Professionals Coping with Vicarious Trauma
Josef Ruzek, Ph.D.
NCP Clinical Newsletter 3(2): Spring 1993
The task of providing medical or psychological help to victims of traumatic events is stressful. Nurses, for example, face the emotional demands associated with exposure to death and dying. Rescue and disaster workers who respond to emergency situations may be distressed by suffering, death, and body recovery. Those providing psychological therapy for victims must endure the strains of hearing detailed accounts of traumatic events and witness the powerful emotional and social aftermath of those events.
Lindy (1) described the possible emotional impact of work with war-traumatized Vietnam veterans: "Withstanding the impact of this powerful and unusual imagery may simply become more than the therapist can manage. During the treatment process, the therapist must carry affectively within himself these terrifying images, and his own character defenses may be inadequate to cope with them". McCann and Pearlman (2) hypothesized that "all therapists working with trauma survivors will experience lasting alterations in their cognitive schemas, having a significant impact on the therapist's feelings, relationships, and life. Whether these changes are ultimately destructive to the helper and to the therapeutic process depends, in large part, on the extent to which the therapist is able to engage in a parallel process to that of the victim client, the process of integrating and transforming these experiences of horror or violation.". It is important to acknowledge that, while the personality and life experience of the therapist is one determinant ("countertransference") of his or her response to the trauma victim, strong emotions are a normal part of this work: "the dialectic of trauma constantly challenges the therapist's emotional balance" and "the therapist should expect to lose her balance from time to time with such patients. She is not infallible" (3).
These quotations suggest a need to think more carefully about the adaptive and maladaptive coping methods employed by professional helpers in responding to the difficulties associated with their job. Program administrators should explore the benefits of support systems for employees; individual staff members have a responsibility to examine their own coping style related to trauma work.
Beyond creation of on-the-job support systems which promote disclosure of helper reactions and utilization of social supports, what is good coping? Janik (4) cited a study by Taylor and Frazer (5), who found that personnel involved in body recovery in the 1979 air crash in Antarctica were underrepresented in the high stress group if they employed "denial imagery" by viewing the bodies as objects (e.g. plane cargo, frozen meat, scientific specimens). Is that good coping? Janik also drew attention to a study by Taylor, Wood, and Lechtman (6), which identified cognitive coping responses used by public safety personnel in coping with distressing situations: "(a) comparing one's self with those less fortunate; (b) selectively focusing on positive attributes of one's self to feel advantaged; (c) imagining a potentially worse situation; (d) construing benefits from the victimizing experience; and (e) manufacturing normative standards that make one's adjustment seem normal". Are these helpful, healthy responses?
Professional coping methods may also bear an important relationship to quality of care. Herman (3), focussing on trauma therapists, noted some commonly observed coping responses: "The therapist, like the patient, may defend against overwhelming feelings by withdrawal or by impulsive, intrusive action. The most common forms of action are rescue attempts, boundary violations, or attempts to control the patient. The most common constrictive responses are doubting or denial of the patient's reality, dissociation or numbing, minimization or avoidance of the traumatic material, professional distancing, or frank abandonment of the patient". Lindy (1) identified groups of defenses which he judged to interfere with the therapy process, among which were the phenomenon of distancing oneself from the patient through "avoidance, disavowal, and clinging to professional role" as well as distancing from one's own feelings, by means of "isolation, generalization, and intellectualization". Similarly, Danieli (7), discussing work with Holocaust victims, listed "various modes of defense against listening to Holocaust experiences and against therapist's inability to contain their intense emotional reactions". She identified, as a way of avoiding listening to pain and suffering, the therapist's focus on "how did you survive" rather than "what happened to you?" or "what did you go through?"
Descriptions of coping processes used by professional helpers raise an important question: What methods of coping are to be advocated for the professional who works with victims of traumatic events? While we wrestle with that question, however, it is important that we do not delay helping our colleagues cope with the risk of vicarious trauma and "burnout" which comes with the job. Our actions in creating support systems may help prevent staff stress-related problems as well as improve quality of treatment. Herman (3) put the issue strongly:
"Engagement in this work thus poses some risk to the therapist's own psychological health. The therapist's adverse reactions, unless understood and contained, also predictably lead to disruptions in the therapeutic alliance with patients and to conflict with professional colleagues. Therapists who work with traumatized people require an ongoing support system to deal with these intense reactions. Just as no survivor can recover alone, no therapist can work with trauma alone".
References
1. Lindy, J, D. (1988). Vietnam: A Casebook. New York: Brunner/Mazel.
2. McCann, I. L. and Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131-149.
3. Herman, J. L. (1992). Trauma and Recovery. U. S. A.: Basic Books.
4. Janik, J. (1992). Addressing cognitive defenses in critical incident stress. Journal of Traumatic Stress, 5, 497-503.
5. Taylor, A. and Frazer, D. (1982). The stress of post-disaster body handling and victim identification. Journal of Human Stress, 39, 19-40.
6. Taylor, S., Wood, J., and Lechtman, R. (1983). It could be worse: Selective evaluation as a response to victimization. Journal of Social Issues, 39, 719-740.
7. Danieli, Y. (1988). Confronting the unimaginable: Psychotherapists' reactions to victims of the Nazi Holocaust. In J. P. Wilson, Z. Harel, and B. Kahana (Eds.), Human Adaptation to Extreme Stress: From the Holocaust to Vietnam. New York: Plenum.
Josef Ruzek, Ph.D. is Assistant Director of Education at the Clinical Laboratory and Education Division of the National Center for PTSD.
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