: "the world is a cruel place, the weak get trodden on; I am a broken down machine; I have failed; men are the cause of all the violence in the world. I’m ashamed to be male.” He felt unsafe walking in familiar streets and emotionally detached from his family. His therapist worked hard to help David reappraise his negative cognitions as well as suggesting behavioural changes such as stop watching television news, reduce alcohol consumption, improve sleep hygiene and maintain physical exercise. |
Relationships between constructs
The concepts of STS, VT and burnout are often used interchangeably within the literature, however it appears they may be distinct but interrelated constructs that represent a developmental process. The theoretical literature supports a developmental process, starting with acute STS, moving to long term VT and burnout (e.g., Pearlman & Saakvitne, 1995). At this stage, empirical research regarding these relationships is limited.
Individual factors
Research on PTSD has revealed that vulnerability to developing traumatic stress reactions is complex, and involves multiple individual factors. More specifically, it has been proposed by researchers (e.g., Yehuda, 1999) that lower magnitude traumatic events are more likely to lead to PTSD under conditions of increased vulnerability. Therefore, conditions of vulnerability such as specific individual factors are also likely to influence the potential impact of secondary exposure to trauma. In addition, there are factors that that may serve to protect the psychologist.
Empathic engagement with clients’ experience of trauma is widely considered to be a significant factor in the development of STS, VT and burnout (Wilson & Thomas; 2004). Empathy has been defined as the psychological capacity to identify and understand another person’s psychological state of being, however individuals who have an increased capacity for empathy tend to be more at risk for developing difficulties associated with secondary exposure to trauma (Figley, 1995).
One’s past history of trauma has also been conceptualised as a likely vulnerability factor in the development of STS and VT, given the potential for reactivation of traumatic memories. Studies have investigated the relationships between past history of trauma and symptoms associated with STS, VT and burnout, producing varied results (e.g., Hargrave, Scott, & McDowall, 2006). It has been proposed by Sabin-Farell and Turpin (2003) that the impact of personal history of trauma upon STS and VT is likely to be affected by the extent to which the therapist has processed his or her trauma, at sensory, affective and cognitive levels, which may explain the conflicting findings.
The most widely researched protective factor is that of social support provided by family, friends and supervisors, and studies have identified that increased levels of social support are associated with reduced levels of symptoms associated with STS, VT and burnout (e.g., Dunkley & Whelan, 2006).
| While David did not have a history of personal trauma, he did come from a family where service to others was encouraged. He was also the eldest of four siblings. Thus he felt an expectation to be the helper and assumed a sense of invincibility in his work. He possessed a strong imagination, which facilitated his capacity to engage in his clients’ experiences, and run the scenarios about his children. His sensitivity to others’ distress and determination to help was a positive as well, as a curse. |
Future implications
The implications for those responsible for training psychologists, as well as workplace health and safety policy and procedures, is to increase awareness of the impact of secondary exposure to trauma, account for individual vulnerability and protective factors, and incorporate ways to reduce the likelihood of difficulties developing. Suggestions for prevention and minimisation include: reducing levels of exposure via managing caseload; if noticing difficulties, to be aware of one’s own personal vulnerabilities based on factors identified in the research; and to regularly seek supervision and social support.
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During his personal recovery, David came across the work of the neuroscientists Tania Singer and Olga Klimecki. These researchers noted that a different neurological pathway is activated in the brain during the empathic response to someone else’s emotional pain, than when a compassionate attitude to the others’ pain is taken. The latter stance, they concluded, appears to inoculate the practitioner to the client’s pain, while still creating the motivation to alleviate clients’ suffering but not taking on the physical and emotional components of this pain (Klimecki, Leiberg, Lamm & Singer, 2013).
David developed a regular practice of mindfulness meditation, giving him greater emotional regulation, a compassion practice, and an understanding of neuroplasticity and its therapeutic applications. He also pursued the acknowledged factors for improving resilience: physical exercise, social connection, sleep, good nutrition, writing a journal and psychotherapy. He no longer works in a clinical capacity but draws upon his past experience together with his skills in writing (e.g., Roland, 2014) and public speaking to help others.
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The first author can be contacted at [email protected]