A Phenomenological Study of Vicarious Traumatisation Amongst Psychologists and Professional Counsellors Working in the Field of Sexual Abuse/Assault

 

 
Abstract

In the past decade the field of traumatology has expanded to incorporate vicarious traumatisation (VT); the impact on the therapist of exposure to traumatic client material. This study was designed to investigate the VT effects experienced by therapists who work with sexual abuse/assault survivors. Twelve psychologists and professional counsellors participated in semi-structured interviews which explored their responses to hearing traumatic material, perceived effects of VT, alterations in their cognitive schemata and their coping strategies. Findings indicated that therapists experience a variety of severe negative effects which may have a pervasive impact on their functioning in both personal and professional domains. However, positive sequelae were also noted, and thus it is suggested that our conceptualisation of VT may be limited. The need to educate therapists about the potential impact of VT and possible coping and preventive strategies is highlighted.

 

Introduction

This study addresses the phenomenon of vicarious traumatisation (VT) which is the impact on the therapist of repeated exposure to traumatic client imagery and material. That therapists working with trauma survivors may be at risk for experiencing negative effects as a result of this exposure has become increasingly recognised in the psychological literature during the past decade. Although only a relatively new area of investigation, findings suggest that VT effects can have a profound impact on both personal and professional domains of functioning. Pearlman & Saakvitne (1995a, p. 31) define the phenomenon:

Vicarious traumatisation refers to the cumulative transformative effect upon the trauma therapist of working with survivors of traumatic life events. …. It is a process through which the therapist’s inner experience is negatively transformed through empathic engagement with clients’ trauma material.

Previous conceptualisations of the impact of trauma work on professionals have included burnout (Farber & Hiefetz, 1982), and countertransference (Danieli, 1980). However these phenomena may occur as a result of working with any difficult client population. In contrast, McCann & Pearlman (1990) construe VT as specific to professionals working with trauma survivors. The potential effects of working with trauma survivors are considered distinct from those of working with other difficult client populations because the therapist is exposed to emotionally disturbing images of horror and cruelty that are characteristic of severe trauma.

The notion of VT is based on a constructivist personality theory, and emphasises the role of meaning and adaptation, rather than focusing primarily on a set of symptoms. An underlying assumption of VT is that it causes profound disruptions in the therapist’s frame of reference, including their basic sense of identity, world view, and spirituality. Pearlman & Saakvitne (1995a, p. 280) summarise the impact of VT as follows:

Multiple aspects of the therapist and their life are affected, including their affect tolerance, fundamental psychological needs, deeply held beliefs about self and others, interpersonal relationships, internal imagery, and experience of their body and physical presence in the world.

Whilst there are many rewards in working as a trauma therapist, Pearlman & Saakvitne (1995a) assert that VT refers specifically to the negative aspects experienced by the therapist. The concept is not intended to assign blame to clients for the therapists’ reactions, rather VT is considered a natural and inevitable response to spending significant amounts of time working with, or studying, trauma survivors. VT is a process which takes place over time, and across clients and therapeutic relationships.

Many of the effects experienced by the therapist parallel those of the trauma survivor, but at subclinical levels (Pearlman & Saakvitne, 1995a). The therapist may experience general changes, such as having no time or energy for self or others, and increased feelings of cynicism, sadness, and seriousness. They may experience other strong emotions such as anger, grief, or despair. The therapist may also develop an increased sensitivity to violence, for example, when watching the news on television or in the cinema (Pearlman, 1993).

Pearlman & Saakvitne (1995a) state that the therapists’ self-protective beliefs about safety, control, predictability, and attachment are challenged through working with trauma survivors. Consequently the therapist may become anxious, and avoidant of situations they now perceive as potentially dangerous, such as being home alone, driving at night, and walking through car parks (Resick & Schnicke, 1993). These and other effects, which can be disruptive and painful for the therapist, may occur as a short-term reaction to working with traumatised clients, or may persist for months or years after the completion of such work (McCann & Pearlman, 1990).

Pearlman & Saakvitne (1995a) identify two major factors that contribute to VT: aspects of the work, and aspects intrinsic to the individual therapist. Aspects of the work include the nature of the clientele, specific facts of the traumatic event, organisational contextual factors and social/cultural issues. Therapist characteristics include personality, personal history, current personal circumstances and level of professional development. VT evolves from a complex interaction between these multiple influences and thus its effects are unique to each therapist.

