This briefing is produced by Brake, the road safety charity. It aims to spread awareness and understanding of the risks posed to support workers by vicarious trauma, and related conditions.
Vicarious trauma can have a debilitating effect on support workers, their family and friends. It is a condition that develops when counsellors and psychiatrists working with trauma victims are strongly affected by their work, to the detriment of their own emotional and cognitive wellbeing.1
This report will identify the signs of vicarious trauma and give an overview of vicarious post-traumatic growth.
This report will discuss
- the impact that trauma work can have on support professionals;
- how vicarious trauma can develop;
- best practice advice on reducing the risk of support workers developing vicarious trauma; and
- how to limit the impact for those already suffering from the condition.
This report is based on the research findings and support recommendations of Dr Keren Cohen (head of therapies and senior lecturer, Goldsmiths, University of London) presented at a webinar for victim support professionals.
The DSM IV (Diagnostic and Statistical Manual of Mental Disorders) definition of trauma is widely used by health professionals.2 This definition states that trauma can result from actions that threaten death or serious injury. It also recognises that an individual can become traumatised without witnessing an event – for example, after learning about a loved one’s sudden or violent death.
Traumatic events can also be defined as those that occur outside of our normal day-to-day experiences. Broader definitions of trauma could include the effects of an interpersonal experience (such as a divorce).
PTSD and the impact of trauma
Traumatic events can instigate a broad spectrum of reactions, and can cause post-traumatic stress disorder (PTSD) to develop.
Common symptoms of PTSD include:
- Arousal, nightmares and intrusive thoughts
- Significant changes to cognition and emotion
- Several psychological impacts, including depression, reduced self-esteem, guilt and/or shame
- An increase in aggression and aggressive behaviour
- Difficulties in creating and/or maintaining intimacy in personal relationships.
The impact of PTSD can also have a ripple effect on an individual’s family, partner or colleagues.
The negative impacts of trauma work
Professionals who support people who have been traumatised are also at risk of developing a range of psychological conditions.
Burnout is a motivational syndrome which can result from emotional exhaustion. The condition can affect people in any form of work.
There are three major aspects of burnout:
- Emotional exhaustion. This can result in tiredness, a lack of motivation and being emotional unavailable.
- Lack of personal accomplishment, causing dissatisfaction with work performance and sense of a lack of achievement.
- Depersonalisation. This could cause support workers to develop a cynical or negative attitude towards their clients.
Burnout usually develops from prolonged exposure to work-related stress, and can be a challenging condition to treat or recover from. It is important that support professionals are aware of the symptoms of burnout, so that they can address and mitigate its impact.
Using monitoring tools like the Maslach Burnout Inventory3 can be a helpful way for support workers to assess whether they are experiencing burnout.
Compassion fatigue is a condition specific to support professionals. People experiencing compassion fatigue may feel emotionally exhausted and numb,4 and may lack empathy towards their clients.5
The effects of compassion fatigue can result in increased clinical errors, and the condition has been linked to depression, anxiety and mental health issues.
Secondary traumatic stress
Secondary traumatic stress occurs when an individual develops PTSD-like symptoms, without having directly witnessed or experienced a traumatic event. The symptoms instead develop through support work with a client who experienced the traumatic event.6 While burnout or vicarious trauma develop over an extended period of time, secondary traumatic stress can present suddenly and unexpectedly.
Vicarious trauma does not necessarily cause psychiatric symptoms, and the effects may not be as severe as secondary traumatic stress; however, vicarious trauma can significantly alter an individual’s perception of themselves and the world.8
Unlike burnout and compassion fatigue, secondary traumatic stress (DSM V PTSD) and vicarious trauma are inherently linked to trauma.
Trauma response theory
Assumptive world and basic assumptions
The assumptive world concept states that people have a shared set of basic assumptions about the world, themselves and others. These tacit assumptions are the building blocks of cognition and form general attitudes and approaches to life.
Generally, people have a sense of self-worth, believe in a rational process of cause and effect, and feel that the world is benevolent. While people will recognise that traumatic events can occur, they do not feel a sense of overt vulnerability.
In the assumptive world, these basic cognitions tend to be stable across life. When negative (but non-traumatic) events occur, people will generally not change their basic assumptions; however, when a person has experienced trauma, the event will be so beyond their day-to-day experiences that they will start to question their understanding of the world.
Procession of trauma9
After a traumatic event, basic assumptions are severely challenged. To recover from the trauma, a person will need to change their previous assumptions or create new ones.
