Vicarious Traumatization of the Therapist
By Christine A. Courtois, Ph.D.
NCP Clinical Newsletter 3(2): Spring 1993
"I love my work but lately I find it contaminating my personal life. I have nightmares about the horrible things I hear about from clients, my sex life has deteriorated, I'm irritable and distractible, I'm afraid for my kids and tend to overprotect them, and I don't trust anybody anymore. I don't know what is happening to me." A Therapist
Many therapists, especially those who treat trauma survivors, have variations of this experience which has come to be know as vicarious traumatization. This term, first used by McCann and Pearlman (1990b), refers to "...the enduring psychological consequences for therapists of exposure to the traumatic experience of victim clients. Person who work with victims may experience profound psychological effects, effects that can be disruptive and painful for the helper and persist for months or years after work with traumatized persons" (p.135). Vicarious victimization overlaps to some degree with burnout, which usually refers to a response to a work situation which is too demanding, stressful, and and/or unrewarding. It also has elements in common with countertransference which generally refers to the activation of unconscious material in the therapist's psyche, evoked by the client and his/her dynamics and material. Vicarious traumatization is conceptualized as a special form of countertransference stimulated by exposure to the client's traumatic material. This article will detail some of the most common stimuli and will provide some suggestions for prevention and help for the helper.
Mental health professionals treating post-traumatic syndromes are increasingly aware of the personal hazards of their work. Victims constitute a difficult treatment population in general; however, victims of long-term human-induced trauma add a further level of difficulty. Victimization which is human-induced, pre-meditated, chronic, and progressive (all of these are found in family violence) involves betrayal, and coerces and confuses a less-powerful victim and is especially both for the victim and the helper. So is war-trauma, torture, criminal assault, sexual violation, and homicide.
Therapists can be directly impacted by the nature of the trauma itself and its unique dimensions and characteristics. The after effects, especially those indicating dramatic post-traumatic deterioration and acute repercussions, can be especially disturbing. The clients previous interactions with medical and mental health personnel can upset the clinician if PTSD went undiagnosed and untreated, causing compounded reactions and additional challenge for the victim. Finally, the treatment process, including the quality of the therapeutic relationship, the victim's style, defenses, resistance's, transferences, ego resources, etc., and the progression of the treatment often evoke strong reaction.
Trauma treatment is often rigorous and requires the therapist's use of self and relationship to provide emotional containment and facilitation of the discharge and resolution of traumatic material. The therapist is called upon to tolerate the story and attendant emotions while remaining psychologically available as support to the client. Reworking of traumatic material involves breaking through patterns of numbing/denial, accepting events and losses, grieving, abreacting, and making new sense or meaning of the victimization. Therapists engaged in treating trauma are called on to be closely engaged but with limits and boundaries delineated (Chu, 1988; Courtois, 1988).
Vicarious Traumatization: Schema Disruption in the Therapist
Mcann and Pearlamn (1990a) developed an interactive model, constructivist-self development theory, to account for trauma response affecting the self and reactions to others. According to this model, victimization impacts and disrupts the schema an individual holds about the self and about others. Seven schema have been identified which are especially susceptible to trauma-induced alteration. These include: (1) the individual's personal frame of reference about self and others in the world; (2) safety; (3) dependency and trust; (4) power; (5) esteem; (6) independence; and (7) intimacy. In parallel process to the trauma victims they treat, therapists may have their self schema altered, and in this way experience vicariously or secondarily victimization. Referring back to the therapist quote at the beginning of this article, we can see the disruption of several of these self-other schema at work -- nightmares: frame of reference and safety; sexual functioning: intimacy, trust, and safety; irritability: frame of reference and safety; fear, mistrust, overprotection of children: safety dependence and trust, and independence.
Therapist Self-Care
Trauma work is best not conducted in isolation. Immunization against vicarious victimization involves education regarding trauma syndromes and their treatment, the normalizing of responses, the recognition of the impact of the material on personal schema, and ventilation in a supportive environment. Prevention and management involve making boundaries between personal and professional activities and including variety in each. Additionally, trauma therapists might want to carefully monitor their caseloads in terms of size and number of trauma cases, and engage in other activities to defuse some of the traumatic impact. Therapists cannot be totally immune to the effects of helping clients work through post-traumatic responsess, and must expect to be affected as a price of the work; they can, however, take steps to provide some degree of protection and relief from the most insidiously destructive effects.
References
Chu, J. (1990). Ten traps for therapists in the treatment of trauma survivors. Dissociation, 1, 24-32.
Courtois, C. A. (1988). Healing the incest wound: Adult survivors in therapy. New York: W.W. Norton & Cop.
McCann L. & Peralman, L. (1990a) Psychological trauma in the adult survivor: Theory, therapy and transformation. New York: Brunner/Mazel Publishers.
McCann L. & Peralman, L. (1990b). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131-149.
Christine A. Courtois, Ph.D. is the Clinical Director of the Center for Abuse Recovery and Empowerment Psychiatric Institute of Washington, in Washington: DC. Dr. Courtois also maintains a private practice.
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