How do I manage the risk of vicarious traumatisation when the trauma resonates with my own life?
By including indirect, work-related, exposure to trauma (criterion A4) in the PTSD diagnosis, DSM5 formalised what many already knew - that psychological therapists working with very traumatised people are at risk of developing PTSD themselves. Even those of us who don’t develop full-blown PTSD may experience some traumatic stress symptoms, or other vicarious distress that might contribute to compassion fatigue, burnout, or ill-health. Being aware of this risk and taking steps to mitigate it are crucial in managing our wellbeing as therapists, and sustaining our ability to continue working with trauma.
Some clients and/or their traumas might have a particular resonance with us; perhaps because their experiences match some of our own, or we relate to them in another way. Lived experience is a potential strength as a therapist, bringing with it a natural empathy, authenticity, motivation to help, and compassion. However, several research studies have found that lived experience is also a risk factor for compassion fatigue (Turgoose, & Maddox, 2017). Perhaps the increased personal salience and commitment also takes a greater emotional toll; or working with matching clients or traumas trigger our own trauma memories and strong emotions, making it harder to maintain the boundaries between professional and personal life. We also run the risk of over-identifying with clients, activating our own beliefs, needs, and biases and leading us to think and act in ways based more on our personal experiences than our patients’.
Key to managing this is cultivating self-awareness and approaching supervision non-defensively. It is best to be open with supervisors about lived experience, to allow conversations about the impact of the work on us, elicit support, and formulate how our and our client’s thoughts and behaviours may interact (we find Stirling Moorey’s ‘Cognitive Interpersonal Cycle’ worksheet helpful for this). It is also okay to choose not to work with particular clients or types of trauma. Most services are supportive of therapists declining cases or passing them to a colleague. For example, many of our colleagues with young children choose not to work with traumas involving harm to children, or those who have had a recent bereavement may prefer not to work with traumatic grief. It is better to be honest with ourselves and our team at the referral stage about what types of client or trauma may cause us difficulty, then need to stop treatment or begin to struggle midway through.
The other priority, for all trauma therapists, is to manage our own wellbeing and mental health, avoiding what might be a strong drive to care for others to the detriment of ourselves. We need to be particularly mindful of our own ‘emotional buttons’ and signs they have been activated, as well as our underlying negative beliefs and unhelpful compensatory strategies. At times, we may need to put on the ‘empathy brakes’ if we find ourselves over-identifying with a client. Self-care will look different for everybody; the key is to balance the emotional energy that we expend at work with activities that replenish us. For some, this is exercise, for others it is rest; we may prefer to have a drink with a friend, keep a journal, or do something creative. One thing we all need is time off, so make sure to take your holiday time allocation, especially when you notice the signs of fatigue kicking in. Personal therapy can be worthwhile to help us reflect on our work, the personal-professional interface, and any secondary traumatic stress symptoms which emerge. Where PTSD symptoms are ongoing, therapists themselves should seek evidence-based treatment. We are often good at advising our clients and those in our network on how to look after themselves; we need to also practise what we preach!
· Working with trauma can lead to traumatic stress symptoms for psychological therapists as well as contributing to compassion fatigue, burnout or ill-health.
· This risk can be greater if we have our own lived experience of trauma or identify with a client for another reason.
· This should be discussed and formulated in supervision.
· Therapists should cultivate self-awareness and know when to decline a case or seek support.
· Self-care is also crucial; therapists need to find their own ways to replenish their emotional resources.