Supporting the supporter: vicarious trauma and support needs

Defining trauma

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
• Hyper-vigilance
• Avoidance of emotional and physical connections to the trauma
• 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.

Professionals who support people who have been traumatised are also at risk of developing a range of psychological conditions.

Burnout

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 Inventory [3] can be a helpful way for support workers to assess whether they are experiencing burnout.

Compassion fatigue

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 [7]

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.

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.

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 [9].

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.

Avoidance of 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.

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 [11,12].

Coping strategies

Self-medication with alcohol or other substances (or withdrawal from these substances) can increase the risk of vicarious trauma.

Personal stress

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.

Gender

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.

Exposure

The more a support professional works with people who have experienced trauma, the more susceptible they are to developing a prolonged, negative outlook.

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.

This section of the report details three academic studies, which can help develop understanding of how vicarious post-traumatic growth develops.

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.

Key recommendations

Organisations should:

• 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.

Support workers:

• 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.