McCann & Pearlman (1990) suggest that VT intrudes on four major areas of the therapist’s functioning: cognitive schemata, psychological needs, the memory system, and frame of reference. They assert that schemata are cognitive manifestations of psychological needs such as trust, safety, power, esteem, intimacy, independence and frame of reference, all of which are fundamental to trauma adaptation. These needs are sensitive to disruption by VT, which can therefore cause subtle and/or acute effects, depending upon the degree of discrepancy between the client’s traumatic memories and the therapist’s existing schemas. Alterations to schemata based on trauma adaptation needs are reflected in the perspectives that therapists may develop. Dutton (1992) notes that therapists may develop some of the following perspectives: there is never a safe place in the world (safety); the therapist is helpless to take care of the self or to help others (power); one’s personal freedom is limited (independence); or working with victims sets one apart from others (intimacy).

McCann & Pearlman (1990) also argue that these and other cognitive shifts that result from exposure to traumatic client material may create emotional distress in therapists, including anger, guilt, fear, grief, shame, irritability, and inability to contain intense emotions. In addition, Dutton (1992) asserts that the cognitive shifts may interfere with effective functioning in the therapeutic role.

In addition to disturbances in cognitive schemata, McCann & Pearlman (1990) assert that therapists who listen to accounts of victimisation may internalise their clients’ memories, and may consequently have their own memory systems altered. Disruptions in their imagery system of memory (Paivio, 1986) are most frequent and thus the therapist experiences flashbacks, dreams, or intrusive thoughts; symptoms constituting one of the primary diagnostic criteria of PTSD (APA, 1994). As with cognitive shifts, disruptions in the imagery system of memory are frequently associated with powerful affective states (Paivio, 1986). Therapists have reported various uncomfortable emotions resulting from their work with trauma survivors, including sadness, anxiety, or anger (McCann & Pearlman, 1990).

McCann & Pearlman (1990) also assert that VT impacts on the therapist’s frame of reference which incorporates their world view, identity, and spirituality. Given that individuals view, experience, and interpret their world through this frame of reference, any disruption to it is inherently disorienting and stressful (Pearlman & Saakvitne, 1995a).

Although the phenomenon of VT has received a great deal of theoretical and clinical attention, there is a paucity of empirical research investigating the impact of exposure to traumatic clinical material on professionals working with trauma survivors. A review of the traumatology literature revealed only three published empirical studies investigating the effects on professionals of providing services to survivors of sexual abuse and sexual assault. Martin, McKean, & Veltkamp (1986) studied the impact of working with survivors of sexual assault on police officers and found that PTSD symptoms were significantly more prevalent amongst police officers dealing with rape survivors than those who did not. Oliveri & Waterman (1993) conducted a retrospective survey of 21 therapists who, five years previously, had been involved in treating sexually abused children in pre-school centres. Therapists reported experiencing PTSD symptoms and distress as a result of treating the children. Follette, Polunsny, & Milbeck (1994) examined the impact of providing services to sexual abuse survivors, and found this to be significant for both mental health professionals and police officers.

These studies provide some evidence of the effects of exposure to trauma material on professionals. However, two were limited by the use of small sample sizes, and all failed to acknowledge the need to distinguish between the impact of VT, and the chronic effects of unresolved personal life issues. Thus there is limited investigation, either empirical, epidemiological, or phenomenological, to guide our understanding and intervention in VT. Consequently, in-depth study of VT in specific therapist populations, working with specific client populations is warranted. Thus the present study was designed to explore the experience of female therapists who work with sexual abuse/assault survivors. Specifically, we wished to determine the extent to which therapists reported effects of VT, the impact of these effects, and the coping strategies used to deal them.

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Method

Participants
A purposive sample of 12 female therapists, (four professional counsellors and eight psychologists), was recruited from relevant agencies in Perth, Western Australia. They were aged between 26 and 59 years with a range of experience of 1 to 18 years in the area of sexual abuse/assault. All were working full-time in this area.

Materials
A semi-structured interview schedule was developed based on earlier work (Figley, 1995; Follette et al., 1994; McCann & Pearlman, 1990; Pearlman & Saakvitine, 1995a). The interview began with general questions about the therapists’ experience of hearing traumatic material, and then became more specific, focussing on cognitive schemata and coping strategies.

