Concepts and Theories Associated with Vicarious Trauma

There are a number of theories and closely related concepts that have been linked to and used interchangeably with vicarious trauma and it is important to bear this in mind whilst reviewing the literature. Before considering how vicarious trauma is similar or different to other theories or concepts, consideration must be given to both the notion of theory and nosology as defined below.

Unlike a hypothesis, which can be wrong or misleading and is made on the basis of limited evidence needing further investigation, theories provide a concise, coherent, systematic and accepted system of ideas, intended to explain facts or phenomena (Bradford, 2015). Nosology is a branch of medicine that deals with the classification of diseases, such as the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013) which defines what causes them, the mechanism by which the disease is caused or the symptoms related thereto (Smolik, 1999; Robison, 2015). However, such classifications can be confusing as they may change with time.

As noted, more recently the term vicarious trauma has been used to describe the phenomenon (McCann & Pearlman, 1990). However, the terms ‘burnout’ (Maslach, 1982); ‘secondary traumatic stress’ and ‘compassion fatigue’ (Figley, 1987, 1995, 2002); and ‘countertransference’ (Freud, 1910; Wilson & Lindy, 1994) have been previously used to characterise therapists reactions to client trauma. These concepts will be considered and linked to the current study.

2.10.1. Burnout

The body of literature on burnout thoroughly describes the phenomena and prescribes preventative and treatment interventions for helping professionals (Gentry, 2002). The term burnout was introduced by Freudenberger (1974) after he observed symptoms of exhaustion, fatigue and various somatic complaints displayed by his staff members working in crisis intervention, free clinics and self- help groups. Burnout is more commonly a consequence of the social environment in which people work and therefore not mutually exclusive to healthcare. Contributing factors for burnout are work overload, lack of control, insufficient rewards, and unfairness, breakdown of community and value conflict (Maslach & Leiter, 1997). Such factors may lead to either an individual not functioning at their full potential or terminating their employment altogether.

Different to vicarious trauma, burnout is a process that develops gradually and progresses in intensity over time rather than being due to trauma and the suffering of a specific patient (Figley, 1995). It has been described as a syndrome that can result in general psychological stress and physical fatigue, and which commonly occurs through working with difficult clients requiring intense care (Maslach, 1978; Pines & Maslach, 1978; Figley, 1999). It has been defined as:

‘…a state of physical, emotional and mental exhaustion caused by long term involvement in emotionally demanding situations…’ (Pines & Aronson, 1988:9)

The multi-dimensional theory of burnout (Maslach, 1982, 1998) provided a theoretical framework for professionals and continues to influence literature linked to the field. Burnout is described as having three core dimensions; ‘(1) emotional exhaustion, (2) depersonalization, defined as having a negative attitude towards clients, a personal detachment or loss of ideals and, (3) a reduced personal accomplishment and commitment to the profession’ (Bell, Kulkarni & Dalton, 2003:463). The underlying consensus within literature, is that these core dimensions can lead to symptoms such as depression, boredom and loss of compassion and discouragement (Bermak, 1977; Freudenberger & Robbins, 1979; Farber & Heifetz, 1982; Deutsch, 1984; Maslach, Schaufeli & Leiter, 2001).

Although accepted burnout can occur in persons in any profession, therapists are particularly vulnerable to it because of their personal isolation, ambiguous successes and the emotional drain of remaining empathic (McCann & Pearlman, 1990). Related to a feeling of being overloaded, secondary to client problems of chronicity and complexity, burnout unlike vicarious trauma, does not lead to changes in trust, feelings of loss of control, issues of intimacy, esteem needs, safety concerns and intrusive images (Trippany et al., 2004).