While trying to rebuild their assumptive world, people may experience contemplation, intrusive memories, flashbacks and other symptoms. During this process, a person will generally assimilate or accommodate the traumatic event into their system.
Assimilation and accommodation
Some people may be able effectively to process a traumatic event, without changing their basic assumptions – this is called assimilation.
However, in most cases, people will have to accommodate and change their basic beliefs to process the trauma.
Incomplete processing cycle
Some people are initially unable to reach the stage of accommodation or assimilation. Instead, they become stuck in an incomplete processing cycle. When this occurs and there is continuous activation of the trauma, PTSD symptoms will develop.
Avoiding emotional or physical connections to the trauma at this stage is understandable but can worsen the situation by further delaying cognitive processing.10
Theory and vicarious trauma
A support worker can experience a similar process with vicarious trauma. Prolonged exposure to clients’ traumatic narratives can have a strong influence on a support worker’s cognitive perceptions.
Potential impacts of undertaking trauma work can include:
- Feeling less safe
- Becoming less trusting
- Reduced self-esteem
- An inability to form intimate relationships
- Becoming withdrawn and less engaged with the wider world
- Feeling a sense of loss of control over life.
For vicarious trauma to manifest, changes to personal cognition need to be pervasive, cumulative and permanent.
Preventing vicarious trauma11,12
When developing a strategy to help support workers avoid vicarious trauma, it is important for organisations to consider factors that can influence and prevent its progression.
Self-medication with alcohol or other substances (or withdrawal from these substances) can increase the risk of vicarious trauma.
A combination of work-related stress and domestic problems (e.g. a role as carer outside of work or a bereavement) can heighten the risk of vicarious trauma occurring.
Some studies have indicated that women experience higher levels of vicarious trauma than men;13 however, this may be due to greater levels of reporting, rather than women being more likely to be affected by the condition.
Proportion of trauma work
Organisations should diversify the responsibilities of their support workers. Work with traumatised clients should be mixed with a combination of other, less-demanding tasks, such as administrative duties.
Personal trauma history
A personal history of trauma can increase the risk of a support worker developing vicarious trauma, particularly when this trauma has not been successfully processed.
The more a support professional works with people who have experienced trauma, the more susceptible they are to developing a prolonged, negative outlook.
How can organisations help?
Organisations working with traumatised people must develop effective guidelines and protocols to identify and support workers showing signs of vicarious trauma.
A positive workplace culture that promotes tolerance and openness is very important. Staff should be provided with a support network and be able to disclose any concerns.
Additionally, organisations should encourage support workers to:
- Engage with self-care. Support workers must be enabled to separate their work from their personal lives. Engaging with physical and social activities can help mitigate the emotional impact of trauma work.
- Utilise any personal resources, such as spirituality, optimism and humour.
While trauma work can have negative effects, there can also be positive outcomes if professionals are fully supported.
What is (and isn’t) growth?
Growth is a separate concept to coping well with the stresses of work. It is also different to looking purposefully for positive aspects of work.
Instead, growth is a term used to describe naturally occurring cognitive changes. These can include post-traumatic growth and vicarious post-traumatic growth. Changes that occur from vicarious post-traumatic growth can be seen as alterations to who we are. It is important to consider how exactly these changes occur, and how trauma work can result in growth.
Vicarious post-traumatic growth
Vicarious post-traumatic growth occurs when a support worker:
- is exposed to a client’s traumatic narrative and empathically engages with that narrative; and
- experiences a fundamental shift in their assumptions, resulting in change to their understanding of the world.
There are two potential outcomes to vicarious-post traumatic growth:
- A negative change, which can result in an individual withdrawing and developing vicarious trauma.
- A positive change, which can result in a person becoming wiser, more empathic and feeling more connected to people.
Understanding vicarious post-traumatic growth
This section of the report details three academic studies, which can help develop understanding of how vicarious post-traumatic growth develops.
Brockhouse, R., et al. 2011. Vicarious exposure to trauma and growth in therapists: The moderating effects of sense of coherence, organizational support, and empathy.14
This study was undertaken in the UK and used qualitative data. It considered reported senses of coherence and control in counsellors and psychotherapists, and also what organisational and personal support these professionals received.
The study sought to identify the impact of trauma work and assess how this affects potential for growth. The investigation results were inconclusive and indicated the need for further research.
Splevins, K., et al. 2010. Vicarious post-traumatic growth among interpreters.15
The second study also used qualitative data, to assess individual growth in interpreters working with refugees and asylum seekers.