Procedure
Interviews lasted approximately one hour and were tape recorded. After transcription, thematic content analysis was conducted independently by two raters and salient issues were identified. A high inter-rater reliability was achieved.

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Results

Therapists’ responses to hearing traumatic client material were predominantly affective, and included anger, pain, frustration, sadness, shock, horror and distress. The anger was mainly directed toward the perpetrator but was sometimes expressed in global statements regarding our inhumanity. Frustration was both self and other directed. Self-directed frustration was related to the therapists’ knowledge of their inability to change the client’s situation. Other-directed frustration was towards clients, their families and societal factors. Participants reported that the nature of the response depends on “who is telling me, and how they are telling me, and the content of what they are telling me”. That is, the responses varied according to the nature of the abuse, age of the client, and its impact on the client’s life. Therapists were also aware that their responses were influenced by their workload and by “… whether it triggers something personally in me, some kind of memory of myself, or some kind of connection that I make”.

Several therapists reported self-protective responses in which they actively sought not to imagine the client’s experience. “I protect myself in some ways. I sometimes find myself automatically able not to let it get to me”. Others reported being able to focus on therapeutic responses, “to concentrate on what my role is and what my job is” without the apparent need for self-protection.

Many negative effects outside the therapeutic session were reported. These effects occurred in various domains of functioning including physiological, emotional, professional and interpersonal. Physiological effects included diminished energy levels, somatic complaints and sleep disturbances. Emotional responses included comments such as “I get more angry than I normally would”. Seven of the twelve participants reported that they experienced overwhelming imagery, dreams and intrusive thoughts. Eight respondents reported increased vigilance regarding their own safety and the safety of others.

Sometimes I don’t feel safe, even in my own environment

I’m more vigilant, and have more safety concerns, and sometimes when I see people with their children I wonder whether they are abusing them.

Some developed mistrust in their ability to do the work effectively, and others reported a negative impact on their relationships and interpersonal functioning, both within the family and beyond. Six therapists reported an increased wariness of men and a decrease of trust with their partner. Seven reported changes in their wider social circle:

Some of my friends feel really uncomfortable about me doing this work and just can’t cope, so I’ve actually lost some good friends

At times it affects my ability to feel close to people, my ability to trust people

In response to the more specific question regarding changes in cognitive schemata, all therapists reported changes. The most frequently cited change was “loss of faith in human beings”.

I’m reminded of something about human beings that is really quite unpleasant, and sometimes I feel sad about that.

I always thought of the world as intrinsically good, but now I know differently.

Related to this is an increased sense of vulnerability:

At times I feel more vulnerable and I think that is just me being aware that it can happen to anyone at anytime and there’s no reason or logic.

Several therapists reported a change in their sense of identity:

Often I’m not sure of myself, particularly with the world, and what I’m doing, and where it’s going, and what it all means anyway. A lot of the time I’m struggling with how I feel about myself and who I am.

However, not all responses were negative. Positive self-identity statements included: “I see myself as being much more adjustable and flexible”, and “I’ve become really clear about what I want to do with my life, and my own identity”.

In addition, some reported a greater appreciation of their clients:

I’ve learnt how strong and resilient people are, and how much inner resources and strengths people have

while others reported a clarification of their values and attitudes, and a greater depth of compassion. These changes appear to derive from the increased questioning of life that the therapists reported:

I spend a lot more time by myself, things like going for walks, and trying to make sense of life, – spending more time thinking about what the whole point of everything is.

Interviewees were asked about the coping strategies that they use to deal with the effects of their work. They were all very aware of the need to be proactive in this regard and reported taking good care of their physical and psychological needs. That is, they reported efforts to maintain healthy eating, sleeping and exercise habits, and recognised the need for self-care and to pursue activities outside their professional duties. They also reported awareness of the importance of boundaries in both their personal and professional lives, the need for debriefing, and ongoing professional development and supervision.

The therapists also reported negative coping strategies such as drinking too much coffee and alcohol, risk-taking behaviours such as speeding, and withdrawing from family and friends. All had experienced episodes of feeling an overwhelming sense of helplessness, and most reported that these episodes precipitated negative self-talk and crises of confidence.