2.10.2. Secondary traumatic stress/Compassion fatigue

The term secondary traumatic stress (Figley, 1985), is often used interchangeably within the literature with compassion fatigue (Figley, 1995). Compassion fatigue has been described as ‘a more user-friendly term for secondary traumatic stress disorder’ (Figley, 2002:3). Similar to vicarious trauma, it refers to those individuals in the helping professions exclusively (Elwood Mott, Lohr & Galovski, 2011). Comparable to views of McCann and Pearlman (1990) when describing vicarious trauma, secondary traumatic stress/compassion fatigue symptoms are considered a normal reaction to engagement with traumatic material (O’Halloran & Linton, 2000; Elwood et al., 2011). As within vicarious trauma, secondary traumatic stress/compassion fatigue can occur as a direct result of exposure to emotionally shocking stories or material, rather than exposure to the actual trauma itself as within PTSD (Figley, 1995). Therefore, a traumatising event experienced by one person may become a traumatising event for a second person, such as a family member, friend or therapist (Canfield, 2005). However, secondary traumatic stress/compassion fatigue, like burnout, focuses on external symptoms unlike vicarious traumatisation, which focuses on the internal experiences and the

gradual change in the therapist’s worldview (Ben-Porat & Itzhaky, 2009). The

onset of symptoms can be rapid and typical of PTSD sufferers but there is a faster recovery than compared to the concept of burnout (Sexton, 1999). Left untreated, secondary traumatic stress can develop into secondary traumatic stress disorder where symptoms become more chronic (Jenkins, Mitchell, Baird, Whitfield & Meyer, 2010).

2.10.3. Countertransference

Countertransference differs from vicarious trauma as it is present in every therapeutic relationship, rather than being a cumulative consequence of trauma work (Adams & Riggs, 2008). Sigmund Freud (1910), developed the concept of countertransference from his earlier work around transference, whereby patients unconsciously transferred or projected their feelings from influential people in their early life onto their therapists in their adult life. He recognised this process not only happened for patients but also for the therapists they were working with. Whilst initially seen as having a negative impact on successful treatments and an obstacle for therapists to overcome (Freud, 1910; Reik, 1937; Fleiss, 1953), since the 1950s, it has been viewed differently. No longer seen as an impediment to treatment but rather a therapist’s conscious and unconscious response, and an important tool in understanding unconscious and interpersonal issues in the client’s everyday life (Heimann, 1950; Pearlman & Saakvitne, 1995a; Reidbord, 2010). Rather than long-term schematic changes, its effects are relatively short-term within the therapy session (Figley, 1995; Harrison & Westwood, 2009). Countertransferential responses outside the therapy session can be due to pre- occupation of clients and their recovery and may be particularly noticeable for those therapists new to trauma work (Neumann & Gamble, 1995).

Due to the overlap in the literature, the distinct differences between the concepts of vicarious trauma, burnout, secondary traumatic stress/compassion fatigue and countertransference are summarised in Table 2 (page 27). Literature exploring the effects of vicarious trauma and its related concepts was reviewed to explore how working directly with trauma clients impacts upon psychological therapists either physically, emotionally, behaviourally, interpersonally or work-related. Various themes emerged from the literature review which are discussed under separate headings to aid the reader.

Table 2: A summary of distinct differences between the effects of vicarious trauma and its related concepts.

Vicarious Trauma Burnout

Secondary Traumatic Stress/ Compassion Fatigue Counter- transference Sudden onset of symptoms which may not be detectable at an early stage. Cumulative process. Develops gradually. Progresses in intensity over time.

Sudden onset of symptoms which may not be detectable at an early stage. Cumulative process. Usually only present during the therapy session itself.

Physiological, intrusive & avoidant symptoms representative of PTSD. Emotional exhaustion, erosion of idealism, reduced sense of accomplishment & achievement. Physiological, intrusive & avoidant symptoms representative of PTSD. Changes in emotional & behavioural responses within the therapist to the client. Specific to working with trauma survivors. Occurs as a result of prolonged work with any group in any profession. Specific to working with trauma survivors. Present in all therapeutic relationships. May result in permanent changes. Focus on internal symptoms. Disruptions in basic sense of identity, world-view, spirituality & cognitive frame of reference.

Effects may be long lasting. Can lead to depression, boredom, loss of compassion and discouragement.

Effects may not last as long as burnout. Focus on external symptoms. Can lead to secondary traumatic stress disorder if untreated. Temporary, short- term effect.