Empathy and growth: The study aimed to determine whether an empathic connection with a client is required for growth. The qualitative data revealed that the interpreters felt empathy and a psychological closeness towards their clients. In some cases, this was due to a shared culture and history, as some of the interpreters were also refugees. A sense of closeness and identification between interpreter and client was facilitated through the required use of the first-person in translation.
Responding to trauma: The interpreters in the study reported two strong emotional impacts. The first reaction, distress, was experienced when hearing the refugee client’s story. After the client had received counselling, the interpreters had a second, more positive reaction. This was reported as a sense of amazement at the recovery and resilience of their client. The shock experienced when seeing this transformation was very similar to the disbelief they felt, when they first heard about the traumatic events. Both impacts caused the interpreters to challenge some of their previous assumptions about life.
Study conclusions: This study recognised that an empathic connection is required to facilitate vicarious post-traumatic growth. It also highlighted that exposure to a client’s growth and recovery can help trigger vicarious post-traumatic growth in a support worker. The study also raised questions about whether vicarious trauma and vicarious traumatic growth can occur together, whether they are mutually exclusive or if one needs to happen before the other.
Cohen, K. and Collens, P. 2013. The impact of trauma work: A meta-synthesis on vicarious trauma and vicarious trauma growth.16
This study analysed data from pre-existing qualitative research, and aimed to determine the impact of trauma work and highlight any positive outcomes.
It also highlighted two strong reactions experienced by support workers – initial distress, and later amazement at the recovery of a client.
The study also considered changes reported by support workers, following trauma work.
Negative changes reported included:
- A sense that the world was unsafe
- Compassion fatigue
- Reduced levels of trust/increased suspicion
- Becoming distant or over-protective in personal relationships.
Positive changes reported included:
- Great compassion, appreciation of life and human resilience
- Increased self-awareness, self-worth and wisdom.
After trauma work, support workers who felt more engaged and open to life often experienced growth, whereas those who became more withdrawn were more likely to experience vicarious trauma.
Nature of the trauma experienced: The nature of a client’s trauma can influence the impact on the support worker. Professionals working with child sexual abuse survivors reported change in levels of trust and in their personal relationships.
Fields of trauma work: This study highlighted that a ‘resilience shock’ needs to be experienced, to facilitate vicarious post-traumatic growth. However, some fields of trauma work may provide limited exposure to client resilience: whereas therapists can work with clients through their journey, helpline workers may only experience clients at their most distressed. Experiencing a client’s traumatic narrative, but not their consequent recovery, can potentially have an impact on a support worker’s level of vicarious post-traumatic growth.
Distress and growth: The study found that further research is needed into the relationship between growth and levels of distress experienced. Studies of PTSD and post-traumatic growth had varying conclusions – some studies found that a lower level of PTSD is required to experience post-traumatic growth, whereas other studies rejected this. There were similar findings in relation to vicarious trauma.
Facilitating vicarious post-traumatic growth
Vicarious post-traumatic growth is a naturally occurring response to trauma. It only happens under certain conditions, and this can be difficult for support workers, their clients and their organisations.
Professionals who have already formed compassionate assumptions and approaches, which accommodate for the shock of human resilience, may not experience the major cognitive changes vicarious post-traumatic growth can cause. This does not automatically mean that they are coping poorly.
Conclusions and recommendations
It is natural that trauma work will have an impact on support workers; however, it is important that the difference between more general negative emotions and vicarious trauma is recognised. Vicarious trauma is a long-term, pervasive change to an individual’s cognitive schema.
- Diversify employee workloads.
- Create a safe work environment. Support workers should feel supported and able to disclose any issues.
- Create safeguards to identify vulnerable support workers, and ensure they receive the help they need.#Monitor and assess the risk of vicarious trauma by introducing tools that highlight the condition. The earlier that symptoms are identified, the sooner support can be provided.
- Educate employees on how to identify the signs of vicarious trauma in themselves and co-workers.
- Run targeted interventions that prevent or mitigate the impacts of vicarious trauma and promote post-traumatic growth.
- Peer support can be an effective means of identifying and preventing vicarious trauma.
- Aim to achieve a healthy work–life balance. Social activities and sport can be helpful.
- Remain alert for periods of heightened stress in both work and personal lives.
- Disclose any concerns to a trusted member of staff.
About Dr Keren Cohen
Keren was trained in psychodynamic psychotherapy, and works as a counsellor alongside her academic career. Her academic background is in clinical psychology, with a particular emphasis on trauma and wellbeing. Keren’s research interests include wellbeing and post-traumatic growth, and, more recently, she has begun to explore and develop the concept of vicarious post-traumatic growth.
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