When asked what kind of preventative strategies they use, interviewees re-iterated some strategies for positive coping, and also reported using a number of additional strategies, both personal and professional. For example, the majority stressed the need to create balance between their work and personal lives, and to endeavour to keep these spheres separate. All participants stressed the need for personal awareness of their own vulnerabilities and stress reactions:

When I first started working in this area I made a commitment to being aware of my own responses and what I react to.

Such self awareness enables the therapist to monitor their responses during sessions, seek supervision, and manage their client load accordingly.

The participants also stressed the need for education and training in both management of sexual abuse/assault clients and the effects of VT. They argued that the former is vital to their feelings of competence and helps to mitigate against crises of confidence mentioned earlier. Knowledge of the potential effects of VT was considered essential in that it provided validation of the therapist’s experience and encouragement to take preventative measures.

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Discussion

The interviews revealed that all the therapists experienced negative effects of working with severely traumatised clients. This is in accordance with McCann and Pearlman (1990) who argue that VT is an unavoidable result of trauma counselling. These responses were predominantly affective, and included anger, pain, frustration, sadness, shock, and distress. All therapists explained that their responses varied depending on a number of factors relating to both their client and themselves, thus lending support to Pearlman & Saakvitne’s (1995a) assertion that because of the complex interaction between aspects of the work, and aspects of the therapist, the effects of VT are unique to each therapist.

It is curious that some therapists were aware of using self-protective strategies with clients while others reported that they were able to continue in the therapeutic role without interruption. The latter may suggest a lack of self awareness on the part of the therapist, a desire to be perceived as competent, or may indicate desensitisation to the traumatic material. Again, although all the participants reported experiencing the negative effects of VT, not all stated that these had a negative impact on their professional lives. The above factors could be operating again, or alternatively, those denying adverse effects could be using effective coping and preventative strategies. Clarification of these possibilities would be useful in predicting therapist vulnerability to VT and its subsequent treatment. A longitudinal study could provide much-needed insight into these issues.

Effects in physiological functioning were frequently cited by the therapists, in particular fatigue, and disturbed sleeping patterns. The majority of therapists had been exposed to traumatic imagery they found too overwhelming to integrate, and also reported experiencing flashbacks, dreams, and intrusive thoughts. However, contrary to Pearlman & Saakvitne’s (1995a) assertion that VT is a cumulative effect, the majority of therapists did not perceive the negative effects as increasing over time. Again, it is possible that some therapists have become desensitised through repeated exposure, or that effective coping strategies are curtailing the accumulation of negative effects.

Over half of the therapists reported that they had become more suspicious and distrusting. Specifically, several therapists mentioned that when they are out in public and see a man with a child, they wonder if the child is being abused. Although Pearlman & McCann (1990) construe such changes as disruptions in cognitive schemas, the therapist may simply be more mindful of child abuse issues; an appropriate response to working in the field of sexual abuse/assault. Pearlman & McCann (1990) do not, however, draw distinctions between increased awareness and disturbances in cognitive schemas. We suggest that the utility of conceptualising alterations in cognitive schemas on a continuum ranging from awareness, to exaggeration and paranoia, be explored.

The finding that many of the therapists experienced positive changes in their sense of identify, and beliefs about self and others, suggests that other than detrimental effects arise from listening to traumatic material. There was evidence of positive alterations in their sense of meaning/spirituality, and world view, including re-evaluation of previously held beliefs, increased self awareness, and the acquisition of new perspectives. As the concept of VT specifically refers to negative changes in therapists’ frame of reference, it is thus inadequate as a conceptual framework for understanding the full range of effects of trauma counselling. Recognition of, and investigation into, the positive effects of trauma therapy on the therapist would constitute a more comprehensive and holistic approach to the phenomenon.

The majority of therapists identified a large repertoire of strategies for coping with, and preventing, the negative effects of their work. The range of individualised strategies reported on both personal and professional levels suggests a high level of awareness of the need to care for the self. Considering the deficits in education about VT, this awareness may be more intuitive than the result of any formal training. Coping and preventative strategies used by these therapists represented all the major types of strategies identified in the literature (Dutton, 1992; Pearlman & Saakvitne, 1995b). Although the respondents had been able to develop their own strategies, all agreed on the need for education and training, both for novice counsellors and those continuing to work in the area.

