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January 1, 2015

For care-givers trauma is a two-way street

Reuel S. Amdur

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Suicide was the topic at the table during a weekend program on health care evaluation, many years ago. One of those present was a child psychiatrist. Mischievously, I asked which medical specialty had the highest rate of suicide. "Psychiatry," she replied without hesitation, "but surgeons have one-car fatal crashes." Her answer illustrates the fact that in helping people who have severe problems the helper may also be affected.

Social workers Erica Watson and Janine Lawford conducted a seminar in Ottawa focusing on what happens to the helper.  They covered several conditions: vicarious trauma, burnout, compassion fatigue, and counter-transference.  Let’s start with vicarious trauma.

A victim of trauma experiences changes in the brain and in brain functioning, both in a biochemical sense and in a mental sense.  The therapist treating such a person may experience such reactions as well.  The therapist’s right brain may not fully distinguish between the actual experience and the experience of reacting to the report.  While a therapist needs to have empathy, that empathy puts him at risk for vicarious trauma.  The condition is cumulative but it may emerge suddenly.

Burnout differs from vicarious trauma in that vicarious trauma is a reaction to the specific content that the client/patient reveals, while burnout is a general exhaustion from the pressure of dealing with stressful cases or heavy caseload. While it is not the same as vicarious trauma, the consequences may be quite similar.  The two social workers list these as physical, emotional, and behavioral symptoms, work-related and interpersonal problems, and decreasing concern for clients.

Compassion fatigue occurs when a helping person loses empathy and becomes unable to feel compassion.  Empathy just gets worn out.  Compassion fatigue and vicarious trauma are conditions to which various professions are prone.  Among them are police, doctors, nurses, social workers, psychologists, teachers, clergy, and caregivers to seniors.

Transference occurs when a patient/client reacts emotionally to a therapist as he would to someone else, often a parent.  A therapist may make appropriate use of transference in treatment.  Counter-transference, on the other hand, occurs when the therapist reacts to the client in a similar manner.  Counter-transference is not useful in the therapeutic relationship and may interfere with it.  Counter-transference may be complicated by vicarious trauma.

The women reported that vicarious trauma is not uncommon, citing one study of child welfare workers, of whom close to half had experienced severe symptoms.  Vicarious trauma, they said, “causes disruptions in cognitive schemas of identity, memory, and belief systems.”  It can alter one’s view of the world.  Changes may or may not be permanent.

Vicarious trauma can have impacts in various areas—emotional, psychological, behavioral, physical, and spiritual.  In the emotional domain, the therapist may be prone to anger, frustration, hopelessness, anxiety, cynicism, and loss of pleasure, among other features.  Psychologically, he may develop a negative self-image, suffer desensitization, have problems with intimacy, and experience intrusive imagery, along with other negative elements.

Behavioral consequences may include absenteeism, a decline in quality of service, difficulty making decisions, smoking, drinking, anger, irritability, and other undesirable behaviors.  Physically the therapist may have headaches, distorted sleep, panic and startle reactions, disruption of sex life, and change in appetite.

Then there are the spiritual ramifications.  Deeply held beliefs may be questioned.  The therapist may lose faith and question life’s meaning.  He may lose trust in others and self, developing a feeling of inadequacy.  Safety and security may be seen as jeopardized. 

It is important for a therapist to be prepared for the dangers of vicarious trauma.  The key is self-care.  He needs to look after his own needs.  Is the caseload too demanding?  Can he rely on a supervisor or other person for support?  Then there are relaxation techniques and yoga.  Again, therapists need to recognize that vicarious trauma is a risk that comes with the territory, and they need to be prepared if it occurs.

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