Results of this study may have been limited by several factors. First, the small sample size is acknowledged, but is acceptable given the exploratory nature of the study. Second, the sample was not homogeneous in that not all the therapists worked with sexual abuse/assault on a full-time basis, and the location of practice varied between private rooms and agencies. However, it may equally be argued that such diversity provides a greater exposure to different experiences.

Perhaps the most serious limitation was some therapists’ inability to accurately remember their beliefs and level of functioning before they began working in the field. This is understandable as nearly half of the therapists had worked with this client group for more than 7 years. In addition to memory recall problems, some therapists may have failed to identify changes that occurred gradually over a long period of time. Clearly there is a need for a longitudinal study to clarify the cumulative effects of VT.

Finally, the therapists’ inability to distinguish the vicarious effects of trauma therapy from the effects of unresolved personal issues, is also of concern. Separating these two sources of stress can, however, be problematic as each aspect may interact with the other. Some therapists demonstrated an ability to separate these effects whilst others did not. Further, it may be functional for therapists to attribute the effects of personal problems to the nature of their work. This would effectively remove the need to deal with their personal issues. The impact of the therapist’s own past traumatic life experiences is also an important consideration. The interaction between therapists’ history of abuse, their responses to hearing traumatic client material, and the VT effects they experience, have received some recent attention (Follette, et al., 1994), and require further investigation.

As questions in the interview schedule related specifically to trauma therapy with sexual abuse/assault survivors, these findings are not generalisable outside of this therapist group to the wider domain of trauma therapy. Research with therapists working in other fields of trauma would be enlightening.

This study has contributed to the understanding of VT by providing experiential evidence of its widespread existence and impact on therapists’ personal and professional lives. The need for a broader conceptualisation of the phenomenon was highlighted, as was the need for further research. As the field of traumatology expands, therapist education and training becomes a top priority.

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References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. Fourth Edition. Washington, DC: APA.

Danieli, Y. (1980). Countertransference in the treatment and study of nazi Holocaust survivors and their children. Victimology: An International Journal, 5(2-4), 355-367.

Dutton, M. A. (1992). Empowering and healing the battered woman: A model for assessment and Intervention. New York. Springer Publishing Co.

Farber, B. A. & Hiefetz, L. J. (1982). The process and dimensions of burnout in psychotherapists. Professional Psychology, 13, 293-301

Figley, C. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Follette, V. M., Polusny, M. M., & Milbeck, K. (1994). Mental health and law enforcement professionals: Trauma history, psychological symptoms, and impact of providing services to child sexual abuse survivors. Professional Psychology Research and Practice, 25, 275-282.

Martin, C. A., McKean, H. E., & Veltkamp, L. J. (1986). Post-traumatic stress disorder in police and working with victims: A pilot study. Journal of Police Science and Administration, 14, 98-101.

McCann, I. L. & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131-149.

Oliveri, M. K., & Waterman, J. (1993). Impact on therapists. In J. Waterman, R. K. Kelly, M. K. Oliveri, & J. MCcCord, (Eds.). Behind the playground walls: Sexual abuse in preschools (pp. 190-202). New York: Guilford Press.

Paivio, A. (1986). Mental representations: A dual coding approach. New York: Oxford University Press.

Pearlman, L. A. (1993). Vicarious traumatization and the treatment of MPD. Presentation at the 5th Eastern Regional Conference of Abuse & Multiple Personality, Alexandria, Virginia, USA.

Pearlman, L. A. & Saakvitne, K.W. (1995a). Trauma and the therapist – counter-transference and vicarious traumatisation in psychotherapy with incest survivors. New York: W.W. Norton & Co.

Pearlman, L. A., & Saakvitne, K.W. (1995b). Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In C. Figley (Ed.). Compassion fatigue; coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 150-177). New York: Bruner/Mazel.

Resick, P. A. & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims. California: Sage Publications.

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Copyright

Lyndall G Steed & Robyn Downing © 1998. The authors assign to the Australasian Journal of Disaster and Trauma Studies at Massey University a non-exclusive license to use this document for personal use and in courses of instruction provided that the article is used in full and this copyright statement is reproduced. The authors also grant a non-exclusive license to Massey University to publish this document in full on the World Wide Web and for the document to be published on mirrors on the World Wide Web. Any other usage is prohibited without the express permission of the author.